The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based upon record reviews and interviews the hospital failed to ensure a written response that detailed the results of the grievance investigation was mailed to the the complainant as evidenced by a lack of documentation that a written response was mailed and received by the complainant (Patient #1's mother). Findings:

Review of the hospital's Grievance Process revealed: "Policy and Procedure for Customer Comments, Complaints and Grievances...The Customer Satisfaction Committee has been established as oversight for customer comments, complaints and grievances...Processing Grievances...A written complaint about the patient's care, abuse or neglect is always considered a grievance...Written Notice Administrative representatives will have the final responsibility for the resolution of the grievance, as well as provision of written notice to the patient. The complainant will be provided with a copy of the written response...A written notice will be required when: Complaints are not resolved, or if the investigation is not or will not be completed within 7 days...the facility will follow-up with a written response within 30 days..."

Interviews, 02/07/14 at 1:30pm, with S1 Registered Nurse (RN) Chief Nursing Officer (CNO), S2 Assistant Administrator and S3 RN Risk Manager, revealed all complaints, grievances, incidents and other events were entered into a computerized system called "Quantros". Once the grievance (in this survey) was entered into Quantros, it was assigned by S10 Resource Manager to S4 RN Patient Care Coordinator (PCC) Pediatric Unit for investigation.

Further interview, with S2 Assistant Administrator (02/07/14 at 1:30pm), confirmed she had received a written letter from Patient #1's grandmother with complaints of: "family wanting to feed the baby but he was still nothing by mouth; something about they were frustrated because nobody was doing anything for the baby except her (Patient #1's grandmother) and the baby's (Patient #1) mother; and she (Patient #1's grandmother) felt the lack of concern for the patient's well-being may have been a result of the fact that Patient #1 only had Medicaid for insurance."

Interview, 02/07/14 at 1:48pm, with S4 RN PCC Pediatric Unit confirmed she had telephoned Patient #1's mother and discussed the problems. S4 RN PCC stated she had listened to the mother's concerns and thought she had answered all the concerns. Following her conversation with Patient #1's mother, she entered her information about the investigation in the Quantros system.

Interview, 02/07/14 at 2:40pm, with S3 RN Risk Manager revealed she had reviewed the investigation (conducted by S4 RN PCC Pediatric Unit), and made her recommendations based on her (S3 RN Risk Manager) assessment of the investigation. This information was entered into the Quantros system and was ready for Administrative determination and follow-up with Patient #1's family.

Interview, 02/07/14 at 3:30pm, with S1 RN CNO, confirmed (according to the hospital's grievance process), a written response should have been sent to the complainant informing them of the results of the investigation. When asked for documentation of the letter, S1 RN CNO stated, "the copy of the letter could not be located". S1 RN CNO stated she recalled composing a letter to Patient #1's family; however, there failed to be documented evidence of the letter.

Hospital staff failed to follow established grievance process/procedures by not sending a written response that detailed the results of the grievance investigation to the complainant; therefore, the requirement was not met.