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 on record review and interview, the hospital failed to ensure written notice of the hospital's response to the complainant for 1(Patient #2) of 1 patient grievances.


Review of the hospital policy titled, Resolution of Complaints/Grievances, Section 4. Patient Care, revealed in part: Purpose: To provide a mechanism to patient or his/her representative to express their concerns/complaints relating to the quality of care, and to receive assistance in a timely manner for resolution of these problems/issues when needed. The procedure will also allow for investigation, identification of the problem/issue, development of a corrective action plan if warranted to prevent reoccurrence, as well as tracking and trending to provide the hospital with patient feedback and measure patient satisfaction.

Definitions: If a patient care complaint cannot be resolved at the time of the complaint, by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of this requirement.

5. Complaints that are considered patient grievances will be referred to the Patient Representative/Quality Director in a timely manner. She/he will review the grievance and will facilitate the resolution of the problems with the hospital departments, as they are involved. The Patient Representative/Quality Director may have input on the action plan as indicated and will provide feedback to the patient or his/her representative. The feedback will be in the form of written notice within 7 business days. It will contain the name of the hospital, the hospital contact person, the steps taken on behalf of the patient to investigate the complaint, the resolution, and the date of completion.

Review of the hospital's complaint/grievance documentation revealed a representative/family member (not Patient #2 or her significant other) for Patient #2 had filed a complaint on 4/15/16 with S3Quality (Director). The complaint was in reference to quality of care and services received by the patient and issues with communication with the team of physicians managing the patient's care. Further review revealed an investigation was required to resolve the complaint/grievance (investigation completed/closed 4/20/16). Additional review of the hospital's investigation revealed no documented evidence that a written response was sent to the complainant upon completion of the investigation.

In an interview on 5/17/16 at 1:36 p.m. with S3Quality, she indicated a written response was usually sent to the complainant after completion of a complaint/grievance investigation. S3Quality confirmed she had not sent a written response to the complainant after she had completed her complaint/grievance investigation. S3Quality indicated Patient #2 was still an inpatient at the time of the completion of the investigation, therefore she had not sent a written response. S3Quality indicated she had spoken with Patient #2 and her significant other in person and they had seemed satisfied with the hospital's actions.