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.

JOHNS HOPKINS BAYVIEW MEDICAL CENTER 4940 EASTERN AVENUE BALTIMORE, MD 21224 July 11, 2013
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on a review of 8 open and 3 closed records, it is determined that 1) hospital policy for responding to patient grievances erroneously allows for a written or a verbal response if done within 7 days, and 2) the hospital responded verbally to a grievance lodged by patient #1's significant other, which does not meet regulatory directives.

The hospital's policy for "Complaint and/or Grievance" defines a grievance as:

"3. Patient Grievance: Any written or verbal concern that is made to the hospital by a patient or patient ' s representative regarding services received that cannot be resolved promptly by staff present. Patient grievances include: ...

b. A formal or informal written or verbal concern regarding patient care, safety, abuse or neglect, or compliance with CMS Hospital Conditions of Participation."

This policy does not meet regulatory directives for responding to a grievance via a formal letter.

Further, an Administrator for the hospital states that they received a verbal grievance by patient #1's significant other on June 12th, which came directly to the Administrator of the Care Center regarding aspects of patient #1's care. An investigation followed resulting in a phone call to the grievant at the completion of the investigation, on June 16th. The phone call was the final response to the grievant, which does not meet regulatory directives for notice of the hospital decision to be by way of a formal letter.