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 the review of the grievance log, the hospitals policies and procedures and staff interviews, it was determined that the facility failed to provide prompt resolution of patient's grievances in four of six resolved grievances.

The facility failed to comply with its policy related to a prompt grievance resolution. Review of hospital policy, "Patient Complaints and Grievances, 200-5" (reviewed 06/2017) states under the "Grievance Process": "The hospital must attempt to resolve all grievances as soon as possible or if the investigation is not or will not be completed within 7 days, the patient or patients' representative will be informed that the hospital is still working to resolve the grievance. The letter is to be sent to the patient/patients' representative within 7 days and must state an anticipated resolution date." The letter sent to patients states a 30- day completion date given by facility.

A total of eleven grievances were logged with six resolved. Only one of six reviewed grievances, # 8, was investigated and completed within the facility seven days time frame. Four of six resolved grievances were completed outside of the 30 day anticipated resolution date stated in the acknowledgement letter sent to patient. Of the six resolved grievances #1, #2, #4, and #5, resolution letters sent exceeded the 30 day period set by the facility for completion. The acknowledgment letter for grievance #3 and #6 which remains under investigation stated an anticipation date of completion in 30 days. In grievance #3 this date was exceeded by 68 days before a follow up letter was sent to inform patient of delays and the continued need for an additional 30 days. In grievance #6 this date was exceeded by 35 days before a follow up letter was sent to inform patient of delays and the continued need for an additional 30 days.

The facility failed to ensure the effective operation of the grievance process, review, investigation, and resolution of grievance. The current practice of this hospitals' grievance process has no provision for how the grievance process is done in the absence of the one employee that currently handles and processes grievances. Staff was questioned regarding the 60 plus days needed to resolve Grievance #1 and #2 and the reply was, "That was when the grievance coordinator was out sick." The staff was unable to state how grievance are handled in the absence of the grievance coordinator. The letter for grievance #1 was originally dated to the facility December 2015, the grievance log date was August 2017, and resolved October 2017. The facility explained the reason for the delay as multiple staff changes.