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.

SPECTRUM HEALTH 100 MICHIGAN ST NE GRAND RAPIDS, MI 49503 Aug. 14, 2014
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on document review observations and interview, the hospital failed to inform all patients, treated in the Adult and Children's Emergency Departments and all inpatients on 8/13/14 with information on how to file a complaint with the State Agency, resulting in all current patients being deprived of information on their right to file a complaint with the State Agency. Findings include:

Policy Review:
On 8/14/14 at approximately 1400, policy review revealed that the facility's policy titled, Patient Complaint/Grievance Process, dated "2/18/13," was reviewed. The policy does not provide a process for informing all patients of the right to file a complaint with the State Agency that has licensure survey responsibility.

Observations & Interviews:
1. On 8/13/14 at 1220, the Adult Emergency Department was toured. No posting with information on filing a complaint with the State survey agency was found.
2. On 8/13/14 at 1310, the patient information packet offered to patients in the Adult Emergency Department by a Patient Registration Specialist (staff G) was reviewed. No information on how to file a complaint with the State survey agency was included in the packet.
3. On 8/13/14 at 1500, the Children's Emergency Department triage and waiting room was toured. No posting with information on filing a complaint with the State survey agency was found.
4. On 8/13/14 at approximately 1510, the patient information packet offered to patients in the Children's Emergency Department was reviewed with Patient Registration Specialist (staff E). No information on how to file a complaint with the State survey agency was included in the packet of materials available to patients and families.
5. The above findings were verified by staff B during tours of the Adult and Children's Emergency Departments on 8/13/14 between 1215 and 1530.
6. On 8/13/14 at 1535, staff F was interviewed in the hospital's Patient Registration Department. Staff H confirmed that the hospital does not provide patients with information on how to file a complaint with the State survey agency, as part of the admission registration process. Staff F stated that a "Resource Guide," in all hospital rooms, provides patients with information on how to file a complaint.
7. On 8/13/14 at 1545 staff H, a Nurse Manager on an Adult Inpatient Unit, stated that the "Resource Guide," available in all patient rooms, provided patients with information on how to file a complaint. A "Resource Guide" from a patient room on the 4 th Floor was provided for review.
8. On 8/14/14 at 0920 staff B confirmed that the "Resource Guide," available in all patient rooms, does not contain information on how to file a complaint with the State survey agency.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation and interview 1 of 1 patients in the hospital's Adult Emergency Department (patient #1) was not provided with personal privacy during treatment, increasing the risk of loss of privacy for all patients treated in the Emergency Department. Findings include:

Observation:
On 8/14/14 from 1200-1207 patient #1 was observed with a basin in her lap having a blood draw in a treatment bay in the Adult Emergency Department. The privacy curtain was not drawn. A visitor was standing in the same corridor outside patient #1's treatment bay. These observations were confirmed by staff B.

Interview:
On 8/14/14 at 1207 a Nursing Tech (staff C) positioned outside patient #1's treatment bay was asked why the curtain was not closed while the patient was having blood drawn. Staff C stated that patient #1 was one of two patients that he was assigned to watch at all times. Staff C stated that the only way he could monitor two patients at once was to keep their privacy curtains open.