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.

ESSENTIA HEALTH DULUTH 502 EAST SECOND STREET DULUTH, MN 55805 Nov. 17, 2011
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on documentation review, interview and policy review, the hospital failed to implement their grievance policy for 1 of 2 (#2) patient written grievances reviewed. Findings include:

Review of Patient #2's progress note dated 7/21/11, at 9:49 p.m. revealed the patient informed staff that she had been touched inappropriately by two male patients.

Review of the facility's Patient Compliment/Concern/Grievance form dated 7/21/11, indicated Patient #2 filed a written grievance concerning being touched inappropriately by the two male patients.

Interview with the nurse manager at 9:43 a.m. on 11/4/11, indicated she had immediately investigated Patient #2's grievance and resolved the issue at the time of the incident but failed to document the investigation.

Interview with the nurse manager at 2:49 p.m. on 11/4/11, confirmed the grievance had been submitted by Patient #1 on 7/21/11. The nurse manager stated after the staff received a grievance, it would be forwarded to Risk Management for further follow-up. That follow-up included a written final decision of the grievance by the facility that would be given to the patient. The nurse manager indicated the grievance for Patient #2 had not been forwarded to Risk Management, therefore the patient did not receive a written notice of the facility's final decision regarding the grievance.

Review of the hospital's grievance policy and procedure titled Grievance Process, with a review/revision date of 1/09, stated, "...a written complaint is always considered a grievance...All verbal or written complaints regarding abuse, neglect, patient harm...will be investigated promptly and...written response will be sent on average within seven...working days..."
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on policy review, documentation review and interviews, the hospital failed to provide a written notice of its final decision regarding a resolution of a grievance for 1 of 2 (#2) patient written grievances reviewed. Findings include:

Review of the hospital's grievance policy and procedure titled Grievance Process, with a review/revision date of 1/09, stated, "...a written complaint is always considered a grievance...All verbal or written complaints regarding abuse, neglect, patient harm...will be investigated promptly and...written response will be sent on average within seven...working days..."

Review of the facility's Patient Compliment/Concern/Grievance form dated 7/21/11, not timed indicated Patient #2 had filed a grievance concerning being touched inappropriately by two male patients. The form stated someone from the hospital would contact the patient.

Review of Patient #2's progress note dated 7/21/11, at 9:49 p.m. stated, "c/o (complained of) not feeling safe...Accused fell ow pt's of touching her inappropriately..."

Interview with the nurse manager at 2:49 p.m. on 11/4/11, confirmed the grievance had been submitted by Patient #1 on 7/21/11. The nurse manager stated when a grievance was received, staff would generate an electronic event report that would be forwarded to Risk Management. The follow-up completed by Risk Management would include a written final decision by the facility that would be sent to the patient. The grievance for Patient #2 had not been forwarded to Risk Management therefore the patient did not receive a written notice of the facility's final decision regarding the grievance. The nurse manager indicated she investigated the grievance and resolved the issue at the time of the incident but failed to document the investigation.