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 interview and document review, the hospital failed to ensure that patient grievances were promptly addressed, for 1 of 1 patient grievances reviewed (P1), when the Behavioral Health Director received a patient complaint and failed to follow the grievance procedure.
Findings include:
P1's hospital emergency department (ED) physician notes dated 8/30/2014 established P1 went to the ED with self injurious behavior (SIB) and suicidal ideation. The notes indicated P1 had been seen by behavioral access nurse (BAN)-A and had a long discussion. The physician documented that P1 reported feeling much improved after the discussion with BAN-A and was able to contract for safety. P1 declined inpatient admission and was discharged . The director of the behavioral health unit/registered nurse-B was interviewed on 10/10/14 at 9:30 a.m. and stated she received a complaint on 9/2/14, related to P1. The complaint alleged that P1 had reported to the representative that BAN-A made sexually inappropriate comments during the assessment that made P1 feel uncomfortable and therefore P1 declined admission to the hospital. Director B stated the caller informed her that a vulnerable adult (VA) complaint would be filed with the common entry point (CEP). Director B stated she immediately started an investigation into the allegation but did not file the complaint as a patient grievance. She stated she felt it was a VA issue and did not want to interfere with a VA investigation, should one take place. Director B also indicated since the complaint did not come from the patient directly is was not considered a grievance. Director B stated BAN-A resigned his position during the investigation and the investigation was then dropped and no further action was taken. Director B did not report the incident to Quality Resources nor did she report to Quality/Patient Safety committee of the Board for review per hospital policy. However, she stated she did work with Human Resources regarding BAN-A and what disciplinary actions would be taken prior to BAN-A resigning from his position.
The Patient Complaint Policy dated 7/11 defines a patient complaint as.. "a formal or informal, written or verbal grievance that is made to the hospital by a patient/representative when a patient issue cannot be resolved promptly by staff present." The policy further directs..."the responsibility for resolution of complaints is placed with the departments involved with the support of Quality Resources. The Quality/Patient Safety Committee of the Board is responsible of the functioning of this mechanism and the evaluation process." Guidelines in the policy direct "Quality Resource staff will be responsible to act on behalf of the patient by interviewing the complainant, writing up the complaint and entering it into the complaint log system, coordinating follow up with any director, administrator, physician or employee to get further information related to the complaint. One key aspect of the process is to evaluate whether any patient rights have been breached."