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 clinical record review, hospital documentation review, staff interview, and staff written statement review, the hospital failed to inform each patient/family who to contact to file a grievance. This was for one (1) of three (3) patients reviewed (Patient #1).

Findings include:

Review of the hospital's "Patients Bill of Rights" revealed:
"You (patient or patient representative) have the right to express a grievance concerning your care and receive a response without your care being compromised by calling the hospital's patients representative or 1-877-BMH-TIPS. You have the right to access an internal grievance process and also to appeal to an external agency."

Review of "Patient Grievances Policy Reference" revealed:
"PURPOSE: Patients will have reasonable expectations of care and services received. Patients will have the right to voice concerns either verbally or in writing when their expectations are not met without being subject to coercion, discrimination, reprisal, or interruption of care, treatment, and services. (The hospital) will address patient concerns in a timely, reasonable, considerate and consistent manner.
DEFINITIONS: A patient complaint is a verbal issuance of any complaint that patients or family members may have regarding services that can be resolved with staff present. Staff present includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location to resolve the complaint. Post- hospital complaints received by telephone that would routinely have been handled by staff present if communications had occurred during the stay/visit will be considered a complaint.
A patient grievance is a verbal or written issuance of any complaint that patients or family members may have regarding the services they are receiving that cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff resolution, requires investigation, and/or requires further actions for resolution. Verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS (Centers for Medicaid/Medicare Services) requirements will be considered a grievance. A Grievance will be handled by an assigned administrative representative or by a grievances committee assigned by the CEO/Administrator. When a Grievance Committee is appropriate, membership will include representatives from Performance Improvement, Risk Management, Patient Relations and Administration. Grievances will be responded to either by phone call or in writing from appropriate party once investigation has been finalized. Documentation will be maintained in the Patient Grievance database and patient and/or family member will receive confirmation that concerns have been addressed. Appropriate hospital staff will review, investigate and resolve a patient's grievance within fourteen (14) business days of receipt. If grievance will not be resolved, or if investigation is not or will not be completed within fourteen (14) business days, the hospital will inform the patient or patient's representative that the hospital will follow-up with a written response with in a stated number of days."

During an interview on 02/15/11 at 09:00 a.m. the Director of Pharmacy (DOP), who was the Administrator on call 09/27/10, revealed that he took a complaint from Patient #1's granddaughter after the week-ends' events. The DOP stated that he planned to bring his findings and report them at the "Service First meeting" on 10/04/10. The DOP stated that on 09/27/10 he made a visit to Patient #1's daughter in the ICU waiting room and that he investigated the complaints concerning Patient #1. The DOP stated, "I did my part by documenting the complaint in the Data Base System. All administrative staff have access to review these complaints via the Data Base System. At present (09/27/10) the daughter did not have concerns about the care her mother was receiving. We have service recovery. This is when the unit managers talk to the families, etc. I have to depend on my counter-parts to do a follow-up on their part of the complaint. All entries and follow-ups should be in the Data Base System." The DOP did not remember if Patient #1's daughter was given a resolution to the complaints she voiced. All of the findings were discussed at the "Service First" meeting on 10/04/10 (at 4:00 p.m.). I went back to the unit on 10/05/10 to do a follow-up and found that (Patient #1) had been discharged ." The DOP denied doing any further investigation. No additional documentation was offered.

Based on clinical record review, hospital documentation review, staff interview, and staff written statement review, the hospital's governing body failed to approve and be responsible for the effective operation of the grievance process and to review and resolve grievances for Patient #1, one (1) of four (4) patients reviewed.

Findings include:

Record review revealed Patient #1 was a 1[AGE]-year-old female taken from an area nursing home to the hospital's emergency room (ER) on 09/24/10 due to mental status changes. The patient had taken in marginal p.o. (by mouth) intake for some time, was very weak, and was found unresponsive by nursing home staff. The patient presented to the ER with significant hyponatremia with a low sodium level of 104 (Norm 135-145), a high Blood Urea Nitrogen (BUN) of 28 [Norm 7-18mg/dl (milligram per deciliter)] , and a Creatinine of 1.0mg/dl (Norm 0.6 - 1.3 mg/dl). Patient #1 was admitted to the hospital and initially consulted by Medical Doctor (MD) #1, a nephrology specialist. A diagnostic workup was initiated.

Review of the Director of Quality Review Services Job Description Form revealed:
"Principal Accountabilities/Responsibilities -
Responsible for planning, implementation and monitoring of services, which meet the needs of, identified internal and external customers. This responsibility is to be accomplished through ongoing evolution and assessment of customer needs and expectations, identification of gaps between needs/expectations."

Interview with the Director of Quality Review on 02/3/11 at 12:30 p.m. revealed that she was not aware of any complaints that other staff members had documented on Patient #1 during her hospital stay from 09/24-09/29, 2010. The Director denied that the Risk Manager or the Chief Nursing Officer (CNO) informing her about the complaints that (Patient #1's) daughter alleged. The Director denied knowing of any additional documentation or any occurrence/incident reports filled out by any staff members concerning complaints about Patient #1.

Review of the hospital's "Job Description" for the Risk Manager revealed:
"1. Participates in the loss prevention program of (Hospital) and its facilities ...
2. Reviews incident reports, investigates further if indicated, and recommends corrective action in consultation with the Director of Risk Management; evaluates effectiveness of corrective action and recommends additional action if necessary.
3. Trends incidents, occurrences, claims and lawsuits within the facility. Recommends corrective action in consultation with the Director or Assistant Director of Corporate Risk Management; evaluates effectiveness of corrective action and recommends additional action if necessary."

An interview with the hospital Risk Manager on 02/03/11 at 2:30 p.m. revealed that the hospital does require incident reporting by all staff as needed. She stated, "...did not receive any incident reports from staff concerning (Patient #1)...lost all paper work filled out concerning (Patient #1's) grievance on the week of September 24-29, 2011. Two (2) people usually work in the Risk Manager Department. That particular week I had to work by myself and I did not have time to follow up with (Patient #1's) complaints like I should have. I think I put my hand written notes concerning this incident in someone else's file. I will try to remember the best I can and document my findings." The Risk Manager also stated that she did talk with Patient #1's daughter back on the first of January 2011 and that she (daughter) did obtain a statement concerning retaliation, verbal abuse, elderly abuse, physical abuse, and system failure while her mother was a patient in the hospital September 24-29, 2010. "In the middle of the conversation (Patient #1's) daughter revealed that she was getting an attorney...informed her that it is hospital policy that if a patient or family says they are talking with an attorney the conversation is over. I told her I could not talk to her anymore since she was bringing an attorney in on this case." No additional documentation offered.

Review of notes taken by the DOP and placed in the Data Base System revealed on "9/27/2010 Pt's grand-daughter (family #2) called Administration to complain. COP went & talked to both daughter and grand daughter in ICU (Intensive Care Unit), facts gathere (gathered) as below:
1. (Pt #1's daughter) (phone number)
2. Pt (Patient #1), [AGE] visiting family from Chicago about a week ago became unresponsive on Fri 9/24/10. Pt brought to ED (Emergency Department) through ambulance & admitted to stepdown. (Intensive Care Step Down Unit)
3. On Sat 9/26 (2010) speech therapist (ST) was conculted (consulted) to evaluate pt's swallowing ability. (ST's name) was the therapist involved. When ST came to pt's room in stpdown, (step-down) family helped to wake pt up for evaluation. Pt was given some ice chips to swallow and some apple source (sauce). Family member said therapist told them pt has (had) a stroke and will be put on NPO (nothing by mouth) until Tues for further evaluation. Family member did not agree with therapist and start (started) arguing with therapist. A lot of words have (were) exchanged between therapist & family membern (members).
4. Somehow when MD #1 came up to examine the pt. more words were exchanged with family members. Family claimed Dr.(doctor) was rude, unprofessional. Family member quoted DR. said "If you don't like this, take here (her) out of here."
5. Nursing Supervisor was called to the unit.
6. Family member also claimed charge nurse and RN (Registered Nurse) #1 were both not taking care the need from pt. (of the needs of the patient). PCA (Patient Care Aide #1) was awared (aware) of special need(s) from (for) pt. (Patient #1). (Patient #1) seemed comfort (comfortable) when sleep (asleep) but when awake will need a lot ot (of) attention and pain relief due to joint pain.
7. Pt (Patient #1) was ordered to have a NG (nasogastric) tube put in without any communication with family member. Pt was transferred to ICU for observation (from pt's family they thought it was a way to separate pt from them).
8. Family member decided to remove pt from MD #1 care and asked MD #2 (their family MD) to take over the case.
9. Pt (Patient #1) was transferred to ICU & placed with NG tube which was later removed by pt.
10. Family member was very upset with the whole situation."

Interview conducted on 02/15/11 at 1:00 p.m. with the ICU Manager revealed that she could not remember Patient #1's admission on 09/24-29, 2010.

On 02/15/11 at 3:00 p.m. an interview with the Nurse Manager of the Intensive Care Step Down Unit revealed that staff did not have any documentation on the events that happened on 09/25/10 concerning Patient #1.
Based on clinical record review, hospital documentation review, staff interview, and staff written statement review, the hospital and the hospital's governing body failed to ensure the hospital's grievance process included a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control and Improvement Organization.

Findings include:

On 2/15/11 at 10:45 a.m. a telephone interview with the Hospital Attorney revealed that the hospital did not have a policy or protocol for instructing the hospital staff to refer complainants to the Hospital Attorney if they start threatening to get their attorney involved during a complaint investigation. The Hospital Attorney stated, "We drill our risk managers to stop talking to the complainant if this happens and refer them to us." The attorney was asked "Is it understood that the list of complaints documented by the patients' daughter is addressed and she is allowed a grievance and resolution?" The attorney replied, "This matter was turned over to our Corporate Risk Manager and all the issues should continue to be investigated by the hospital and a resolution be completed. I am unaware of the resolution of (Patient #1) at this time."

On 2/16/11 at 3:00 p.m. an interview with the Corporate Risk Manager (CRM) revealed that he had been working for this hospital for several years and that one of his responsibilities was to "over-see" each individual Hospital's Risk Management programs. He confirmed that he received a telephone call concerning complaints from family members of Patient #1. "I did not write up a formal report. I just took notes. I did not send anyone this complaint because I understood that these concerns had already been resolved."
Based on clinical record review, hospital documentation review, staff interview, and staff written statement review, the hospital failed to provide Patient #1/family, one (1) of four (4) patients reviewed, with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.


Review of the 09/29/2010 document handwritten by the facility's CRM revealed multiple broken thoughts jotted down. In red were handwritten notes by staff nurses to explain some of the notes. The CRM's notes stated that the patient (pt) was to have late Friday tests; sodium doctor said her Sodium was low; Speech Therapist (ST) was needed to evaluate pt's swallowing; pt was screaming out in pain and given a PCA pump (delivered pain medication intravenously); ST said pt needed to be awake for swallowing test with water and applesauce and that the pt had a stroke as determined by her mouth and her facial features and she was slumped over to one side. Family said that was normal for pt. Pt had not eaten or had meds (medications) in two (2) days. CRM also noted that the pt's physician was belligerent, arrogant, condescending with family stating this was not normal for the pt and that she did have a stroke; got into a shouting match with family who requested another physician; this was done. Orders were received to move pt to ICU (Intensive Care Unit) for observation; would not let family ride with her in elevator; staff in ICU began inserting tubes; pt woke up and started screaming in pain as staff was putting in a NG tube; actions were abuse; they (family) did not authorize tubes and did not think NG tube was needed; doctor moved pt and caused the pain. Pt was separated from family who had always stayed at her bedside; doctor did this intentionally to get back at family for questioning his actions; family said they were taking pt back home to Chicago. Staff nurses documented in red that pt had come from Chicago to stay with her daughter because her other daughter in Chicago had an operation; pt was moved to ICU for LOC (loss of consciousness); was a full code. CRM documented that on 09/26/2010 another doctor took over pt's care; family did not want NG tube or life support measures; family was told again pt had a stroke; was NPO (nothing by mouth) with no meds; was doing 0 (zero). In red nurses noted that tubes were inserted on arrival to ICU (09/25/10) while still a full code to give pt other meds; full code meant they treated her needs per MD (medical doctor) orders; was transferred to ICU for LOC; was NPO per doctor's order related to aspiration; family was allowed to stay at bedside in ICU 24/7 and had liberal visitation throughout day for other family and friends; pt pulled out NG tube on 09/26/10 at 2 a.m.; was treated in ICU for low Na (Sodium) of 108; was a full code until 09/27/10; ST noted/documented drooling and facial droop; CVA (Cardiovascular Accident) was mentioned; CT (cat scan) of head, done 09/24/10, was negative. Next to 'Said doing "0".' nurses documented that pt had LOC, failure to thrive, low Na, was getting labs/tests and meds. Pt was transferred to ICU from lower level of care and treated as emergent.

There was no documented evidence available in these notes to show that these complaints made by the patient's family were ever followed up on or that the family was ever given a resolution to their complaints.