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 review of hospital policies and the grievance and complaint log, selected grievances and complaints, and interviews with hospital staff, the hospital failed to ensure the hospital's established grievance process was implemented.


1. The hospital's grievance policy, entitled "Patient Grievance ," with an issue date of June 30, 2011, defined a grievance as "a formal or informal written or verbal complaint that is made to the (hospital) (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital compliance with CMS Hospital Conditions of Participation or a Medicare beneficiary billing complaint related to right and limitations." Although the hospital's policy correctly defines a grievance, the hospital failed to educate, train staff and implement the policy.

2. The hospital failed to identify grievances: The surveyors reviewed the grievance log for 2011. Three grievances (2,3,4) did not have a letter written to the complainant with all required elements. In an interview on the afternoon of 11/1/2011 Staff B told surveyors at times complaints/grievances are provided through several avenues. Two complaints provided by Staff C were identified as complaints although they required an investigation. In an interview on the afternoon of 11/1/2011, Staff B told surveyors that all of the grievances and complaints were not always provided to the patient liaison and/or risk manager and were not always logged correctly Staff F stated if the grievance went to governing board first they were not always acted on by the Patient Relations department and followed the grievance process.

3. The data provided to the surveyors did not demonstrate the hospital investigated all the grievances. The grievance log provided to surveyors did not contain all grievances received by the hospital in 2011. There was no documentation of investigation and required elements on the grievances that were forwarded to the Patient liaison. There was no documentation of investigations of all personnel involved and actions taken on behalf of the patient in several of the grievances.

4. The hospital does not ensure the written response to the complainant contains all of the required elements. All of the grievances listed on the log were reviewed by surveyors. Not all of the complainants received letters. Not all of the letters to the complainants included what was done to investigate or what actions were taken to resolve the grievance.

5. The hospital does not ensure grievance data is incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program with analysis of the data and implementation of processes to improve patient care:
In an interview on 11/1/11 Staff A told surveyors the quality department reviewed all grievances. Staff A told surveyors the meetings did not have minutes but staff in the department discussed grievances routinely. There was no evidence that grievance and complaint data was reviewed, trended and analyzed with implementation of corrective and/or process changes to improve patient care. There was no evidence the Governing Body reviewed, trended, and analyzed grievance and complaint data.
Based on review of records, interviews with staff, and review of policies, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent in the hospital's grievance process. Six (1,2,3,4,5,6,) of nine (Patient #1,2,3,4,5,6,7,8,9) complaint/grievances did not follow the grievance process or include all required elements.

1. On 11/1/2011 surveyors reviewed the grievance log from January 2011 to present. Grievances #2,3,4 indicated allegations had been reviewed but there was no written response sent to the complainant.

2. Grievance #1 (the patient mentioned in the complaint) included a response letter. Hospital documents provided to surveyors did not indicate all of the practitioners involved had been interviewed and appropriate personnel action documented. Staff A told surveyors on the afternoon of 11/1/2011 she had given the information to Staff F administration (also mentioned in the grievance) but she did not know what actions had been taken on behalf of the patient with regard to Staff E the practitioner involved in the grievance. The investigation does not stipulate Staff E had been interviewed by Staff F and any actions deemed necessary taken.

3. According to the policy "Patient Grievance, IV.I Following the investigation and review of the patient's complaint/grievance, a formal review of corrective or preventive action is conducted under the supervision of the Compliance Office and will include, as necessary a meeting with involved associates, the patient and patient Advocate." The policy does not stipulate Staff F had been delegated the responsibility of corrective/preventive action. None of the documents provided to surveyors indicate Staff F had been given the responsibility of the grievance process or oversight.

3. On 11/1/2011 surveyors reviewed incident logs from March, April, and May of 2011. Two (#5,6) of seven incidents reviewed were incorrectly noted as complaints. Both incidents involved patient care issues and required investigation. There was no information provided to surveyors the grievance process was followed.

4. On 11/1/2011 Staff A told surveyors information from grievance investigations was provided to administration but Staff A did not attend Board Meetings and could not tell surveyors how or if grievances were reviewed through governance. According to the policy "Patient Grievance"IV.I "data from grievances is also used in formal Performance Improvement efforts under direction of the Director of Quality and/or Quality manager." There is no documentation the Governing Body reviews grievance data. The policy does not stipulate the governing body delegated the responsibility of the grievance process to the Quality Department.
Based on review of the hospitals grievance policy, log and individual grievances, the hospital failed to provide a written response to the complainant with 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. This occurred for three of three patients/patients' representatives who filed grievances (Grievance #3,4,5) and the complaint was not resolved at the time of the complaint by staff present or immediately available.


1. The hospital's grievance policy, provided to the surveyors on the morning of 11/1/2011 and identified by the Quality Administrator as the current policy, stipulated that grievances would be investigated and the complainant would be provided a written response with the required information within 7 days. The policy stated that if the investigation was not completed within the 7 days, a written response would be sent to the complainant stating the hospital was still investigating and then another written response, with the required information, would be sent when the investigation was complete.

2. From the grievance/concern log, five grievances (Grievances #1 through 5) were selected and the surveyor requested all documentation the hospital had concerning the grievance, including investigation and any written correspondence. Three of the grievances were not resolved at the time of the grievance/concern. The material supplied did not contain documentation a written response had been provided to the complainant as required. The surveyor again asked Staff A if the hospital had any additional documentation. None was provided.

Based on review of medical records, interviews with staff and hospital documents the hospital failed to supervise the development of a discharge plan.


1. According to the policy "Initial Transition/Discharge Planning Process" the "RN and Social Worker Case Managers are jointly accountable for assessing the patient and determining the needs and interventions. The assessments consists of a personal interview with the patient and/or family, a modified physical and/or psychosocial assessment and review of Medical Record.
Another policy "Case Management Process" 8. Facilitate and coordinate discharge process by identifying patient's readiness based on pre-determined discharge goals. Confirm date and final discharge plan with physician, patient, and family. 9. Ensure all discharge/transfer activities are completed effectively for follow up care or post discharge services with necessary paperwork completed."
2. Pt#1's medical record indicates the patient had been hospitalized for [DIAGNOSES REDACTED]. According to hospital documents, Pt#1 was told by Staff E she was to be discharged the following day and if the patient had not selected a hospice prior to discharge, Patient #1 would be discharged without hospice care. Documents also indicate Staff E returned to Patient #1's room the next morning and told the patient she would need to pick out a hospice by 1100 AM or be discharged without hospice services. Staff E is credentialed and privileged as a hospitalist nurse practitioner. Staff E was not listed on the hospital's case management/discharge planner roster. There was no documentation Staff E contacted case management/discharge planning. In an interview on the morning of 11/1/11 Staff A told surveyors she was not aware of any policies stipulating the patient had to be out of the hospital by 11:00 AM.

After the initial contact with Staff E, Patient #1 spoke with the physician in charge of her care and requested Staff E not return to her room. Documents stipulate Pt#1 was told by the physician she needed another x-ray before she could be discharged and Pt#1 would not be leaving the next morning. He also indicated he would "handle" the situation with Staff E. There was no documentation the physician contacted case management/discharge planning to delay the discharge or expedite arrangements for hospice.

Although an initial discharge planning evaluation had been completed, documents provided to surveyors did not indicate a case manager or discharge planner had been contacted to expedite an effective discharge. According to documents at the hospital, the patient was so upset after the second interaction with Staff E the patient was discharged without hospice arrangements procured. The patient was discharged on a holiday weekend. The hospital failed to ensure appropriately qualified staff oversaw discharge for effective and safe coordination of post hospital care.