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 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 "Grievance and complaint/patient, family" with an issue date of 9/28/10, defines the difference between complaints, significant complaints, grievances recurring grievances. The policy provides time frames for investigation and resolution of grievances and stipulated that a written response with the required information would be provided to the complainant; and the Grievance Coordinator will present the finding of the review to the Performance Improvement Committee which acts as the Grievance Committee and reports finding to the Medical Staff Committee. The hospital failed to follow policy in ten of ten grievances.

2. The hospital failed to identify grievances: The surveyors reviewed the grievance log for 2010 and 2011. Six (Grievance 1,7,8,9,10, 11) of ten grievances were not correctly identified as grievances.

3. The data provided to the surveyors did not demonstrate the hospital investigated all the grievances. There was no documentation that a complete investigation of the care issues in grievances #'s1,5,6,7,8,9,10, 11 were completed.

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. Letters to the complainants did not stipulate what was done to investigate or what actions were taken to resolve the grievance.
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. Ten of ten grievances documented on the grievance log had not been identified, reviewed and resolved.

1. On 3/30/11 surveyors reviewed the hospital's policy 1000 A-18. The policy stipulates "a written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative. A written complaint also includes those complaints received via electronic mail or facsimile. The policy further stipulates a verbal complaint is a grievance if it cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it is referred to other staff for later resolution, if it requires investigation and/or if it requires further actions for resolution." Further the policy stipulates "C. Grievance Resolution Process, 2. Upon receipt of a grievance, the Quality Service Specialist shall confer with the appropriate department manager to ensure review investigation and resolution in writing with the patient and/or patient representative within seven days of receipt of the grievance with the exception of complaints that endanger the patient (i.e., abuse or neglect). The quality service specialist will maintain responsibility for investigation and timely response. These grievances should be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient. "

1. On 3/30/11 surveyors reviewed the complaint and grievance log. Ten grievances (#1,2,5,6,7,8,9,10,11,12) were reviewed. Ten of ten grievances either were not correctly identified as a grievance, did not have a written response, or were not investigated. Ten of ten grievances did not follow hospital policy.

Grievance #1 included multiple care complaints with nursing and dietary. The grievance was initially submitted verbally by the patient's significant other October 2010. There was no initial response letter sent to the significant other. In a letter to the patient in February 2011, Staff C indicated the "assumption at the time was that all issues had been resolved satisfactorily and there was no need for follow up". The hospital failed to identify the complaint as a grievance and failed to provide timely follow up to the complainant.

Grievance # 5 2/11/11- included complaints regarding nursing and dietary. The grievance was submitted in January of 2011 by a friend of the patient and sent directly to the Chief Executive Officer. Documentation on the grievance log indicates Staff A and Staff D called and spoke with the patient's friend in January 2011. There was no written response provided to the complainant. Staff C did not receive notification of the grievance until one month after Staff A and D telephoned the complainant.

Grievance#6 2/24/11 included multiple care concerns regarding nursing. The grievance was submitted in February of 2011. Family members alleged the patient was left alone when transferred into the nursing care area. Information submitted to Staff C indicated the nurses on duty voiced staffing concerns to the house supervisor. There was no documentation the hospital investigated staffing concerns. There was no written response letter provided to the complainant.

Grievance #7's 2/24/11-included multiple care issues. The grievance was submitted by the patient's parent in February of 2011. Documentation in the grievance log by Staff C indicated the patient told Staff C in a follow up telephone conversation, she did not report nursing care issues because she was afraid she would make the nurse caring for her mad. A grievance response letter was not sent to the complainant. There was no investigation documented as to the patient's allegations in the second conversation.

Grievance #8 2/16/11-included concerns regarding medical and nursing care provided in the emergency room . The grievance was submitted in February of 2011. Documentation provided by Staff C indicated there was a review of the medical care provided to the patient. There was no documentation of investigation into the nursing care issues.

Grievance #9, 2/21/11- included concerns about post operative wound management. Staff C indicated on the grievance log the patient was advised on how to care for the concerns. There was no documentation indicating the patient's chart had been reviewed or the patient's complaints had been investigated. Notation on the grievance log indicated the complaints were not considered grievances.

Grievance #10, 2/23/11- included concerns regarding medical care and billing issues. In particular, the complainant stated there were care issues including a perforated esophagus by a anesthesia provider. There was no documentation provided to surveyors care issues had been investigated.

On the afternoon of 3/30/11 surveyors reviewed the above information with Staff A and B. There was no further documentation provided to surveyors.
Based on review of policies, personnel files, and interviews, the hospital failed to provide adequate training and oversight to dietary personnel. On 3/30/ 11 surveyors asked Staff D who was responsible for preparation and delivery of dietary trays. Staff D stated the dietary technicians are responsible for plating and delivery of trays. Two of two employee records (K and L) did not have specific dietary department training or competencies. This finding was reviewed with administration at the exit conference. No further documentation was provided.