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 Complaint and/or Grievance Resolution," with an issue date of 10/2010 stipulates complaints from patients and their families will be investigated promptly and resolution measures initiated. If the issue cannot be resolved within 24 hours, the patient and/or family will be notified. The policy further stipulates if a complaint is not promptly resolved to the satisfaction of the patient and/or their family and the complainant wishes to proceed, the complaint will formally become a grievance. The hospital failed to develop, approve, implement a grievance policy or process which includes all the required elements.

2. The hospital failed to identify grievances: The surveyors reviewed the grievance log for 2011 and January 2012. Three grievances (1,2,5) did not have a letter written to the complainant with all required elements.

3. Six (3,6,7,8,9,10) complaints provided by Staff A were identified as complaints although they required an investigation. One variance report provided by Staff A was identified only as a variance. The variance was a complaint from a staff member about care provided by another clinician. According to staff A the variance had been investigated. There was no documentation this variance was treated as a grievance.

3. The data provided to the surveyors did not demonstrate the hospital investigated all the grievances. Several of the grievances reviewed did not have documentation of investigation and required elements on the grievances. 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. These findings were reviewed with administration at the time of the exit conference on 2/17/2012. No further documentation was provided.