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.


Intakes: TN 919

Based on policy review, medical record review and interview, it was determined the facility failed to ensure patient grievances were addressed and resolved for 1 of 1 (Patient #3) sampled patients with a complaint or grievance.

The findings included:

1. Review of the "Patient Complaint Resolution" policy revealed, "...It is the policy of [name of hospital] to respond timely and thoroughly to any complaint or grievance made against the organization. Patient feedback, including complaints or grievances, are reviewed for opportunities for improvements and trends that may have led or could lead to a particular situation. Patient concerns are reported to the Governing Body...Concern...may be categorized as complaints or grievances...Complaint...concern expressed by a patient or their representative regarding a billing..., facility cleanliness, customer service, food quality, noise level, communication, wait times, lost items or other similar issues. Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation...Resolved: The complaint or grievance has been addressed, an investigation does not substantiate the allegation and the complainant is informed of such, or in the event that the medical center determines that reasonable actions were taken to address the expressed concern....Procedure...The individual managing resolution of the concern should forward a copy of the concern, along with a summary of the actions taken and current status, to the Patient Relations Coordinator upon resolution or as soon as possible..."

2. Medical record review for Patient #3 revealed the patient was admitted on [DATE] with diagnoses of Closed Right Tibial Plateau Fracture, Left Scapular Fracture, Questionable Left Rib Fractures, Renal Insufficiency, Post Traumatic Pulmonary Insufficiency and Acute Blood Loss Anemia. The patient was discharged from the hospital on [DATE] and transferred to another hospital.

Review of the documentation provided on 1/21/15 revealed there were no complaints or grievances regarding Patient #3. During an interview in the conference room on 1/21/15 at 8:50 AM the Interim QA Director verified there were no documented complaints or grievances logged regarding Patient #3.

During an interview in the conference room on 1/22/15 at 9:25 AM the Nurse Manager stated the patient's wife and daughter complained about the patient's pain and care the patient received. The Nurse Manager was asked to provide the documentation of the complaint or grievance and any investigation or resolution.

During an interview on 1/22/15 at 10:00 AM the Nurse Manager stated there was no documentation regarding the complaint or grievance, investigation or resolution. The Nurse Manager stated "Not exactly sure what his [patient's] issues were. If I feel like I can't resolve it [concerns] I get the Patient Advocate involved..."

There was no documentation the hospital took appropriate actions to identify and resolve the grievance/complaint regarding Patient #3 in accordance with the hospital's policy.