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 documents and staff interview it was determined the hospital failed to ensure documentation of a review and response to an abuse allegation which was a component of one (1) of one (1) complaints reviewed involving allegations of abuse (Patient #1). This failure creates the potential for a violation of the rights of all patients and for the care and condition of all patients to be adversely impacted.

Findings include:

1. The policy "Patient Complaint/Grievance Management & Procedure", last revised 2/12, was provided for review. The policy states in part: "The Director of Quality Management will manage all patient and family complaints and they will be investigated by the Patient Advocate...The Patient Advocate will log all clinical complaints on the 'Initial Patient Complaint Form,' which will be used for all follow-up documentation...All follow-ups done by a particular department/unit should be done as soon as possible and documented on a Response Sheet (available through the Patient Advocate) then returned to the Quality Management Department. The Patient Advocate on the 'Initial Patient Complaint Form' will document follow-up or responses by telephone calls or emails...A response will be given to the complainant within 72 hours of receiving complaint...The contact will be documented on the 'Initial Patient Complaint Form."

2. Review of an Initial Patient Complaint Form, dated 8/20/13, revealed a complaint was filed regarding patient #1. The documentation in the Description section of the complaint form reflected six (6) different components of the complaint. The third component of the complaint was an allegation the patient was abused by other patients.

Review of the Followup section of the complaint form revealed only part of the components of the complaint were addressed. There was no documentation related to an investigation or finding related to the allegation of abuse.

Further review of the complaint form revealed the documentation reflected the complaint was closed on 8/20/13 with a notation of "no further follow-up required." The file lacked any documentation regarding whether a response was provided to the complainant.

3. At 1600 on 9/9/13 this Initial Patient Complaint Form was reviewed and discussed with the Patient Advocate. She stated she talked with staff involved and there was no indication the patient was abused. She acknowledged she failed to document any investigation or resolution of the abuse allegation or any response provided to the complainant.