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.

ST MARYS HOSPITAL MEDICAL CTR 1726 SHAWANO AVE GREEN BAY, WI 54303 Feb. 4, 2014
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of MR, review of P&P and interview with staff (B), in 2 of 3 MRs requiring and IM for the Pt (3 and 5) the facility failed to ensure the IM is presented within 48 hours of discharge. This deficiency potentially affects all Medicare Pts treated at the facility.

Findings include:

Review on 2/4/14 in the AM of facility P&P titled Medicare Discharge Rights, dated 6/13, it states under #2 "Within 2 days of discharge, patients who stay 3 days or longer will receive a second copy of the Important Message from Medicare about Your rights (that they previously signed), initialed by the case manager or designee who delivered it to the patient bedside. Case manager or designee will also initial the remaining copy and place it in the patients (sic) skinny chart."

Pt #3's MR review on 2/3/14 at 1:30 PM revealed Pt #3 was admitted on [DATE] and discharged on [DATE]. The IM was provided on admission on 12/18/13 at 3:50 PM, there is no documentation the second notice required within 48 hours of discharge is provided to the Pt and/or their representative. This is confirmed in interview with DRM B on 2/3/14 at 4:30 PM, adding the noticed should be dated, timed and initialed by the Pt prior to discharge.

Pt #5's MR review on 2/3/14 at 1:50 PM revealed Pt #5 was admitted on [DATE] and discharged on [DATE]. The IM was provided on admission on 12/26/13, there is no documentation the second notice required within 48 hours of discharge is provided to the Pt and/or their representative. This is confirmed in interview with DRM B on 2/3/14 at 4:30 PM, adding the noticed should be dated, timed and initialed by the Pt prior to discharge.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of C/O, review of P&P and interview with staff (B), in 2 of 3 C/O's reviewed, filed on behalf of Pts #'s 1 and 6, the facility failed to ensure a response letter is sent to the C. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Review of facility P&P on 2/3/14 in the PM titled Patient Complaint and Grievance Policy dated 2/13 states under 2.f. "In the resolution of the grievance, the hospital provides in written format to the patient/patient representative 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 is communicated to the patient or the patient's representative in a language and manner the patient or the patient's legal representative understands."

Review of the C/O filed with the facility on behalf of Pt #1's and an 11/15/13 fall, that "staff were inattentive", Pt #1 was confused, bed was urinated in and not cleaned for an hour, and no bed alarm or fall bracelet on the Pt at time of the fall. The C/O is dated received on 11/18/13 via phone call. The status of the C/O is "closed" on 11/20/13 with a phone call contact with the family member. The 11/20/13 documentation on the closure of the C/O, by D C, includes "(family member) understood my answers and appreciated my time. (family member) would like a follow up call from Risk after our summary today." The report states it is "unknown" if it met the satisfaction of the C. There is no documented letter to the C indicating the steps of the investigation, and results of the investigation. This is confirmed in interview with DRM B on 2/3/14 at approximately 1:00 PM, adding per the facility policy this C/O was not considered a grievance and did not require a letter, that a verbal contact was sufficient.

Review of the C/O filed with the facility on behalf of Pt #6 alleging verbal abuse by an MD and an MD breach of confidentiality of Pt information with an unauthorized relative, and wanted the Pt "out of the hospital". The investigation documentation included evidence one MD was spoken to regarding the C/O, and the C/O was resolved to the satisfaction of the C. The record was closed on 1/31/14. There is no documented letter to the C indicating the steps of the investigation, and results of the investigation. This is confirmed in interview with DRM B on 2/3/14 at approximately 1:00 PM, adding per the facility policy this C/O was not considered a grievance and did not require a letter, that a verbal contact was sufficient, and resolution with C was documented.