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 interview and record review the facility failed to follow the facility Complaints/ Grievances Policy when a verbal complaint involving abuse and neglect was not documented and investigated.

Findings Include:

During an interview on 1/22/16 at 2:57 p.m. by telephone, Family #1,the daughter of Patient #1, stated she had made a verbal complaint on 9/25/15 after entering Patient #1's room and finding Patient #1 attempting to the out of bed. Patient #1 was crying and told Family #1 the facility's staff would not answer call lights and assist her to the bathroom. Patient #1 reported to Family #1 that a facility nurse Staff #3 was rude and shoved and pushed Patient #1 while providing care. Family #1 stated the bed alarm, did not alarm, and was not used to prevent Patient #1 from trying to sit up to get out of bed. Family #1 stated she talked to the administrator that evening, but the administrator never called her back and Family #1 did not receive a written notice from the facility regarding the resolution of the complaint.

Review of Physician's Summary for Patient #1 reflected an [AGE] year old female admitted on [DATE] with a diagnosis of Lumbar laminectomy (back surgery) with impaired ADL (activities of daily living) and post-operative bladder retention.
Postop patient has been receiving physical therapy, occupational therapy requiring contact guard to minimal assist with the transfers and ambulation with a walker about 20 feet. Postop confusion.

Review of the facility provided policy Patient's Rights (revised 7/17/15) reflected:
Patients at the hospital have the following rights, to the extent allowed by law
-The right to receive care in a safe setting ...
- The right to complain about service or file a grievance regarding their care according to the hospital Grievance Policy and Procedure, and to receive Notice of Right to File a Grievance.

Review of the facility provided policy Resolution of Patient Complaints/Grievances (dated 9/15) reflected
I. PURPOSE: To establish a process for initiation, review and resolution of patient complaints.
II. POLICY: A "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by the patient and/or family representative regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, or issues related to the hospital's compliance with CMS Hospital conditions of Participation.
- All verbal or written complaints regarding abuse, neglect, patient harm, or hospitals compliance with Medicare Conditions of Participation are considered grievances.
III. PROCEDURE: C. Patient Grievances
1. Role of the employee
a. Complete an incident report at the time of the identification of a patient grievance
b. Forward the incident to their immediate supervisor for action
2. Role of the employee supervisor
a. Immediately react and either
i.) Notify the department manager that can resolve the issue OR
ii.) Contact the patient/facility regarding the follow up action AND
iii.)Notify the risk manager of the grievance.
b. Document on, or in an attachment to, the incident report actions taken.
E. Communication of grievance resolution
1. The administrator will provide a written notice of the decision involving the grievance
2. this written notice will be provided at the earliest time possible, but should not exceed 14 days.

During an interview, in the afternoon on 1/25/16 in the conference room, Staff #1, RN, MSN, Nurse Manager, when asked about the complaint, he stated, "I don't remember. Vaguely, god that was so long ago I don ' t remember the content of the conversation or complaint. I can't tell you what point in the visit that I visited with them. I feel like after the conversation, if there was a residual bad feeling, they would contact me again, so I feel like it was resolved at the point I left. I feel confident in our ability to resolve complaints." When asked about anything written regarding this complaint, he stated, "No, I usually don ' t write it up. I usually maintain contact with them and make sure everything continues to be ok. I feel like this one was resolved."

During an interview on 1/25/15 at 4:00 p.m. in the conference room, Staff #9, RN, Chief Nursing Officer, after reviewing the facility Grievance Complaint policy, confirmed the facility did not follow the policy.