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.

BAYPOINTE BEHAVIORAL HEALTH 5800 SOUTHLAND DRIVE MOBILE, AL Jan. 12, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interviews, medical record review and review of the hospital's grievance investigation and grievance/complaint policy and procedure, the hospital failed to provide written notification of the results of a grievance investigation dated 12/3/10.

This deficient practice affected Patient Identifier PI # 1, one of ten sampled patients.

Findings Include:

Medical Record Review:
PI # 1 was transferred from Hospital # 2 status post surgery and admitted to Hospital # 1 on 11/24/2010 with diagnoses to include Major Depression and Generalized Anxiety Disorder.

Documentation in a Progress Note, dated 11/26/2010, reveals PI # 1 was "... angry about... perceptions of staff attitudes."

Review of Hospital # 1's "Consumer Interaction Report," dated 12/3/2010, reveals that a complaint was received by Employee Identifier (EI) # 1, Coordinator Consumer Needs, from PI #1 ("the consumer.")

This report includes: "Details: The consumer called (Hospital # 1) and left a voice mail message for (Administrator)." The "consumer" reported a voluntary admission due to depression. PI # 1 reports being assigned numerous discharge diagnoses, including "opioid addiction." PI # 1 denies drug use. PI # 1 is "very unhappy with the treatment received at Hospital # 1, was treated like a dog and wanted to discuss all the problems with" the Hospital.

In response, EI #1, Coordinator Consumer Needs, reportedly called PI # 1 on 12/3/2010 to discuss the patient's concerns and noted, "The consumer was afforded the right to file a formal grievance."

The Coordinator documented that PI # 1 reported Hospital staff, "particularly the aides that sit out in the hallway in chairs," are rude, curse, and sleep. PI # 1 complained, "They sit out there and cuss up an down the hall. They also sleep...and the nurses sleep at the nurses' station."

EI # 1 documented that the patient expressed concern about the Hospital's "discharge information under home care instructions" related to drug abuse. According to PI # 1, the instructions directed the patient, "to keep away from illegal drugs." PI # 1 denied drug abuse. PI # 1 was status post surgery and was prescribed pain medication. PI # 1 complained that, "Nursing staff (at Hospital # 1) acted as if they did not want to give the medication" as prescribed because they (nursing staff) "thought...(PI #1) was a drug abuser." PI # 1 provided a physical description and a first name of a nurse related to the medication complaint. EI # 1 documented that the patient, "Could not provide this writer with names of staff members from the unit."

PI # 1 felt staff did not listen to the reported concerns and described the inpatient stay at Hospital # 1 as, "Absolute hell."

Response from Hospital to PI # 1:
On 12/10/2010, EI # 1 contacted PI # 1 to advise the patient that Hospital "leadership" were "informed" of the complaint. PI # 1 was informed that "staff are trained to treat consumers (patients) with dignity and respect. PI # 1 was also informed that (Hospital # 1), "Has 5 star customer service training for staff to improve consumer and staff relationship."

According to EI # 1's documentation, PI # 1 was advised:
1) Some medication identified by PI # 1 in the complaint, is not available from the pharmacy registry;
2) Nursing staff denied refusing any prescribed medications;
3) "All medications listed on the consumer (patient) medication list were available" as "prescribed by the doctor on the unit."

"Consumer (PI #1) acknowledged understanding of resolutions but conveyed concern about services."

There was no evidence that PI # 1 was provided a written response to this grievance or notice of the hospital's resolution of the complaint/grievance.

Interviews:

During a telephone interview on 1/12/2011 at 1:40 PM, Employee Identifier (EI) # 1/Coordinator Consumer Needs, verified responsibility for the investigation of PI # 1's complaint. Because the patient complained about the aide's behavior, the Coordinator was asked the reason for not interviewing any of the aides. The Coordinator said no aides were interviewed because PI # 1, "Did not identify particular staff." PI # 1 reportedly said it was "all aides." EI # 1 says she forwarded the complaint to the Director of Nursing and the Administrator. However, there is no documentation in the hospital's investigative report that Administration was notified of PI # 1's grievance. The Coordinator verified no written response regarding the outcome of the investigation was provided to PI #1.

During an interview on 1/3/11 at 3:30 PM, PI # 1 stated, "They talked down to everyone and mistreated everyone." PI # 1 stated the aides, "Sat outside of patient rooms with their feet in another chair and laughed, talked and treated patients terribly." PI # 1 reported the concerns about staff on the day of discharge. This staff person allegedly replied, "I'm sorry you feel that way." PI # 1 stated there has been, "No follow up from the hospital" related to the submitted grievance.

Policy and Procedure Review: "Policy # CR 1.13
Subject: Complaint and Grievance Procedure
Effective Date: 8/88 Revised: 7/09"

"Policy: Any consumer...has the right to file a formal complaint/grievance as a notice of dissatisfaction with Hospital # 1...A series of three steps are involved in the procedure. Consumers shall have the right to proceed through each step.."

"Procedure: "(Name of Hospital) shall have in effect the position of Consumer Needs Specialist and the standing committee of Consumer Needs for the purpose of handing consumer complaints/grievances..."

"Step I:
A. All oral or written complaints shall be routed to the Consumer Needs Specialist to be appropriately classified, logged and documented. The Consumer Interaction Report form shall be utilized for routing complaints/grievances to the Consumer Needs Specialist. A log of all complaints shall be submitted bi-monthly...

B. The Consumer Needs Specialist shall document the nature of the consumer's complaint and subsequent findings/recommendations for
resolution of the complaint...on the form...

C. After a determination is made regarding the complaint, the consumer shall be provided with a response within ten working days of the proposed actions for the resolution of the complaint.

D. The consumer shall be given the opportunity to respond to the proposed plan for resolution. The consumer response shall be documented on the Consumer Interaction Form - Step 1.

E. Should the proposed resolution be deemed unsatisfactory by the consumer, the Consumer Needs Specialist shall forward the form to the
Chairman of the Consumer Needs Committee for the initiation of Step 2 within 5 working days.

Step II:
A. Upon receipt of the ...complaint..., the Consumer Needs Committee
shall review the complaint, proposed resolution and shall gather additional information...as may be needed for investigating and responding to the complaint. The Committee shall respond to the consumer within ten working days of receipt of the complaint. The response shall include additional (if appropriate) actions to be taken to facilitate resolution.
B. The consumer shall be given the opportunity to respond to the proposed...resolution...
C. Should the ...resolution be deemed unsatisfactory by the consumer, the Committed shall forward the form to the CEO for the initiation of Step 3 within 5 working days.

Step III:
A. Upon receipt of the ..complaint...the CEO shall review the complaint, proposed resolution and...gather additional information as...needed for investigating and responding to the complaint. The CEO shall respond to the consumer within 30 days of receipt of the complaint...
B. The findings and recommendations of the CEO shall be final."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interviews, medical record review and review of the hospital's grievance investigation and policy and procedure, the hospital failed to thoroughly investigate an allegation of verbal abuse of patients by staff. This deficient practice affected Patient Identifier, PI # 1, one of ten sampled patients.

Findings Include:

Medical Record Review:
PI # 1 was transferred from Hospital # 2 status post cardiac surgery and admitted to Hospital # 1 on 11/24/2010 with diagnoses to include Major Depression and Generalized Anxiety Disorder.

A Progress Note, dated 11/26/2010, reveals PI # 1 was "... angry about... perceptions of staff attitudes."

Review of Hospital # 1's "Consumer Interaction Report" dated 12/3/2010:
"Details: The consumer called (Hospital # 1) and left a voice mail message for (Administrator)." PI # 1 is "very unhappy with the treatment...received" at Hospital # 1, "was treated like a dog" and wanted to discuss all the problems with the facility (Hospital # 1)..."

In response, the Coordinator Consumer Needs, reportedly called PI # 1 on 12/3/2010 to discuss the patient's concerns and noted, "The consumer was afforded the right to file a formal grievance."

The Coordinator documented that PI # 1 reported Hospital staff, "particularly the aides that sit out in the hallway in chairs," are rude, curse, and sleep. PI # 1 complained, "They sit out there and cuss up an down the hall. They also sleep...and the nurses sleep at the nurses' station."

PI # 1 felt the staff did not listen to the reported concerns and described the stay on the unit at Hospital # 1 as "absolute hell."

Response from Hospital to PI # 1:
"12/10/2010, this writer, (EI # 1) contacted consumer (PI # 1) and informed" the patient that hospital "leadership was "informed" of the complaint. EI # 1 documents that the patient was "informed" that "staff are trained to treat customers with dignity and respect. EI # 1 also "informed" the patient that (Hospital # 1), "Has 5 star customer service training for staff to improve consumer and staff relationship."

"Consumer acknowledged understanding of resolutions but conveyed concern about services."

Although the complaint alleged verbal abuse by staff, a review of the hospital's investigation revealed no documentation of interviews with any of the behavioral aides. Only two nurses were interviewed regarding PI # 1's concerns.

Policy and Procedure Review: "Policy # CR 1.13
Subject: Complaint and Grievance Procedure
Effective Date: 8/88 Revised: 7/09"

"Policy: Any consumer...has the right to file a formal complaint/grievance as a notice of dissatisfaction with Hospital # 1...A series of three steps are involved in the procedure. Consumers shall have the right to proceed through each step.."

"Procedure: "(Name of Hospital) shall have in effect the position of Consumer Needs Specialist and the standing committee of Consumer Needs for the purpose of handing consumer complaints/grievances..."

"Step I:
A. All oral or written complaints shall be routed to the Consumer Needs Specialist to be appropriately classified, logged and documented. The Consumer Interaction Report form shall be utilized for routing complaints/grievances...A log of all complaints shall be submitted bi-monthly...

B. The Consumer Needs Specialist shall document the nature of the consumer's complaint and subsequent findings/recommendations for
resolution of the complaint...

C. After a determination is made regarding the complaint, the consumer shall be provided with a response within ten working days of the proposed actions for the resolution of the complaint.

D. The consumer shall be given the opportunity to respond to the proposed plan for resolution. The consumer response shall be documented on the Consumer Interaction Form- Step 1.

E. Should the proposed resolution be deemed unsatisfactory by the consumer, the Consumer Needs Specialist shall forward the form to the
Chairman of the Consumer Needs Committee for the initiation of Step 2 within 5 working days.

Step II:
A. Upon receipt of the ...complaint..., the Consumer Needs Committee
shall review the complaint, proposed resolution and shall gather additional information...as may be needed for investigating and responding to the complaint. The Committee shall respond to the consumer within ten working days of receipt of the complaint. The response shall include additional (if appropriate) actions to be taken to facilitate resolution.
B. The consumer shall be given the opportunity to respond to the proposed...resolution...
C. Should the ...resolution be deemed unsatisfactory by the consumer, the Committed shall forward the form to the CEO for the initiation of Step 3 within 5 working days.

Step III:
A. Upon receipt of the ..complaint...the CEO shall review the complaint, proposed resolution and...gather additional information as...needed for investigating and responding to the complaint. The CEO shall respond to the consumer within 30 days of receipt of the complaint...
B. The findings and recommendations of the CEO shall be final."

During a telephone inerview on 1/12/2011 at 1:40 PM, Employee Identifier (EI) # 1/Coordinator Consumer Needs, verified responsibility for the investigation of PI # 1's complaint. Because the patient complained about the aide's behavior, the Coordinator was asked the reason for not interviewing any of the aides. The Coordinator said no aides were interviewed because PI # 1, "Did not identify particular staff." PI # 1 reportedly said it was "all aides." EI # 1 says she forwarded the complaint to the Director of Nursing and the Administrator. However, there is no documentation in the hospital's investigative report that Administration was notified of PI # 1's grievance. The Coordinator verified no written response regarding the outcome of the investigation was provided to PI #1.

During an interview on 1/3/11 at 3:30 PM, PI # 1 stated, "They talked down to everyone and mistreated everyone." PI # 1 stated the aides, "Sat outside of patient rooms with their feet in another chair and laughed, talked and treated patients terribly." PI # 1 reported the concerns about staff on the day of discharge. This staff person allegedly replied, "I'm sorry you feel that way." PI # 1 stated there has been, "No follow up from the hospital" related to the submitted grievance.