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 Patient record review and interview the facility failed to ensure grievances were addressed for 2 (Patient #11 and Patient #12) of 3 sampled patients for grievances.

The findings included:

The facility form titled " ...Hospital complaint/Grievance log" included a "description" section, an "action taken" section and a "Status: Substantiated (S) or Unsubstantiated (U)" section.

Review of the grievance log for 11/17 revealed on 11/24/17 Patient # 11 reported witnessing a staff member hit a patient. The "action taken" section indicated the Patient Advocate met with patient and referred the case to the Risk Manager for full investigation. Risk Manager met with patient and conducted investigation. The "status" section of the form documented the grievance was unsubstantiated.

Review of the investigation for the grievance filed by Patient #11 on 11/24/17 revealed a typewritten statement with a date of 11/24/17 at 10:33 a.m., and a received date of 11/27/17 at 9:00 a.m., was signed by the Patient Advocate. The form indicated Patient # 11 said after breakfast she witnessed a female mental health technician push a male patient when he was throwing away trash in the dayroom.
The Patient Advocate documented that due to the nature of the grievance the case was transferred to the Risk Manager for full investigation.

On 1/9/18 at 2:35 p.m. the Risk Manager said she could not locate the interview conducted with Patient # 11 or her notes on the investigation. She stated "I guess I am not doing a good job at documenting my interviews".
She provided the surveyor with incident report forms and witness statements describing a patient to staff altercation on 11/26/17 and 11/28/17. The Risk Manager said she had no information regarding the alleged incident of 11/24/17. She concluded the Patient Advocate must have entered the wrong date on the log and on her statement.

On 1/8/18 at 3:00 p.m. a record review and interview conducted with the Risk Manager revealed a handwritten "Grievance/Complaint Received by Staff" form dated 11/24/17 and signed by Patient # 11. The patient complained about being forced medications against her will more than once. The disposition section of the form was blank. The Risk Manager said she wasn't aware of this particular grievance.

Review of the grievance log for November 2017 revealed on 11/29/17 Patient # 12 reported staff did not intervene when a patient was aggressive with another patient. The log indicated the grievance was received on 11/30/17. The "action taken" section of the grievance log documented the Patient Advocate met with the patient and provided the information to the Chief Nursing Officer. The log further indicated the staff denied the incident. The facility logged the complaint as unsubstantiated.

A typewritten statement with a date of 11/29/17 at 9:00 a.m., and a date received of 11/30/17 at 9:00 a.m., was signed by the Patient Advocate. Documentation on the statement included Patient # 12 said that another patient was entering patients' bedrooms and pushing/hitting patients. Patient # 12 said the staff present that night was not intervening.

A handwritten "Grievance/Complaint Received by Staff" form dated 11/29/17 at 9:30 a.m., lists Patient # 12 as the complainant. Patient # 12 wrote that a patient came into her room crying and saying that another female patient hit her. Patient # 12 said a female staff member was in the room at the time of the alleged incident.

Interview on 1/8/18 at 3:35 p.m. with the Risk Manager revealed the Chief Nursing Officer would have documentation of the full investigation.

Interview on 1/8/18 at 4:30 p.m. with the Chief Nursing Officer revealed she did not recall being involved in any investigation related to Patient # 12 but will reach out to the staff mentioned in the grievance.

The facility was not able to provide documentation of the steps taken to investigate and reach the conclusion that the allegation was unsubstantiated.