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, document review, record and policy review, the facility failed to inform a patient whom to contact to file a grievance in 1 of 20 charts reviewed (patient #3). Findings include:

Record and Document Review:
On 10/15/12, a review of the clinical record of patient #3 indicates she was admitted on [DATE] and discharged on [DATE].

A physician progress note dated 4/13/12, documented "She [patient #3] reported that on her first night of admission here that she heard a young male screaming and crying that 'I am not a girl, I am a guy, please don't do it to me' and said it repeatedly. She believes that this person was 'raped.' The social worker is aware of it and was going to notify the recipient rights person. We will follow up on that."

A social work & group progress note dated 4/13/12 at 12:20 pm, documented that patient (#3) had reported to her doctor that she believed that someone was raped on 4/4/12 or 4/5/12. It was further documented on 4/13/12 at 12:30 pm, that the social work director informed the unit manager and director of nursing that patient (#3) had reported to her doctor that she believed someone was raped on 4/4/12 or 4/5/12.

A group therapy note dated 4/21/12, documented, "Patient...making accusations of multiple rapes on the unit...Social worker informed charge nurse of patients worker informed by RN that pts (patient's) allegations were already investigated, found to be false, and appear to be symptoms of paranoia."

On 10/16/12 at approximately 10:00 am, an incident report for patient #3 dated 4/13/12 was reviewed. On 4/13/12, the social work director had completed the incident report and indicated on that same date that the director of nursing #1, risk manager #1, adult unit manager #1 , and recipient rights officer (RRO) #2 were all informed of the incident.

On 10/16/12 at approximately 9:00 am, RRO #1 was requested to provide any and all grievances pertaining to patient #3. There was no grievance addressing the alleged rape on 4/4/12 or 4/5/12.

On 10/16/12 at 4:50 pm, a "Patient Safety Council Report" dated 5/10/12 was reviewed. The report documented that risk manager #1 had investigated the "complaint made by adult female patient regarding belief that she could hear an unknown male peer being sexually assaulted during the night shift (April). Classified as Customer Relations Complaint- no known victim...referred to Recipient Rights Advisor."

On 10/16/12 at 2:00 pm, RRO #1 was queried regarding the incident report filed on 4/13/12 on behalf of patient #3. RRO #1 stated, "I was on vacation" so RRO #2 would've taken care of it.

On 10/16/12 at 2:10 pm, RRO #2 was queried regarding the incident report filed on 4/13/12 on behalf of patient #3 and whether there was a grievance file. RRO #2 stated, "No, all I did was talk with the patient (#3). I talk with patients every time I walk through the units...I haven't even been to training yet, I'm new in this role."

On 10/17/12 at 8:50 am, risk manager #1 was queried if there was an investigation of the incident alleged by patient #3 that took place on 4/4/12 to 4/5/12. Risk manager #1 stated, "I personally reviewed the security tapes for a 1 week period and observed nothing out of the ordinary." He also interviewed staff and determined the incident was, "unsubstantiated."

Facility Policy:
Policy:ADM-I-035A (revision date 2/12) states, "For the purposes of this policy, a grievance is defined as an allegation involving a violation of a patient's rights,...or any complaint that cannot be promptly resolved by staff present."... 6. "The facility staff person should express concern and empathy for the patient's condition and assure him/her that immediate attention will be given to the problem. If the complaint cannot be resolved the staff person should instruct the patient to complete a Recipient Rights Complaint form...or assist the patient in completing the form, and if necessary, assist the patient in calling the Recipient Rights Advisor line at extension #128."

The facility failed to inform this patient, who was reaching out to several staff members within the facility, whom to contact to file a grievance.