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.

COMMUNITY BEHAVIORAL HEALTH HOSPITAL - BEMIDJI 800 BEMIDJI AVENUE NORTH SUITE 200 BEMIDJI, MN Nov. 21, 2014
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and interview, the hospital failed to follow their grievance policy including providing written documentation to a patient of the actions taken to investigate the grievance, the name of a hospital contact person, the results of the grievance process, and the date of completion for 1 of 3 (P1) patient grievances reviewed.

Findings include:

Interview with the administrator on 11/19/2014, at 2:30 p.m. during a tour of the unit, the administrator stated the hospital had received a grievance from P1 through P1's case manager. According to the administrator, two weeks following P1's discharge from the hospital, P1's county case manager contacted hospital staff to inform them of P1's grievance. P1 revealed to staff at another hospital that she had consensual sexual intercourse with another patient in a TV lounge area of the hospital. P1 indicated she felt threatened and coerced by the male client into having intercourse. The administrator said because the grievance was received following P1's discharge from the hospital no investigation into the grievance and no written notification of the results of the investigation were provided to P1.

During a tour of the unit on 11/19/2014, at 2:10 p.m. the TV lounge area where P1 said she had sexual intercourse with a male client was located approximately 25 feet to the left of the nurses station. The door to the room locked and required a badge to unlock the door. The inside of the room was not visible from the nurse's station, had a window where patients could be seen only when standing, and did not have camera monitoring.

Review of the hospital's policy and procedure titled Grievance and Complaint Process dated 6/27/2014, stated all verbal and written complaints regarding abuse, neglect, client harm or facility compliance with regulations were considered grievances. In every procedure, if a grievance was not resolved or a review not completed within specified timeframe's, the facility must inform the patient and/or legal representative that the facility was working to resolve the grievance. The facility would follow-up with a written response to the patient within 7 days. The facility must respond to the substance of the grievance and identify, investigate and resolve any systemic issues related to the grievance.