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 a review of documentation and hospital policies and procedures, and based on interviews with facility staff members, it was determined that in one of two records reviewed, Patient #1, the hospital failed to assure that patients, or patients' representatives, received an appropriate, timely, and formal written response from the hospital, including the name of a hospital contact person, steps taken on behalf of the patient to investigate the grievances, the results of the grievance process, and the date of completion, in response to a grievance that was lodged verbally.

Findings include:

A complainant alleged that an incident took place in the hospital on [DATE] at approximately 0600 hours involving Patient #1 and Patient #2.

The medical record for Patient #1 contained the following information:

A document titled: "Physician Progress Note" dated 3/11/11, and timed 1045, contained the following: "Upset (with) a peer for playing prank on him," and "Feels victimized, 'I can use the tools now.' "

A document titled: "RN Daily Reassessment/Progress Note" dated 3/11/11 and "shift-days" contained the following information:

"Pt (patient) became hostile and makes verbal threats toward peer after getting (his/her) shorts pulled down by that particular peer. Staff mediated incident, (name) Program Director interviewed each client individually about pranks that have been going on around the unit. Pt regained control of anger and stated (s/he) will not act out violently. Will continue to monitor. Patient in meeting with counselor, nurse, and program director to discuss the inappropriate incident from this morning. Pt was able to maintain a calm attitude during the meeting."

A document titled: "Physician Progress Note" dated 3/12/11, timed 1400 contained the following: "I feel validated by (name of Program Director)."

The medical record for Patient #2 contained the following:

"RN Daily Reassessment/Progress Note" dated 3/11/11 and "shift-days" contained the following information:

Patient met with counselor and (name) Program Director, regarding inappropriate behavior with peer. Patient states (s/he) was not intending to be inappropriate but to be funny. Patient agreed to be more aware of personal boundaries."

A history and physical assessment dated [DATE], timed 7:30 a.m. contained the following:
"Date of Discharge: 03/15/2011" and, "(S/He) got caught up in some inappropriate behavior, i.e. writing provocative notes to females. One incident that stands out is the fact that (s/he) pulled down another soldier's pants which the patient thought was funny. Later on that same day, (s/he) got into a physical confrontation with a young soldier about somebody sitting in (his/her) chair. Because things were escalating, (s/he) had to be transferred to unit with civilians. (S/He) did not have any further incidents of acting out behaviors while downstairs."

A review of the hospital's incident reports and grievances for March of 2011 was completed, revealing 25 "Customer Communication Forms" and 38 "Risk Management/Incident Reports." A Risk Management-Incident Report dated 3/18/11 contained the following:
"DATE OF INCIDENT" section had been left blank.
"TIME OF INCIDENT" section had been left blank.
The front of the Risk Management/Incident Report was divided into three sections. The first section documented the date of the report, the names of the two patients involved, Patient #1 and Patient #2, the sex of Patient #1, but areas for the diagnoses, the names of the attending physician and information about whether the physician and family/guardian had been notified had been left blank. The second section, which contained two check-lists with the headings "Patient Care Incident" and "Environment Incident" had also been left blank. The third section contained the following: "How were you informed of the incident: Staff informed (name of Program Director) that (Patient #2) pulled (Patient #1)'s pants down and (Patient #1) indicated that (s/he) was unhappy with the way reacted (sic)." This statement was signed by the Director of Performance Improvement on 3/18/11, but a time was not indicated on the form.

The back of the Risk Management-Incident Report was divided into two sections. The first section included: "ADDITIONAL INFORMATION, EVALUATION, AND/OR RECOMMENDATION: Met with the patient who was very upset with the staff, indicating that (s/he) felt they minimized the situation. Processed with the patient and was able to sit with the patient and 1 counselor to discuss and resolve (his/her) anger. Staff apologized for (his/her) perception that they were not taking (him/her) seriously and (s/he) accepted their apology. Also spoke with the patient's (spouse) to report the event and how it was being handled. The patient's (spouse) reported that (s/he) was OK with the way we were processing and handling the patient. Also talked with the patient who pulled the patient's pants and moved (him/her) to another unit (to South) . Also called the patient's commanding officer to report the incident." This entry was signed by the Program Director and timed and dated 0915 18 March 2011.

The second half of the back of the Risk Management-Incident Report contained the following:
"CNO FOLLOW-UP AND RECOMMENDATIONS: Excellent follow-up by (Program Director), who talked with the pt at length and then followed up with staff and contacted AOC. No further action required. PI (Performance Improvement) also met with patient and (Program Director) and patient indicated resolved by later in the week, Meeting took place on about 3/18/11." This section was signed by the Director of Performance Improvement with the following notation:
"Late entry for 3/31/11." Below this, the date "7/15/11" had been written.

An electronic mail received from the PI on 08/18/11 at 1332 hours contained the following information regarding the Risk Management Incident Report: "...and below are answers to your questions:
How many incidents? There was one incident documented on 03/11/11
Why was the late entry dated 03/31/11? Late entry was dated on 03/31/11, because that was the day I received the report back to PI."

In an interview with the Chief Operations Officer (COO) on 08/17/2011 at 1025 hours, the COO stated that the definition of 'assault' was: "If somebody hits you," and the definition of 'sexual assault' was: "When somebody puts their hands on you that has a sexual connotation and you perceive it as unwanted, and you can determine the intent to harm." Asked of one person could sexually assault another person verbally, the COO stated, "I don't know; I don't know the law well enough." Asked to define the difference between a Customer Communication Form and a grievance, the COO stated that the Customer Communication form was usually given to a patient by a nursing supervisor, and that this form was usually used if a patient wished to speak with a patient advocate. The COO stated that if the Customer Communication could be resolved "at the unit level," then it was considered a complaint, and not a grievance.

A document titled: "Customer Communication" with a "flow process" which described the steps in order to resolve a "Customer Concern," contained the following:

"Can customer concern be immediately resolved by unit staff right (sic). No, Contact RN (Registered Nurse) Supervisor, Not Resolved, RN Supervisor starts a Customer Communication form, RN alert DON/(Director of Nursing)/COO/Risk Manager of further investigation, RN Supervisor completes additional investigation and documents outcomes on form, discuss with patient, Not Resolved, Complete documentation and send to DON/COO who will forward to PI once complete. PI will alert CEO (Chief Executive Officer) of risk issues/ongoing complaints and grievances. Note: if the complaint is not resolved at the COO level, this now becomes a grievance."

The "flow process" above directs that after three prescribed attempts to resolve a complaint, the complaint them becomes a grievance.

During the interview with the COO on 08/17/2011 which began at 1025 hours, the COO stated that s/he recalled an incident on March of 2011 when one patient had "pantsed" another, clarified to mean pulling a person's pants down revealing what was or was not underneath. The COO stated that his/her recollection of the incident was that the patient who had his/her pants lowered was "embarrassed and mad," and that most to the patient's anger had been directed at the staff, who the patient felt had minimized the situation. When asked if Patient #1 had filed a grievance related to this incident, the COO stated that s/he had not. When asked if Patient #1 had been offered or completed a Customer Communication Form related to the incident, the COO stated that s/he had not done that either. When asked why the incident had not been considered a grievance, the COO stated that the incident had been "resolved at the unit level, and stopped there. This was not a grievance, and we had no indication that (Patient #1) wanted to file a complaint," and that "(Patient #2) didn't touch (Patient #1), s/he just pantsed him." When asked why Patient #2 had been transferred to another unit after the incident, the COO stated: "There are many reasons to transfer a psych patient. They get in each other's faces, or they may be a better fit on another unit."

At 1030 hours on 08/17/11, the Director of Performance Improvement (PI) entered into the interview with the COO. Asked if any of the 25 Customer Communication Forms had resulted in a grievance as recognized by the hospital, the PI stated that none had, as they had all been resolved at the unit level. The PI stated, "We weren't even aware that (Patient #1) thought (s/he) had been assaulted until long after." Asked if any of the 25 Customer Communication Forms had resulted in a follow-up letter to the patient, the PI stated that as none had risen to the level of a grievance, a letter had not been sent.

An interview with the Program Director on 08/17/11 at 1130 hours revealed that the Program Director recalled this incident. The Program Director stated, "I remember hearing a commotion, and it was (Patient #1) yelling at the staff. He was really upset at the staff. This is the only time we've had this happen. (Patient #1) thought the staff didn't take (his/her complaint) seriously. Another patient pulled (his/her) pants down, but not all the way. I dealt with the aftermath. The patient was fine, (the spouse) was fine, and the commander was OK. We moved the other soldier. It was a bantering thing, it's what soldiers do. Afterward, (Patient #1) said, 'I'm OK with it.' " The COO, also present during this interview, stated, "Sexual assault never came up while (Patient #1) was a patient here. Washington County came in and looked at the charts, and they found no grounds. The military investigators came in, and they found no substantial claims against Cedar Hills."

Centers for Medicare and Medicaid Services defines a "grievance" as "a formal of informal written or verbal complaint that is made to the hospital by the patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with CMS Hospital Conditions of Participation (COPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489."

By this definition, it is the determination that Patient #1 filed a grievance.

The hospital failed to provide appropriate follow-up to a grievance, as required by this regulation.
Please see the citation located at Tag 0123, which describes a grievance lodged by Patient #1, who had received care in a setting that was both physically and emotionally unsafe. The patient has the right to receive care in a safe setting, as required by this regulation.