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 record reviews and interviews, the facility failed to investigate a complaint lodged by patient #1's parent/guardian and/or did not inform the parent/guardian of the results of her written complaint. This could effect all patients/patient family members who file a complaint at the facility.

Findings include:

Review on 09/05/12 of a letter sent to the facility by patient"1's parent/guardian revealed that she was writing the letter to file a "formal complaint against the facility." The letter alleged the facility provided inadequate care to her sixteen year old daughter (patient #1) who was admitted to and discharged from the facility on 07/03/12. The parent stated she was "appalled and immediately removed her" after she was sent to the medical emergency room twice in the same day by the facility. The parent stated "I attempted to call the patient advocate but that person was out until Thursday morning at 8:00 AM because of the July 4th holiday. I then asked to speak to someone because the level of care was deplorable". She indicated she spoke with the nursing supervisor but she indicated she was not satisfied with the response she received from the nursing supervisor. The parent alleged in her written complaint "the facility and level of care the staff provided is deplorable and the upper levels of personnel are lazy, unprofessional, incompetent, and flat out rude." The parent gave her name, address, telephone number, and email address in the letter.

Interview on 09/05/12 at 11:45 AM with patient #1's parent/guardian revealed that "she would like the facility to explain their procedures and admit to their lack of care for her daughter". She stated that she had sent the facility the same letter she sent to the regulatory agency. She further stated that she had called the patient advocate two times asking for contact but never received a call back from anyone at the facility.

Interview with the facility director of risk management on 09/05/12 throughout the course of the complaint investigation revealed the following: She confirmed the facility received a letter from patient #1's parent/guardian that was the same letter reviewed by this surveyor. She stated she was on vacation during the time this letter would have been received by the facility. She stated she believed the patient advocate attempted to call the parent but did not receive a return phone call from the parent. She stated the patient advocate did not document her attempts to contact patient #1's parent/guardian. She stated that if a patient/patient's family makes a written complaint, they log in the complaint, take action, and let the complainant know the results of the facility findings regarding the complaint. She confirmed this did not occur after this complaint was received.

Review on 09/05/12 of facility policy entitled Patient Advocacy/Conflict and Grievance Resolution, last reviewed by the facility in January 2012, revealed the following: "The patient advocate shall respond to complaints and grievances within 3 days of receipt." A grievance was defined as "a written or verbal report, the nature of which prevents it from being resolved within 3 days of receipt and involves the patient's care, abuse, neglect, issues related to rights. All reports in which the patient or family requests a written report from he facility shall be considered a grievance. The response shall be as follows:
i. Immediate measures will be taken to ensure the safety of a patient if the grievance involves perceived immediate danger.
ii. The CEO will be informed immediately of the grievance.
iii. A preliminary investigation of the grievance will be conducted by the Patient Advocate or designee, who shall, under the direction of the CEO convene the Grievance Committee.
iv. A written response shall be provided to the individual within seven days informing them of resolution of grievance of status of the investigation.
v. The nature of the grievance shall be classified for trending."