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 facility documentation and staff interviews, the facility failed to follow its grievance process for 1 of 10 patients (Patient #1).

Findings were:

A verbal complaint was received by the facility regarding the care received by Patient #1 by Staff #3, an RN. In an interview with Staff #2, the facility CEO, on the morning of 9/10/15 in the facility meeting room, he stated, "When I got a call from the mother of [Patient #1], I said I'd look into the matter...The mother had asked for a call back. And I promised her I would call her back once I looked into it. I said I was sorry this happened and it wouldn't happen again. She wanted me to tell her that I'd fired the nurse. I called her back and she wanted to know exactly what had happened. I said I couldn't disclose that to her...When I called the mother back, she seemed satisfied. She didn't seem angry. But I have no documentation of any of the follow-up I did or of the conversations,"

In a telephone interview with the patient's mother, at 10:31 a.m. on 9/10/15, she stated, "I spoke to the CEO...I called him. He called me back and he said, "I took care of it." I asked him, "How did you take care of it?" He said [RN, Staff #3] wouldn't work anymore...I was not satisfied. I'm still not satisfied..,"

Facility policy #RI-200 entitled Grievances: Patient & Family; The Role of the Patient Advocate," last reviewed 1/20/2014, stated in part: "A "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a 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 the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489...

5. The hospital will review, investigate and attempt to resolve each patient's grievance within a reasonable time frame...The timeframe for the resolution of the grievance may fluctuate depending on the nature and complexity of the grievance. All attempts will be made to address the grievance as early as possible. On average, the hospital will adhere to a timeframe of 7 days for the provision of a written response...

6. Written response to the person filing the grievance will include:
a. the name of the contact person,
b. the steps taken to investigate the grievance on behalf of the patient,
c. the results of the grievance process, how the grievance was resolved,
d. the date of completion of the investigation,
e. the process to follow if the patient/complainant is not satisfied with the response...

7. The grievance will be logged into the Grievance Log by the Patient Advocate or designee.

8. The hospital Grievance Committee will convene as necessary to review grievances...

10. If a grievance is received from legal counsel or regulatory authority it will be forwarded directly to the CEO, who is a member of the Grievance Committee. The Committee will delegate investigation to the appropriate staff members..,"

These findings were again confirmed in an interview with the CEO and other administrative staff on the afternoon of 9/10/15 in the facility meeting room. The CEO acknowledged the facility's patient grievance process had not been followed for the complaint made on behalf of Patient #1.