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 document review, interview, and policy review, the hospital failed to complete a grievance investigation within the designated time frame for one of two grievances reviewed. Failure to respond to patients creates feelings of distrust and insignificance by patients and denies them the ability to fully exercise their rights.

Findings include:

Review of the Complaint and Grievance log on 05/09/18 showed Patient #27 issued two grievances to the hospital. The first grievance was dated 05/17/17 and the second was dated 02/28/18. Review of the follow-up conducted for each grievance showed the 05/17/17 was finalized with a letter of resolution mailed to the patient on 05/23/17.

Review of the follow-up conducted for the second grievance showed a letter dated 03/13/18 stated the hospital would conduct a review of the grievance and respond to the patient within 45 days.

During a telephone interview on 05/09/18 at 12:15 PM, Staff V, Registered Nurse (RN), Patient Relations, stated she remembered both complaints issued by Patient # 27 and her husband on 05/23/17 and 02/28/18. She stated she did not remember why she notified Adult Protective Services (APS) after the initial complaint was made but did remember visiting with police (KUPD). Regarding the 02/18/18 complaint she referenced the final letter she mailed to the patient dated 03/13/18 stating an investigation of the grievance had begun and that the patient would be contacted within 45 days with results. Staff V stated she forwarded a copy of all the listed agencies the patient had contacted with complaints about her care to risk management (RM) along with a copy of the letter she sent to the patient. The agency complaint list had been sent with complaints to the hospital. No documentation of follow up was available.

During an interview on 05/09/18 at 12:30 PM, Staff A, Director of Risk Management (RM), stated that RM did not have a record of the grievance or documentation of follow-up regarding the grievance. She stated the plan going forward is to do a full investigation.

During an interview on 05/09/18 at 12:45 PM, Staff W, RN, Director of Patient Relations, stated she was aware of the first complaint issued by Patient # 27 in 2017 but did not really remember it. She further stated she had not spoken directly to the patient or her husband. She had reviewed the documentation of the 2nd complaint of 02/28/18 and "realized the hospital missed the 45-day window of opportunity to respond". She stated the plan going forward is to get with Staff V and "get a response to the patient by the first of next week".

Review of the hospital document titled, "Patient Rights Document," undated, showed the patient has the right to be informed of a response to a complaint.

Review of the hospital document titled, "Patient Rights and Responsibilities," revised 02/18, showed all staff are responsible for preservation of each patients' rights.

Review of the hospital document titled, "Management of Patient/Family Complaints and Grievances", revised 05/18, showed quality of care grievances related to standards of care are to be referred to RM and a resolution letter will be sent to the patient or patient's representative that included the name of the hospital, contact person, steps taken on behalf of the patient in the investigation process, results, and date of completion.