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 interview, the review of grievance policy and Grievance Committee minutes, it was determined that the facility's Governing Body did not demonstrate effective oversight of the grievance process. Specifically, the governing Body did not: 1) delegate in writing the responsibility for the operation of the grievance process to the Grievance Committee and, 2) ensure prompt resolution of grievances.

Findings include:

1. At interview with Staff #2 on 8/5/15 at 9:45 PM, she stated the Governing Body delegation of the Grievance Committee is evident in the policy and procedure for complaints and grievances. Staff #2 added that the Grievance Committee reports monthly to the "Quality Care Executive Committee" and those reports are forwarded quarterly to the Governing Body through the Medical Executive Committee.

The review of the policy titled "Responding to Patient Complaints and Grievances" revised on 5/13/14 notes that the policy was prepared by the Director of Patient Relations and approved by the Chief Operating Officer, Chief Nursing Officer, and Chief Medical Officer. The policy lacked evidence of Governing Body approval of the grievance process, and the authorization it provided to the Grievance Committee to review and resolve grievances.

2. The review of the "Grievance Committee minutes for June and July 2015 noted that the Grievance Committee measures the timeliness of grievance resolution against a 30-day timeframe and not the seven-day timeframe specified in the initial acknowledgement letter to complainants.

The June 2015 minutes notes that the three grievances received in May 2015 were resolved within 30 days. The July 2015 minutes notes four of the six grievances received in June 2015 were resolved within 30days and remaining two grievances are pending resolution. It was noted that none of the nine grievances received in May and June was resolved within the seven-day timeframe indicated in the formed acknowledgement letter to complainants

Based on interviews, the review of facility's grievance policy and other documents, it was determined the facility did not ensure its grievance policy is developed to assure timely resolution of grievances. Specifically, the grievance policy did not specify timeframes for the resolution of grievances. This is evident in 5 of 5 grievance files reviewed (Files #1, #2, #3, #4, #5,).

Findings include:
File #1 revealed a grievance was filed on 5/12/15 regarding delay care of two pediatric patients who (MDS) dated [DATE] with exacerbation of asthma. The complainant also alleged unprofessional conduct by a pediatric physician.

A written acknowledgement letter was sent to the complainant on 5/12/15 that notes, "We will investigate and respond to you within 7 days. A second letter was sent out to the complainant on 5/19/15 indicating the investigation is in progress and "we will notify you in writing of the outcome when the investigation is completed no later than June 11, 2015." The response to the grievance was issued by the facility on 6/11/15, approximately one month from the date of intake on 5/12/15.

File #2 revealed the patient made a verbal complaint on 6/8/15 alleging physical abuse by a staff member he identified as Hospital Police,while he was in the Psychiatric Emergency Department. Although video footage reviewed on 6/8/15 by the Director of Hospital Police did not validate issues described by the complainant, the investigation remained open. On 6/24/15, two weeks after the verbal complaint was made, three Hospital Police Officers each gave detailed description of the incident, which revealed officers assisted in escorting a patient that attempted to elope back to the psychiatric ED.
At interview with Staff #1 on 8/5/15 at approximately 11:30 PM, she stated the patient did not want a written response but insisted in meeting with the Director of Hospital Police. She reported the meeting was held on July 27, 2015 and the patient was satisfied with the facility's response.
There were delays in the investigation of this grievance. Although the issues of the complaint were not verified on 6/8/15, it took another two weeks to obtain a written statement from Hospital Police Officers. The grievance remained opened until a meeting with the patient on 7/27/15; this was approximately seven weeks after the grievance was documented.

File #3 notes a grievance filed by a patient on 6/30/15 alleging delay evaluation and management of urinary retention. The complainant noted he waited three hours for urology evaluation and he was in discomfort and pain.
The Patient Relations Department report indicated the grievance investigation was completed on 7/6/15 by the Urology Department. However, the provision of a response to the complainant was completed nineteen days after on 7/25/15.

In file #4, patient's daughter complained on 6/9/15 that her mother reported she was physically mistreated the previous day by a nurse who pinched her buttock. The patient's daughter acknowledged that her mother is confused and suffers from dementia.
The acknowledgement letter sent to the patient's daughter on 6/9/15 promised a written response in seven calendar days; however, another letter written by the facility on 6/16/15 deferred the provision of a response to 7/9/15. The grievance file revealed a response letter was sent to the complainant on 7/7/15; approximately one month after the complaint was filed.

Similar findings were noted in file #5 that demonstrates a pattern of noncompliance with providing a written response to grievances in no more than 30 days. The grievance for File #5 was filed 5/18/15 and the provision of a response was one month later on 6/18/15.

The facility's Administrative policy and Procedure Manual titled "Responding to Patient Complaints and Grievances" last revised on 5/13/14 notes, "If the Patient Representative is unable to complete the investigation (of a grievance), the Patient Representative will send a memorandum to the department involved requesting that a written response with the findings and corrective action should be sent to the Patient Relations Department within seven (7) calendar days of the initial complaint "

While the policy indicates seven (7) calendar days for the completion of grievance investigation, it failed to specify timeframes for provision of timely response to complainants.

At interview with Staff #1, Director of Patient Relations on 8/4/15 at 2:45 PM she stated that upon receipt of a grievance, an acknowledgement letter is sent out that explains the grievance process and the timeframe for resolution of the grievance. She stated that seven calendar days is the timeframe indicated in the initial acknowledgement letter to the complainant; however, if the facility is unable to complete the investigation within the timeframe indicated, a second letter is sent to the complainant indicating a written response will be sent on a specified date. She stated that the date specified in the second letter to the patient is always within 30 days of the receipt of the grievance.

The review of the "Grievance Committee Meeting" minutes for June and July 2015 noted that none of the nine grievances received in May and June was resolved within the seven-day timeframe indicated in the formed acknowledgement letter to complainants.