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 review of facility documentation and employee interviews (EMP), it was determined that the facility failed to comply with its established process for grievances for one of one grievances identified.

Findings include:

Review, at approximately 2:36 PM on September 24, 2018, of Policy RI 58, "Patient Complaints and Grievances," published September 15, 2017, and Administrative Policy #091, "Patient Complaints and Grievances Version Two Hospital Addendum - Sharon Regional Health System," reviewed May 2016, revealed, "... Policy Number: RI 58 ... Procedure ... D. Receipt, Investigation and Resolution ... 4. Documentation: All grievances will be entered into the [Corporate Owner] Complaint database inclusive of all investigation information, follow-up meetings, communications with colleagues and documentation of final resolution with the patient. ... Hospital Addendum - Sharon Regional Health System Patient Complaint/Grievance - Administrative #091 ... Procedure: ... 4. Data collection/tracking of complaints/grievances is done on a database in the Patient Advocate's office. The issues and their resolution are recorded on a complaint log so that the information and the volume and nature of patient complaints are available for internal performance measurement activities. ..."

1. Review, at approximately 10:00 AM on September 18, 2018, of the Complaint/Grievance Log from May 2018-current, did not reveal documentation of the grievance filed by OTH1.

2. At approximately 10:21 AM on September 18, 2018, after being informed of the nature of the investigation, EMP1 stated, "We [administration] did talk to that [complainant] ... so they [EMP6 and EMP3] did know about it. ..." When asked why the grievance did not appear on the Complaint/Grievance log, EMP1 stated, "Because the patient never complained ... and they [administration] didn't know who the patient was ..."

3. When asked, at approximately 12:53 PM on September 19, 2018, why the grievance from OTH1 was not referenced on the Complaint/Grievance log, EMP3 stated, "Because it is not a formal grievance yet. I cannot put anything into the [complaint database] without a patient name. It requires a name, date of birth, date of event and [OTH1] was not willing to provide any of that information to us. ..."

4. At approximately 2:58 PM on September 24, 2018, EMP1 confirmed that the facility's grievance database application does not permit entry of a grievance without a patient's name.

5. When asked, during an interview conducted at 10:42 AM on November 8, 2018, if EMP2 had been aware of the facility's receipt of the complainant's concerns, EMP2 confirmed, and further added, "... It was Thursday ... [EMP6] called us [management] up immediately with this complaint letter ... to do some research. ... They [administration] were actually going to make a phone call to the complainant to try to get some more information. ..."