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 review, document review and staff interview it was determined the facility failed to ensure prompt resolution of a patient grievance in one (1) of one (1) record reviewed (patient #1). Failure to ensure all staff follow the facility grievance policy has the potential to negatively impact all patients who report an issue with staff care and no investigation is conducted to resolve the issue.

Findings include:

1. A review of the medical record for patient #1 revealed an admission date of [DATE] to the behavior health unit at the facility. Patient #1 had a history of intellectual disability, bipolar disorder and homicide/suicide threats. She had acting out behaviors of hitting staff, threatening staff and other patients and verbal abuse to staff and other patients. She had a total of three documented seclusion periods where she was locked in a room until she had calmed down. The last documented seclusion was on 7/2/18 at approximately 5:24 p.m. She had calmed down enough to be removed from the seclusion room at approximately 6:01 p.m. Review of Physician #1's note for the debrief of the patient at the end of her time in seclusion on 7/2/18 at 6:11 p.m. revealed it stated in part: "Patient also reported that she was bruised as she was placed in seclusion, and did show me some areas of bruising on her right arm/biceps, 3-4 1 centimeter marks around the size of fingertips." Registered Nurse (RN) #1's documentation for 7/2/18 at 6:01 p.m., when the seclusion was stopped, stated "Dr. [name] on unit. Though patient reported no issues previously when seclusion was D/C, she now reports bruising to right arm to Dr. Will continue to monitor."

2. The facility policy titled "Patient Grievances" with a publication date of 2/16/17 defined a grievance to "include all verbal complaints regarding the patient's care." It further states "All grievances will be documented using the Quantros Feedback Manager with a timely and appropriate review conducted."

3. In an interview with Physician #1 on 8/1/18 at approximately 9:50 a.m. the above documentation and incident was discussed. He stated the patient told him she felt she had been handled rougher than she should be. He stated the patient showed him some bruises/red marks on her upper arm and said to him, "they were too rough with me." His documentation of the debrief process after the incident, documented what he just confirmed in interview. When asked if he reported the patient's grievance that she had been handled too roughly and had bruises, he stated "No. I apologized to her." He stated he did not document the patient's grievance per facility policy.

4. In an interview with Registered Nurse #1 on 8/1/18 at approximately 9:10 a.m., the above documentation and incident was discussed. She stated she did see bruises on patient #1's arm and stated "the day before staff had a rough time getting her in seclusion due to her out of control behavior." When asked if she reported the patient's grievance per facility policy that she had bruises, she stated "No." She stated she did not document the patient's grievance per facility policy.