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 and record review, the facility failed to provide for one of one patients reviewed (Patient #1) a written notice of decision following Patient #1's representative/mother complaint that occurred on 06/02/2018 regarding an allegation of verbal and physical abuse by an unknown facility employee towards Patient #1.

Specifically as of 06/26/2018, Patient #1's representative/mother had not received resolution of her grievance or a written response from the facility with adequate information to include steps taken on behalf of Patient #1 to investigate the grievance, the results of the grievance process, the date of completion in accordance with the facility Grievance Policy.

The deficient practice affected Patient #1's rights when the facility failed to resolve Patient #1's representative/mother grievance related to the allegation of verbal and physical abuse of Patient #1 by unknown facility staff.

Findings included:

Review of facility Patient Advocacy/Conflict & Grievance Resolution policy, effective November 2010 and last revised April 19, 2018, revealed, in part:

"For the purpose of this policy, a grievance is defined as a "patient grievance" when: 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 hospital 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.

If the complaint cannot be satisfied during the initial conversation with the patient or family member, the complaint becomes categorized as a grievance and the Patient Advocate must be notified.
a. This notification can be through submission of the Patient Grievance Form or via a telephone call to the Patient Advocate providing him/her with the information contained in the Patient Grievance Form, including:
i. patient name; ii. name of party initiating grievance; iii. contact information for the complainant; iv. date and time that complaint was first made; and v. detail of the concern and what was discussed with he person making the complaint.

The Patient Advocate will then facilitate the investigation and resolution of the grievance through a complete investigation conducted by the Patient Advocate or by an appropriate member of the leadership team.

The Patient Advocate responding to the grievance shall inform the patient or family the timeframe within which he/she shall expect follow-up. The time frame shall not exceed 7 days unless there are extenuating circumstances, at which the point the patient shall be notified of the need for an extended time and an agreement made as to when follow up shall occur.

Once the issue has been resolved, the Patient Advocate shall provide a timely written response to the patient and/or family member. The response shall include: a. the name of the contact person; b. the steps taken to investigate the grievance; and c. the results of the grievance process (i.e. how the grievance was resolved).

Review of the Department of State Health (DSHS) Complaint Intake Form, dated 06/26/2018, revealed that Patient #1's representative/mother made a verbal complaint through the Department of Family and Protective Services (DFPS) hot line on 06/03/2018. She alleged that on 06/01/2018 Patient #1 (her son) wanted to call her. He got 10 minutes on the phone. Two men grabbed him hard from the wrist and the chest. He had a bruise on his rib cage, scratches on his back and cuts on the sides of his wrists. She stated the facility is aware of her complaint. She stated he was admitted to the facility on [DATE] and removed by her on 06/02/2018.

Review of Facility Abuse/Neglect/Allegation Response Plan, signed by the Director of Risk Management on 06/04/2018, revealed but was not limited to the following: "At 1400 on 06/02/2018, supervisor was notified of patient (Patient #1) being discharged AMA (against medical advise) by mother. 1730 supervisor was notified by admissions that SAPD (city police) dropped off a case number in reference to mother pressing charges against the facility for assault on her child (Patient #1). RN (registered nurse) called Patient #1's unit to debrief with the charge nurse on the unit who wrote a statement based on what the mother related that patient (Patient #1) was assaulted Friday 06/01/2018 on the 3-11 shift.

Review of facility self-report to DSHS, reported on 06/03/2018 by the facility Director of Risk Management, revealed but was not limited to the following: "This is the case of a 7 year old male who reported to his mother on 06/02/2018 that a facility staff member yelled at him and pulled him by his arm on 06/01/2018. Neither the patient (Patient #1) or the mother was able to give a time of the incident or the description of the staff member that pulled him by his arm. The child's mother appeared on 06/03/2018 to discharge him AMA based on allegations that were made. The Abuse/Allegation Neglect Form was completed, a self-report was made and interviews were conducted with staff members. The LVN reported that at no time was the kid "grabbed". She reported that he was allowed to make additional calls because he was constantly crying. The charge nurse reported that she checked the patient for bruising prior to him exiting with his mother. The Director of Risk Management (DRM) conducted a camera review for the day beginning at noon. At no time was the DRM able to see a staff grabbing the child aggressively or yelling at him."s

Interview with Patient #1's representative/mother on 06/27/2018 at 8:00 AM revealed but was not limited to the following: " she confirmed that she made a verbal complaint to the nursing staff at the facility on 06/02/2018 when she removed Patient #1 from the facility AMA. She stated that her verbal complaint included allegations of verbal and physical abuse by unknown facility staff towards Patient #1. She stated that as of this date she has not received any written notification from the facility regarding the status of her complaint (defined as a grievance by facility policy).

Interview on 06/28/2018 during the exit conference, facility administrative staff confirmed that no one at the facility sent a written notice to Patient #1's representative/mother that contained the name of hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.