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.

FORT MEMORIAL HOSPITAL 611 SHERMAN AVE E FORT ATKINSON, WI 53538 June 12, 2019
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on record review and interview the facility failed to ensure there was documentation on notification of patient rights for inpatient hospital stays in 10 of 10 medical records reviewed (Patient #'s 1, 2, 3, 4, 5, 6, 7, 8, 9 & 10) in a total universe of 10 inpatient medical records reviewed.

Findings include:

Per interview with Manager of Inpatient Services C on 6/10/2019 at 2:15 PM "We don't have a policy on patient rights. Patients are given a copy in the admission folder in their room but we don't document anywhere that the patient received them. I agree with you. It's not happening."
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, the hospital failed to ensure it provided patients/patient representatives with a written grievance response containing the required regulatory elements, in 4 of 5 (Patients #1, 11, 13, 14) patient grievance files reviewed out of a total sample of 5 grievance files reviewed.

Findings include:

On 6/10/19 at 11:00AM, review of hospital policy titled, "Complaints and Grievances," last reviewed on 05/04/2018 revealed, "...2. Unresolved Complaint Process...a. When the complaint is not resolved to the satisfaction of the patient/family at the time of the complaint, if it is postponed for later resolution or is referred to other staff for later resolution, or if it requires further investigation or action for its resolution, the complaint becomes a grievance...3. Grievance...c. A written response will be sent to the griever within (10) days of receipt of the grievance with a summary of the investigation, findings, and resolution and the name and phone number of the person who the patient may contact should they have further concerns. A copy of this letter shall be scanned and become part of the Clarity report on the complaint...1. If an investigation and subsequent resolution letter cannot be completed within the ten (10) day timeframe, the Manager/Director or Sr. [Senior] Director/VP [Vice President] involved will send a follow-up letter to the griever informing the patient/family that an investigation has been initiated and a summary of the investigation, findings and resolution are forthcoming...2. The Manager/Director will send the final grievance response letter to the patient/representative no later than fourteen (14) days from the time of the receipt of the complaint to the griever..."

On 6/10/19 at 11:41AM, the facility's electronic complaint files were reviewed with Quality Director D who confirmed the following:

Review of Patient #1's complaint file titled, "Healthcare Safetyzone...Event Number 3," revealed the complaint was received via face to face contact and entered on 10/18/18. Further review revealed the mailed follow-up letter sent by the facility was dated 10/30/18, 12 days after the receipt of the complaint.

Review of Patient #11's complaint file titled, "Healthcare Safetyzone...Event Number 2," revealed the complaint was received via mail and entered on 4/5/19. Further review revealed the mailed follow-up letter sent by the facility was dated 4/23/19, 18 days after the receipt of the complaint.

Review of Patient #13's complaint file titled, "Healthcare Safetyzone...Event Number 2," revealed the complaint was received via telephone and entered on 3/15/19. Further review revealed the mailed follow-up letter sent by the facility was dated 5/17/19, 63 days after the receipt of the complaint.

Review of Patient #14's complaint file titled, "Healthcare Safetyzone...Event Number 0," revealed the complaint was received via telephone and entered on 9/17/18. Further review revealed no follow-up letter was sent to Patient #14.

During an interview on 6/10/19 at 11:46AM, when asked about the delay in sending the follow-up letters, Quality Director D stated, "we contacted them all by phone within 5 days." When asked to review the procedure outlined in the facility policy, Quality Director D stated, "you're right; letters were not sent within the 10 days."