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 document review and interview, it was determined that for 1 of 2 (Pt #1) patient grievances, the Hospital failed to ensure that prompt filing of a patient grievance was followed.

Findings include:

1. The Hospital's policy titled, "Safety Event Analysis and Reporting Policy" (revised 7/9/19) was reviewed and included, "Patient Safety Events will be gathered, investigated and evaluated under a comprehensive review process ...PROCEDURE: Required Action Step 1. Notify care provider and immediate supervisor ..."

2. The clinical record of Pt #1 was reviewed on 10/17/19. Pt #1 was admitted on [DATE] with Sepsis (life threatening complication of an infection). A Physician's Progress Note dated 9/19/19 at 10:23 AM, included, "Physical Exam-General: thin frail male, unable to arouse, receiving nebulizer (medication in form of mist used to help treat respiratory diseases) treatment. Skin: warm, dry, no rashes. Skin breakdown to frontal forehead and nasal bridge due to BiPap (Bilevel Positive Airway Pressure-a breathing device used to treat sleep apnea, or lung diseases).

3. On 10/17/19 at approximately 12:50 PM, an interview was conducted with a Registered Nurse (RN-E #1). E #1 stated, "I did take care of this patient (Pt #1) on the day of discharge. I recall that Pt #1 was going to a Skilled Nursing Facility by ambulance. I got a call back later that night by the Nursing Home Nurse saying that Pt #1 was in worse condition than when Pt #1 left. The Nurse said that Pt #1's knee was dislocated and was sent to nursing home with paper towels in the rectum. I recall that Pt #1 had a scab on the bridge of nose, but I do not know when Pt #1 got it. It was skin breakdown because he had a BiPap mask on his face. Pt #1 was very rigid, and his knees were contracted, I did not notice any deformities or injury to knees or lower extremities when I did my assessment. I explained this to the Nursing Home Nurse over the phone and that was it, I did not report this to anyone. I do not have a reason why I did not report it but I should have. Our policy is to report any incident to our supervisor as soon as we become aware."

4. On 10/17/19 at approximately 1:00 PM, an interview was conducted with the Director of Medical Surgical Units (E #2). E #2 stated, "I was not informed of this incident by E #1, I received an email on 9/20/19 from our CNO (Chief Nursing Officer) about this incident that occurred on 9/19/19. The Ambulance Supervisor called to file the report, E #1 should have reported it when he became aware..."
Based on document review and interview, it was determined that for 1 of 2 (Pt #7) patient grievances, the Hospital failed to ensure that the patient was provided with written notice of the Hospital's investigation and results of the grievance process.

Findings include:

1. The Hospital's policy titled, "Review and Resolution of Grievances" (revised 07/2018) was reviewed on 10/17/19 and required, "Definitions:... "Grievance": A formal or informal written complaint... regarding the patient's care, abuse or neglect... Resolution of Grievances:... Within (7) days of receipt of any grievance, the reporter shall receive a written acknowledgement of receipt of the grievance... For all grievances, a Follow-up to the patient and/or their designated representative will include a written response... the author must provide adequate information to address each item stated below... The written report shall contain the following: i. Name of the contact person who addressed the grievance ii. A summary of the steps taken to investigate the grievance iii. The results of the process iv. The date of completion..."

2. The grievance report regarding Pt #7 was reviewed on 10/17/19 at approximately 1:00 PM. Pt #7 was admitted to the Hospital's Medical Surgical Unit (M1) on 7/19/19 with a diagnosis of syncopal episode (episode of dizziness) when standing up from a sitting position. The grievance regarding Pt #7, dated 7/24/19, included, "[Pt #7] had terrible care. There was a urine in unrinal bottom and no one wuld be emptying and there was nothing to wash his hands... [Pt #7] was not bathed, no water... Asked RN (Registered Nurse) for something to bath [Pt #7] and she tossed wipes at patient. States [Pt #7] got up at night because no one was around... no assistance when [Pt #7] did get a shower. Felt things were not in [Pt #7's] reach. No leader rounded... went to nurses' station and they were on their cell phones. Never walked [Pt #7] once and then wheel chair out to care and never walked..."

- The acknowlegement letter, dated 7/24/19, that was sent to Pt #7, completed and signed by the Director of the Medical Surgical Unit (E #2), was reviewed on 10/17/19 at approximately 1:10 PM and included, "I wanted to acknowledge the concerns you expressed... Your experience will be addressed with the staff involved in your care..."

- The grievance report indicated that E #2 called the reporter of E #7's grievance on 7/24/19 and discussed the concerns addressed in the grievance. The grievance report did not include any documentation of the steps taken to investigate the grievance.

- The grievance report included that the grievance status was changed to "resolved" on 7/25/19.

3. An interview was conducted with E #2 on 10/17/19 at approximately 1:45 PM. E #2 stated that this grievance was investigated. E #2 stated that all of the staff involved in Pt #7's care were interviewed and re-educated on the patient care concerns identified in the grievance. E #2 stated that there was no documentation of these interviews or re-education, and no follow-up letter was sent to Pt #7.

4. An interview was conducted with the Regional Director of Accreditation (E #4) on 10/17/19 at approximately 1:50 PM. E #4 stated that there should be documentation of the investigation of a grievance, and a follow-up letter should be sent to the patient regarding the resolution of the grievance.