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, the facility failed to provide written resolution of a grievance on closed abuse investigations in 3 (#5, #17, #19) of 10 cases reviewed, resulting in the potential for loss of patient rights. Findings include:

On 11/18/19 at approximately 1300, review of the facility Grievance Log provided for the past six months (5/2019 - 11/2019) revealed open and closed cases, five of which included allegations of potential patient abuse. Interview with Risk Manager N, on 11/18/19 at 1400, verified that patient #5's allegation of abuse was not on the Grievance Log, nor on the Occurrence Log (incident report log). On 11/18/19 at 1405, Risk Manager N stated that grievances were usually handled through the Patient Experience Department, but Risk Management was notified of case #5 and they coordinated the investigation. A request for all allegation of abuse cases (staff to patient) handled through Risk Management for the past six months was requested.

On 11/19/19 at 0930, interview with the Patient Experience Manager L revealed that when her department was made aware of grievances of potential patient abuse, it was tracked, investigated and notice of resolutions were provided. On 11/19/19 at 0935, Manager L stated she was not made aware of patient #5's allegation of abuse.

On 11/19/19 at 1030, interview with Risk Manager N and Risk Manager O provided verbal summaries of file review information on investigations of five additional closed abuse allegation cases. Three (#5, #17 and #19) of the five closed allegation of abuse cases included:

Patient #5 alleged a male caregiver fondled the patient's breast on 9/30/19 when assisted to the bathroom.
Patient #17 alleged a male caregiver fondled the patient's breast on 6/28/19 when placing EKG leads on (cardiac chest monitor lines).
Patient #19 alleged a male caregiver fondled the patient's breast on 4/17/19 while the patient was on hallucinogenic drugs.

Further interview with Risk Managers N and O, on 11/19/19 at 1115, revealed that these cases were unsubstantiated, but resolution letters were not provided to the patient or responsible party.

On 11/19/19 at 1400, review of the facility policy titled "Grievance and Complaint Management, dated 4/19, page 3" documented "Regardless of the nature of the grievance, the hospital will make sure that it is responding to the substance of each grievance while identifying, investigating, and closing any deeper, systemic problems indicated by the grievance. The hospital will also document when a grievance is so complicated that it may require an extensive investigation...However, in all cases the Patient Experience Department must provide a written notice (response) to each patient's grievance(s)." This had not been done.