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.

ESSENTIA HEALTH ST MARY'S MEDICAL CENTER 407 EAST THIRD STREET DULUTH, MN 55805 Nov. 26, 2019
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the facility failed to follow their own policy and respond in an appropriate time frame for 1 of 2 patients (P6) who had filed grievances.

Findings include:

P6's grievance dated 11/4/19, indicated R6 thought she was sexually assaulted when she was in the hospital. An internal email indicated P6 alleged two males entered her room to do a "four point inspection," and they touched her all over her body. P6 also reported this to her primary care provider on 11/4/19. P6 couldn't remember many details about her stay and didn't think about it at the time, but as time has passed, P6 came to believe she was assaulted.

The grievance documentation titled Feedback by File ID dated 11/4/19, indicated internal investigation, but there was no documentation of a letter being sent to P6 within seven days of the grievance to indicate the hospital was still working to resolve the grievance. There was no documentation of communication between P6 and hospital staff during the investigative process. The Feedback by File ID indicated P6 was explained the policy of "Four Eyes on Skin" during a telephone call P6 made to the facility on [DATE], and that an internal investigation had been completed. P6 asked for a copy of the policy and was denied this. The file indicated P6 "seemed satisfied at this time." There was no documentation of written closure to P6.

On 11/22/19, at 4:02 p.m. in a telephone interview, the complainant stated P6 had called the facility on 11/4/19, on 11/5/19, and again on 11/6/19, and the hospital hadn't call P6 back yet. The complainant stated P6 had been having a difficult time emotionally since this incident, with symptoms of post-traumatic stress disorder (PTSD), and had also called the police.

On 11/26/19, at 10:47 a.m. RN-A stated the Four Eyes on Skin policy was a new hospital procedure just to see if a pre-existing skin injury or pressure sore existed, and was a standard part of the admission assessment. RN-A stated they tell patients why they do the assessment, and then ask if they can do a head to toe assessment to ensure their skin was okay. RN-A stated P6 didn't refuse the exam. RN-A stated P6 was quiet and nice. RN-A stated there were no issues during the exam, nor after, when RN-A brought P6 her medications.

On 11/26/19, at 11:43 a.m. in a telephone interview, P6 stated the policy needed to be more carefully monitored, and patients need more of an opportunity to say no. P6 stated she had not heard back from the facility in regards to her concern, and that she had called several times. P6 stated she had not gotten a call back nor any written response from the hospital.

On 11/26/19, at 12:11 p.m. RN-C stated he investigated P6's grievance, and interviewed both nurses, and did not determine anything inappropriate happened.

On 11/26/19, at 1:00 p.m. the director of patient relations (DPR) stated she had told staff that they don't have to write a letter 100% of the time when letting a patient know the outcome of their grievance. DPR stated staff could make a call to the patient, and then just document that the call was made. The DPR also stated sometimes the unit manager would call the patient, and sometimes it would be her department, but it all depended on the circumstances. The DPR stated they attempted to respond within 7 days, and to ask for extensions if the issue was more complicated. The DPR stated this issue was forwarded to the department manager for investigation. The DPR stated it wasn't presented to the patient in a way P6 could understand, and staff would want to be particularly attentive to how it was presented to a patient. The DPR stated they attempt to resolve grievances within seven days.

On 11/26/19 at 2:19 p.m. the patient relations specialist (PRS) stated P6 called for an update on 11/18/19, and was told she could not get a copy of an internal policy, and the facility had investigated the incident. The PRS stated she would have called or written P6 if P6 hadn't called. The PRS confirmed she hadn't contacted P6 from when she first received her grievance on 11/4/19, until P6 called back on 11/18/19. The PRS indicated she considered the 11/18/19, phone call with P6 closure to the complaint.

The facility's Grievance Process, Patient-Patient's Representative Policy dated 12/5/16, directed a grievance could be a verbal complaint by a patient, a telephone compliant, or a complaint regarding abuse, neglect, patient harm or facility compliant with CMS requirements. The policy further directed grievances would be investigated promptly, and whenever possible written response would be sent within seven (7) working days. If the most effective communication method for follow up was oral, then a written summary would be sent following the oral discussion.