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 record review and interview, the hospital failed to ensure the patient/patient representative was provided written notice of a decision, which included the name of the 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, when a resolution to a grievance was reached. This deficient practice is evidenced by failure of the hospital to ensure an effective grievance resolution system was in place which resulted in failure of the hospital to provide written notification of resolution of a grievance/results of a completed investigation, to a patient/patient representative for 2 (#1, #6 ) of 3 (#1, #6, #9) sampled patients reviewed for grievances.


Review of the hospital policy titled, "Grievance, Patient", Policy Number: RR-10, revealed in part:
Policy: All patient grievances will be investigated and the results of the investigation reported back to the complainant.
Definition: A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by the patient, or the patient's representative, regarding patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with CMS Hospital Conditions of Participation, or a Medicare beneficiary billing complaint related to rights and limitations provided by 42CFR 489.
A grievance is considered resolved when the patient is satisfied with the actions taken on his/her behalf or if the hospital has taken appropriate and reasonable action and followed CMS/State required processes.

Patient #1
Review of a grievance submitted by the family of Patient #1 revealed the grievance was dated 5/21/19 with the allegation that Patient #1 had not spoken to a psychiatrist since his admission on 5/17/19. Further review of document related to this grievance, provided by S4CCQA revealed no evidence a written response was provided to the patient or his representative.

In an interview on 6/26/19 at 12:38 p.m. with S1CEO, he verified there was no evidence that a response regarding resolution of the grievance had been sent to the complainant. S1CEO reported S5PA was responsible for Patient #1's grievance and had not yet received re-education on the grievance process that had been presented to other staff members on 5/23/19.

Review of a sign-in sheet for patient advocates that handle grievances, dated 5/23/19, and presented by S1CEO, revealed S5PA had not attended the in-service.

Patient #6
Review of the hospital's grievance log for 2019 revealed a grievance, dated 5/22/19 at 11:45 a.m., entered by S5PA, alleging physical abuse of Patient #6 due to the patient having bruises and a hand laceration. Further review revealed the patient had reported she had been "choked and the staff had tried to kill her, putting an elbow in her chest, another woman jabbed her and they wouldn't give her medical attention". Further review revealed the complainant also reported the hospital had failed to notify the patient's family of the incident resulting in the patient's injuries.

Review of the hospital's self-reports of allegations of abuse/neglect to LDH - HSS, revealed the allegation of physical abuse of Patient #6 had been self-reported to LDH-HSS on 5/22/19. Further review of the documentation related to the incident revealed an investigation into the allegation had been conducted and the alleged abuse had been unsubstantiated.

In an interview on 6/25/19 at 3:18 p.m. with S5PA, she indicated she remembered the complaint alleging abuse of Patient #6. S5PA indicated she had been told the allegation was a state issue and administration became involved because it was reportable as an allegation of abuse/neglect. S5PA indicated Social Services staff (7 total) were going to be rotating monthly in the role of Patient Advocate. S5PA indicated she had only been Patient Advocate for May 2019 and had not been trained for the duties she had been responsible for carrying out as Patient Advocate. S5PA also indicated she was unfamiliar with the grievance resolution process. She confirmed she had not sent a letter to the complainant because she had not known she needed to send a written response. S5PA confirmed as of 6/25/19 (at the time of the interview) she still had not received training regarding the grievance resolution process.

In an interview on 6/25/19 at 3:45 p.m. with S3CCNsg, she reported she had listened to the interviews during the investigation of the alleged abuse of Patient #6. She said S1CEO had called in the report after the allegation of physical abuse of Patient #6 had been made when the patient was being discharged . S3CCNsg confirmed the complainant and the patient/patient's representative had not received a letter upon completion of the investigation. S3CCNsg reported the hospital was presently looking into the hospital's complaint/grievance processes and revising the process to have more oversight by the PI Director with all grievances being reported to the PI Director. S3CCNsg indicated the PI Director would be the responsible party for responding, in writing, to grievances.