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 staff interview, record review and facility policy review the facility failed to follow up with a complaint on a grievance made concerning a family member.

Review of document entitled " Patient Grievance " revealed the purpose is to provide guidance in a process for timely, reasonable and consistent response to grievances expressed by patients about the care and services provided ... ...Patient Grievance is a written complaint (including an electronic mail to hospital web site) by a patient or the patients representative regarding the patients care, abuse or neglect, issues related to the hospitals compliance with the center of Medicare and Medicaid services Hospital Conditions of Participation, or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489 ....It may also be a verbal complaint( when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient or patients representative, regarding the patients care, abuse or neglect, issues related to hospitals compliance with the CMS Hospitals Conditions of Participation ... If a verbal patient care complaint cannot be resolved at the time of the care by staff, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance ....A person of the Grievance committee or designee will attempt to establish personal or telephonic contact with the person to patient to confirm that the hospital has received the grievance and will be addressing it within Seven (7) business days of the receipt of the grievance. at the conclusion of any review and information gathering regarding the patients grievance, a letter will be sent to the patient outlining investigative efforts of the hospital and the results of the process ..... Depending on the complexity of the grievance, the hospital will attempt to conclude the grievance process by a written response a letter within 30 days of the receipt of the Grievance.

During an interview on 05/30/19 at 10:00 AM, Daughter #1 revealed on 4/18/1`9 she contacted the facility DON (Director of Nursing) with her aforementioned concerns. Daughter #1 asked the DON to investigate and get back with her on these concerns to let her know if they were substantiated or unsubstantiated. As of today (May 30 2019) the DON has not contacted her.

During an interview on 05/30/19 at 3:30 PM, the DON revealed she did not consider Daughter #1 ' s complaint a grievance but thought she was just mainly reporting a concern over Narcotic Diversion. SA then read the definition of a grievance from the State Operations Manual and then the DON confirmed the verbal complaint made by Daughter #1 was a grievance. Then State Agency asked DON if she was following the Facility Policy concerning grievances and she said no.

During an interview on 05/30/19 at 3:35 PM, the Facility Risk Manager revealed she would of considered Daughter #1 ' s telephone comp0laint a grievance and would of warranted a response. She revealed she was not employed with the facility at that time and the Facility was without a Risk Manager because of the exiting of the prior one a couple months ago.