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 review of hospital policies/procedures and interviews, it was determined the hospital failed to evaluate the quality and effectiveness of the complaint and grievance process. This deficient practice poses a risk to the health and safety of patients when patient/patient representatives' complaints are not investigated or evaluated in a timely fashion to allow corrective actions to improve the quality of care.

Findings include:

Policy titled "Swing Bed: Patient Rights" revealed "...The Rights include...To be encouraged to exercise his or her rights as a patient and citizen, and to be permitted to make complaints...."

Policy titled "Patient Concern, Complaint and Grievance Resolution Process" revealed the facility "...recognizes the right for all patients to express concerns, complaints or grievances about the care and service they receive and to have those complaints addressed in a timely fashion...Concern Process:...upon satisfying the patient or representative, the concern is considered closed...Complaint Process...The Quality/Risk Manager will log the complaint into the electronic database and forward the complaint...for investigation...Within 72 hours the supervisor or manager will conduct an investigation and attempt to resolve the complaint...C. If the issue cannot be resolved within 72 hours at the unit/department level...the Quality/Risk Manager...will date and designate the complaint as a Grievance... Grievance Process...B. For Medicare Patients, an acknowledgement generated by the director or chief officer within 7 business days of the grievance being filed by the patient or representative...The director or chief officer will provide ongoing contact to the patient or representative as needed during the investigation process until the grievance is resolved...G. the patient or representative is notified of the final grievance resolution within ninety (90) days of the grievance being received (actual date noted) by the director or chief officer in writing...."

Employee #1 confirmed during an interview on 10/20/20 that an e-mail was received from the patient's representative on 02/12/20 and that was considered a complaint. Employee #1 did respond to the patient's representative within 7 days, on 02/19/20 via e-mail and mail informing the representative that an investigation would follow.

Employee #37 confirmed during an interview on 10/21/20 that the patient's representative e-mailed the Chief Medical Officer (CMO) on 02/19/20. The CMO forwarded the message to Employee #37 on 02/20/20. The Unit Manager investigated and responded on 02/26/20. It was further confirmed that the complaint became a grievance when there was no resolution and yet there was no further communication with the patient's representative. Telephone calls had been placed to the complainant but none were returned. Employee #37 further confirmed that no one had contacted the complainant since the letter of 02/19/20. This employee confirmed that there was a breakdown in the system and that the Quality/Risk Manager was not correctly notified of the complaint. It was further confirmed that it had been greater than 90 days and the complainant should have been notified of the findings and determination of this grievance.