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 interview and record review the facility failed to follow their procedure for complaints and grievances investigation and resolution for one (#1) of three patients reviewed for complaints and grievances out of a total sample of 11, resulting in the potential for unresolved grievances and the denial of patient rights.

A review of the medical record for patient #1 was conducted on 1/11/2021 at 1215 and revealed the patient (MDS) dated [DATE] at 2319 for a complaint of a mental health crisis. The patient was discharged on [DATE] at 0128.

On 1/11/2021 at 1515 a review of the facility's Complaints/Grievance logs were reviewed with the Director of Patient and Guest Relations (Staff I) and revealed the patient of concern #1 had filed a grievance on 11/25/2020.

A review of the correspondence with the complainant and Staff I was reviewed and revealed the following:
On 11/25/2020 (lst letter sent out to the complainant): "...Your concerns are being shared with the appropriate leaders for review and investigation. You will receive a written follow-up letter at the completion of this investigation, within 30 days...If I may be of further assistance to you, feel free to call me at (office number for Staff I)..."

On 1/11/2021 at 1530, during an interview Staff I was asked to prove evidence that documented an investigation had been conducted, and evidence that a follow-up letter had been mailed out to the complainant that noted the completion of an investigation and the outcome of their findings. At that time, Staff I said I don't have anything. She said I contacted the Interim Emergency Department (ED) Director (Staff D) and the (ED) Nurse Manager (Staff E) on 11/25/2020 and they never responded.

Staff I further stated, "I received another grievance from the complainant (#1) on 12/29/2020 regarding the same concerns." Staff I stated, "I emailed the letter to the same people, (Staff D and Staff E) and they have yet to respond.

On 1/12/2021 at 1445, during an interview the Chief Nursing Officer confirmed that Staff D and Staff E were responsible for investigation and follow-up of the patient's grievances.

Review of the facility's "Patient & Family Complaints and Grievances" policy dated September 1, 2020 documented:
C. Patient Grievance:
1. Complaints meeting the definition of a grievance are forwarded to the manager/director of the affected or involved department for investigation and resolution.

2. If the grievance is determined by the manager/director to be a patient rights violation or standard of care breach, the manager/director forwards a copy of the Patient and Family Complaint/Grievance report to the Director, Clinical Quality Improvement (DCQI) or the Patient Safety Officer enacts the bill hold process and completes an event report (see Clinical Safety Policy CO-2.008) Event Reporting).

3. The seriousness of the grievance drives the response times.
-Grievances should be resolved and the patient notified of the response in 7 days. (Note: allegations of abuse or neglect are managed in accordance with time frame of policy RCC-4.60.

-If the resolution of the grievance is determined to take longer than seven days, the Grievance committee or designee sends a response to the patient informing him/her that the Hospital is still working to resolve the grievance and that the Hospital will follow-up with a written response within a stated number of days (a "Deferral letter").

-No more than seven days elapses before a response is sent to the patient.

4. Each issue is defined as a grievance is followed up with a written notice of decision in a manner and language that the patient and the patient's legal representative understands within 30 days from Patient/Guest Relations. The hospital may use additional tools to resolve the grievance such as meeting with the patient or family. The written response contains the following minimum elements:
Date of receipt of grievance
Name of the hospital contact person for patient follow-up if needed
Steps taken to investigate, and results and dates completed
Date of investigation completion.

However, this was not done.