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 observation, interview and record review, the facility failed to protect the rights of two (#1 and #2) of two patients reviewed for complaints and grievances. Findings include:

See specific tag:

A 0123 - Based on interview and record review the facility failed to follow their complaint/grievance resolution policy for two (#1 and #2) of two patients reviewed for complaints and grievances resulting in failure to ensure investigation and resolution of multiple complaints/grievances, failed to ensure accurate reporting of investigation results to the complainant, and failed to implement corrective measures for identified concerns resulting in missed opportunities for quality improvement and decreased patient satisfaction.

Based on interview and record review the facility failed to ensure that complaints and grievances documented in the clinical record were addressed, investigated and followed up accurately and timely per facility policy for two (#1 and #2) of two patients reviewed for complaints and grievances out of a total sample of ten, resulting in missed opportunities for quality improvement and decreased patient satisfaction for the patients concerned. Findings include:

On 11/17/20 at approximately 1500 Patient #2 's clinical record and Complaints/ Grievances and facility Complaint/Grievance investigation were reviewed with the facility Office of Recipient Rights (ORR)/Patient Satisfaction Officer Staff C and the Director of Nursing Staff A and the following was revealed:

Patient #2 was a [AGE] year old female who was admitted into the facility on [DATE] and discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED]

Patient #2's written grievances submitted to the facility were reviewed and included the following:

1. A facility Grievance form dated 6/15/20 documented that Patient #2 alleged that Nursing Staff were not following standards of practice for blood sugar sample collection with a detailed description of what she felt was not done correctly.
2. A facility Grievance form dated 6/16/20 documented a complaint from Patient #2 alleging that the nursing staff were not performing her blood sugar checks correctly.

An undated facility internal email with a handwritten date in the margin of 6/16/20 documented that Patient #2 contacted the ORR to file complaints/grievances including allegations that staff spent too much time playing with their phones and that her blood sugar checks weren't being done properly.

There was no documentation to indicate that an acknowledgement letter was sent to Patient #2 regarding these Complaints/grievances or that any complaint/grievance resolution letters were sent within a proper timeframe. These complaints or grievances were entered on the facility Complaints/Grievance log until 7/28/20 (41 days after her last written complaint/grievance was documented).

A letter dated 7/28/20 from the County Mental Health Authority ORR to the facility ORR documented that Patient #2 made allegations to them regarding her care at the facility and wanted to file a complaint/grievance. Patient #2's complaints/grievances were noted to include billing concerns, an allegation that she was held against her will (involuntary commitment through probate court), an allegation that the facility did not manage her diabetes properly, and allegations that staff ridiculed patients and that a nurse (name was provided) was "really mean".

Handwritten undated facility complaint investigation notes documented that Patient #2's physician ordered for her blood sugar to be checked four times daily (before meals and at bedtime). The note documented that the 1430 (before dinner) blood sugar checks were missed on three occasions, 6/17/20, 6/20/20 and 6/22/20. Review of Patient #2's clinical record at this time confirmed this.

Review of a laboratory (lab) result report for Patient #2 for a blood sample collected on 6/16/20) revealed that her blood sugar on that date was critically high at 278 milligrams per deciliter (mg/dl) (normal range < 127) and that her hemoglobin A1C (measures overall control of blood sugar) was high at 6.6 (good control <5.7). There is no documentation to indicate that this was ever addressed or that corrective measures were discussed or implemented. Staff C was interviewed during the record review and reported that she did not investigate this as it was a Nursing concern.

On 11/17/20 at approximately 1600 Staff A was interviewed and reported that no investigations were done to see if staff were performing blood sugar checks correctly and that no staff education or corrective measures were implemented for the concern identified with missed blood sugar checks for Patient #2. Staff C and Staff A reported that no investigation was done for Patient #2's allegation of staff rudeness.

A facility "Report of Investigative Findings" dated 8/4/20 (45 days after Patient #2's last complaint/grievance was made in the facility) documented that Patient #2's complaints were investigated and found to be unsubstantiated. There is no evidence to indicate that any investigation was done regarding the allegations of staff rudeness or failure to perform blood sugar checks consistently and correctly. There is no mention of the fact that Patient #2's blood sugar was not checked consistently per physician orders and thus this allegation was substantiated..

An unsigned complaint resolution letter addressed to Patient #2 dated 8/3/20 (one day before the "Report of Investigative Findings" was completed) documented that Patient #2's complaints were not substantiated.

On 11/18/20 at approximately 1100 the facility Chief Operating Officer (CEO) was interviewed about this and stated that the Grievance Resolution letter was not correct, as one of the allegations (blood sugar not correctly managed) was substantiated and not unsubstantiated as Staff A documented in the complaint resolution letter to Patient #2. The CEO noted that any complaint made in writing should be treated as a grievance per facility policy. The CEO said that the time frames for notifying the patient (acknowledgement letter) that the complaint/grievance was received and for informing the patient of the facility findings (resolution letter) did not meet facility policy and the fact that the complaint resolution letter was dated the day before the investigation was dated as completed was a problem..

On 11/18/20 at approximately 0900 Patient #1's clinical record, facility Complaint/Grievance forms and an abuse investigation file for a staff to patient abuse allegation made by Patient #1 were with the facility Office of Recipient Rights (ORR)/Patient Satisfaction Officer Staff C and the Director of Nursing Staff A and revealed the following information:

Patient #1 was a [AGE] year old female who was admitted on [DATE] and discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED].

Patient #1 was transferred to the facility from an acute care hospital Emergency Department for acute psychosis with religious preoccupation, auditory hallucinations, acute paranoia, and religious delusions.

Nursing Notes, a facility Incident and Accident Report (I&A) and a facility abuse investigation file documented that Patient #1 was allegedly physically abused by an Agency Nurse on 7/18/20 at approximately 2300.

A facility I&A dated 7/19/20 at 0100 documented that Patient #1 was allegedly physically abused by Agency Nurse Staff F. Written witness statements documented that Staff D, Staff E and Patient #1 all reported during abuse investigation interviews dated 7/20/20 (no time noted) that Patient #1 yelled at Staff F at the nursing station demanding that she give her more prednisone and Staff F grabbed her and dragged her by the arm to the Seclusion room, threw her against the doorframe and then threw her down on the bed.

On 11/18/20 at approximately 1000 Staff A was interviewed and said that when Patient #1 was assessed on 7/19/20 after she reported she was abused by Staff F she had bruises on her arm in the shape of a hand.

A Physician Progress Note dated 7/19/20 (no time noted) documented that Patient #1 had significant bruising on her left thigh and left arm after she was "physically abused by a night shift nurse" the previous night.

Review of Patient #1's abuse investigation file for the alleged abuse on 7/18/20 at 2300 revealed Patient #1 called the police on 7/19/20 and two officers came to the facility on [DATE] at 1040 to interview Patient #1. Staff A provided documentation that the Staffing Agency was contacted on 7/20/20 (no time noted) to notify them that Staff F "used unreasonable force with a patient and was terminated from employment at the facility and will no longer be eligible for employment at the facility".

Concerns were identified with the facility complaint/grievance resolution process for Patient #1's allegation of abuse. Written documentation dated 7/19/20 (no time noted) revealed Patient #1 filed a complaint/grievance regarding the alleged physical abuse by Staff F on 7/19/20 . Documentation in the abuse file revealed that this was reported by the Assistant Director of Nursing Staff G to Staff C for investigation on 7/20/20 (no time noted). The abuse investigation file Report of Investigative Findings was reviewed and revealed the following:

The allegation that Staff F used unreasonable force with Patient #1 was dated as received on 7/20/20. Staff and patient interviews were dated 7/20/20 (no times noted). Staff C was interviewed during this review and said that the interviews with Staff D and Staff E substantiated Patient #1's allegations and so substantiated that staff to patient physical abuse occurred. The Report of Investigative Findings documented that the investigation was completed on 7/24/20 and substantiated that unreasonable force (Abuse II - Unreasonable Force) occurred.

A Complaint/grievance resolution letter to Patient #1 was dated 7/20/20 (four days before the investigation was documented as completed) and advised Patient #1, "This is to inform you that the investigation has been completed, which began after you filed a rights complaint with the (facility) Office of Recipient Rights. The preponderance of evidence was not found to substantiate a violation of recipient rights."

On 11/18/20 at approximately 1110 the CEO Staff M was interviewed and said that there were concerns with the abuse investigation and complaint process for Patient #1. Staff M stated that the first problem was that the grievance resolution letter was dated four days before the investigation was completed. Staff M said that the second problem was that there was no complaint acknowledgement letter (letter to the complainant informing them that the facility had received their complaint and was going to investigate the allegations). Staff M said that the third concern was that the investigation substantiated Patient #1's allegation of physical abuse but the grievance resolution letter to the patient notified her that her allegation was not substantiated.

On 11/18/20 at approximately 1600 the facility policy on complaints/grievances was reviewed and revealed the following statements:
"A grievance is also any any complaint regarding abuse or neglect of a patient."

"A grievance is a formal or informal written or verbal complaint that is not resolved promptly by staff present or requires further investigation..."

"The Recipient Rights Advisor facilitates the resolution of unresolved complaints or grievances and oversees the grievance process."

"A written response will be provided within seven business days to the patient who is the subject of the complaint...The written response must contain the name of the (facility) 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."

"a log will be kept documenting all grievances, date of the grievance, name of the grievant, how the grievance was received, of resolution and outcome."