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 identify grievances and failed to follow their policy and procedure for complaints and grievances for 1 (# 2) of 4 records reviewed for complaints and grievances resulting in the potential for less than optimal outcomes for all (165) patients served by the facility. Findings include:

On 8/3/2021 at 1300, review of the facility's complaints and grievance logs were reviewed with Recipient Rights (Staff F) and revealed there was one entry for patient #2 dated 6/28/2021 logged for "customer service". Staff F said at that time, "that was a complaint that was resolved quickly after meeting with the patient and chart review."

However, during further interview at that time, Staff F explained the patient (#2) had submitted many other forms after 6/28/2021 for the office of the Recipient Rights to review concerning wanting to see his records and to obtain a copy of his records. Staff F said, I have them here in his file. However, there were no entries for the patient of concern, noted on the complaint and grievance logs after 6/28/2021 nor on the July 2021 logs.

Review of complaint forms with Staff F at that time revealed the patient had submitted forms dated 7/1/2021, and 7/3/2021 and the following was revealed:

On 7/1/2021, the patient wanted access to his medical record. Staff F said at that time she told the patient that he could have a copy of his medical record upon discharge.
On 7/3/2021, the patient made 2 requests to see his record. Staff F said after meeting with the patient regarding his first request on that day she said she told the patient that he could get them upon discharge. Staff F said after meeting with the patient regarding his second request on the same day the patient said "he did not remember her explaining."

Staff F was asked if she had provided the patient with an acknowledgement letter explaining the facility's policy/procedure for investigating and resolving complaints/grievance. She replied she did not. Staff F stated, whenever I spoke with him he was "fine with my explanation."

On 8/4/2021 at 1100 review of the medical record revealed the following:
Patient #2 was a 32- year-old male admitted to the facility on [DATE] and was discharged home on 7/9/2021.
Review of the patient's "Interdisciplinary Treatment Plan Update" notes dated 7/7/2021 at 1337 revealed the patient was requesting a "doctor change" and on 7/7/2021 at 1930 the patient was requesting "documentation in regards to putting in a formal complaint".

However, there was no evidence in the medical record that the patient's requests for a "doctor change" was addressed. Additionally, there was no evidence that documented a "formal complaint" was made on behalf of the patient or for the patient.

On 8/4/2021 at 1115 Interim Clinical Director (Staff H) was asked to explain if anyone could have, and/or should have submitted a complaint on behalf of a patient who was requesting "formal documentation" for a complaint. At that time, Staff H responded yes to both queries. However, there was no evidence that it was done.

On 8/4/2021 at 1600, a review "Interdisciplinary Treatment Plan Update" notes for patient #2, dated 7/7/2021 were reviewed with the Director of Nursing (Staff C). At that time, Staff C confirmed a complaint should have been submitted on the behalf of the patient as he requested on that date. Staff C said her nursing staff should have addressed the patient's request for a different doctor as well and followed the necessary steps for a physician change. Staff C said, I will address with staff.

A review of the facility's "Patient Complaint and Grievance Process" dated last revised on December 12, 2018 documented the following:
Complaint is defined as a verbal allegation or source of dissatisfaction about care, services, or safety from a patient that can be resolved by staff or their supervisor present...
Recipient Rights Advisor will be responsible for ensuring complaints and grievance are forwarded to the appropriate administrators and departments for resolution in accordance with this policy...
Grievance is a formal or informal written or verbal complaint that is not resolved promptly by staff present or that requires further investigation and is made by a complainant or grievant regarding a patient's care.
...B. 3. Any staff member may help a patient to complete or submit a written grievance. The written grievance should then be placed in the box for the Recipient Rights Advisor. 4. Complaints that can not be resolved immediately should be referred to the Recipient Rights Advisor at which point it will be considered a grievance. The Recipient Rights Advisor facilitates the resolution of unresolved complaints or grievances and oversees the grievance process...b. Issues regarding the use and disclosure of Protected Health Information (PHI) are not considered complainants or grievances and will be immediately referred to the HIPPA (Health Insurance Portability and Accountability Act) Privacy Officer for review and resolution. However, that was not done.