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Based on staff interview, record review, review of the hospital ' s grievance policy, and review of 2 of 9 grievance reports (regarding Patient #1 and Patient #2), the hospital did not resolve the grievances by providing the patient or family member with a written notice of its decision including investigative steps taken and the results of the grievance process.

Findings include:

1. A review of Meriter Policy #506, with an effective date of October 2010, entitled, "HOSPITAL & CLINICS PATIENT COMPLAINTS/GRIEVANCES" included the following:

"Meriter shall provide a mechanism whereby a patient or patient's family may bring a complaint or grievance to the attention of Meriter staff for action and shall provide a process for resolving the patient's complaint or grievance."

General information included the following. "Types of grievances include: 1. Any written complaint received by personal e-mail, fax, delivered mail or attached to a survey ...4. Any verbal complaint received during the hospital or outpatient encounter that cannot be resolved prior to discharge ... "

Implementation of the policy included the following. " ...(when the frontline staff cannot resolve), the complaint should be documented on a " Patient Feedback Report. " The form should include a description of the issue and actions taken to investigate and resolve the complaint ...If the complaint cannot be resolved to the patient's satisfaction prior to discharge ..., the complaint becomes a grievance ...The Patient Representative will send the patient a Letter of Acknowledgement within 7 days of receipt informing the patient that the grievance has been acknowledged, that the area manager/director is continuing to investigate and resolve the grievance, and that the manager/director will follow-up with a written response ...The Patient Representative will coordinate the written response ...Meriter ' s goal is to resolve all grievances within 30 calendar days. If the patient requests a response via e-mail, Meriter may respond by e-mail and this will meet the requirement of a written response ...If the problem cannot be resolved at the manager/director or Patient Representative level, the issue will be forwarded to the appropriate Vice President or Administrator-on-Call ...Once the grievance is resolved, the completed " Patient Feedback Report " and supporting documentation should be sent to the Patient Representative Office for filing ...Patients are permitted to have a representative of their choice to represent their interest during the complaint process ..."

Per review of Patient (Pt.) #1 ' s record, the patient was admitted to this hospital on 12/09/12. Social service notes written by Social Worker (SW) E, dated 12/10/12, identified there was concern by the hospital that a Power of Attorney for Healthcare (POA-HC) document, naming Pt. #1 ' s Family Member (FM) A as the legal representative, was not legal " due to dates that appear to have been changed and different signature dates. " It was also identified on 12/10/12 that a physician had initiated certification of incapacity on 12/05/12 (based on the POA-HC document). Social service notes written by SW E, dated 12/13/12, identified that temporary guardianship and protective placement was being considered by the hospital. Social service notes written by SW E, dated 12/14/12, identified that an attorney, representing the hospital, was contacted. The notes identified the attorney " stated that Meriter does not have to communicate with, (FM A), anymore as our understanding is the patient revoked the POAHC. "

On 12/16/12, social service note written by SW F identified that FM A, while visiting Pt. #1, was " upset " and " unsatisfied " when it was explained that guardianship proceedings (by the hospital) were underway. On 12/18/12, social service notes identified Pt. #1 was discharged to an inpatient Hospice facility.

The surveyor requested and reviewed the " Patient Feedback Report, " related to FM A ' s concerns. The report identified that a complaint was filed by FM A and received by Patient Representative B on 12/14/12. Neither the type of complaint nor the description of the complaint was identified. The investigation and actions taken for resolution stated the following: " 12/14/12attempted 3 times to call (FM A) and left messages. No response. 12/14/12 Guardian ad litum given to patient. Will not respond to questions of discharge to (FM A). " The " Date Resolved " on the form was not filled in.

Attached to the 12/14/12 Patient Feedback Report related to Pt. #1 was a copy of an e-mail sent by FM A on the morning of 12/14/12 to Patient Representative B regarding care and discharge concerns. Another e-mail was attached which confirmed, that on the afternoon of 12/14/12, Patient Representative B was aware of the plans for protective placement and temporary guardianship. Also attached was a copy of another e-mail sent by FM A on 12/15/12 to Patient Representative B regarding the fact there had been no response to the previous e-mail, " ...leaving me in the dark about the situation ... "

Despite Pt. #1 being discharged on 12/18/12 there is no record of a letter of acknowledgement or a letter of resolution being sent to the daughter (A).

On 01/23/13 at 11:00 a.m., it was confirmed per interview with Patient Representative B that no additional communication with A was attempted by the hospital. SW E, SW F, Physician G (the Hospitalist caring for Pt. #1), as well as several other nurses involved in Pt. #1 ' s care. None were able to provide evidence that FM A ' s complaint/grievance had been resolved as per the hospital policy.

2. The surveyor requested and reviewed a " Patient Feedback Report, " related to FM C ' s concerns regarding Pt. #2.

The report identified that Pt. #2 was admitted to the hospital on 07/16/12, that a complaint " Occurred " on 07/19/12 which was filed by FM C (no date), and received by Patient Representative B on " 09/14/12 " (following a telephone call by FM C on 09/13/12). The description of the complaint stated that FM C called the hospital and talked with someone else, but was upset that she did not get a response from Patient Representative B regarding the complaint. It was stated that FM C wanted to know why she did not get the information from the doctor when Pt. #2 was incapacitated. The investigation and actions taken for resolution identified this was reviewed and a letter was sent, " I apologized for not getting back to her. I had thought she told me that this was unnecessary. "

A letter of acknowledgement was not sent. A letter of resolution was sent on 09/19/12 only after a follow-up phone call from C on 09/13/2012. The " Date Resolved " on the form was identified as 09/20/12.

On 01/23/13 at 9:10 a.m., it was confirmed per interview with Patient Representative B that she was aware of and familiar with the hospital ' s policy regarding complaints/grievances.

Based on record review, staff interview, and review of hospital policies, the hospital did not ensure, for 1 of 10 patients (Patient #1), a care plan was developed when the patient displayed signs/symptoms of pain with current orders for pain medications to be administered.

Findings include:

Patient (Pt.) #1 was admitted to the hospital on 12/09/12 with diagnoses that included lung cancer with metastasis to the bone and brain. The admission history and physical (H & P), dated 12/09/12, stated, " The patient nods when asked if she has jaw pain ... " The H & P identified that current medications included Oxycodone 20 milligrams (mg) every 12 hours.

A review of Pt. #1 ' s Medication Record identified the following pain medications were ordered and administered on 12/09/12: Tylenol 325 mg at 6:00 p.m. (ordered to be given every 4 hours as needed). A nurse ' s note on 12/09/12 at 11:24 p.m. identified that Pt. #1 had difficulty swallowing liquid Tylenol that was requested for discomfort and that she moaned with turns. Pt. #1 did not receive any further pain medication through the night and there was no care plan in place related to pain to assure that the patient received pain medication at the appropriate time.

A review of the hospital ' s policy #32, " Pain Management, " dated November, 2008, referred to the patients ' " treatment plan " and " pain management plan, " but is not specific regarding the timeframe for development.

A review of the hospital ' s policy #8, " DOCUMENTATION IN THE PATIENT RECORD, " with the most recent revision date of " 8/2012, " included the following information related to care plans, " History along with the assessment drives the Plan of Care ...Plan of Care is based on functional areas with problems, goals, and interventions ...An initial screening and assessment (patient profile) by nurses is initiated within 8 hours and completed within 24 hours of admission ... "

On 12/10/12, a " Palliative Care Consult Note, " written by Licensed Clinical Psychologist (LCP) H included the following, " The patient was seen at 1 PM today ...The patient did endorse having pain in her abdomen ...I reassured her that keeping her comfortable by managing her pain will be a priority ... "

A review of Pt. #1 ' s Medication Record identified the following pain medications were ordered and administered on 12/10/12: Oxycodone 20 mg at 9:00 a.m. (ordered to be given daily each morning) and Tylenol 325 mg (administered at 5:00 a.m. and 11:00 p.m.). Pt. #1 did not receive pain medication related to the abdominal pain at 1:00 p.m. and there was no care plan in place related to pain to assure that the patient received pain medication at the appropriate time.

Per an interview with LCP H on 01/23/13 at approximately 8:15 a.m., LCP H stated that with Pt. #1 ' s stage of lung cancer with esophagitis, she would expect the patient to have pain. LCP H stated that with the patient ' s grimacing, body language, and oral confirmation, there was no question that Pt. #1 had pain.

On 12/11/12, a physician progress note written by Physician G (the Hospitalist caring for Pt. #1) included the following, " Patient drowsy this am ...When asked what I can do to help her she replies: ' pain killers. ' Reports pain ' all over ' ...Unclear if she has pain with swallowing ...Her inability/unwillingness to eat/drink is likely multifactorial as treatment for severe erosive esophagitis ...has not improved her intake ...She asks for ' pain killers " today ...will start IV (intravenous) dilaudid ... "

Per an interview with Physician G on 01/23/13 at 3:23 p.m., Physician G stated that Pt. #1 " seemed uncomfortable " on 12/11/12 and confirmed that the nursing staff was concerned as well.

A review of Pt. #1 ' s Medication Record identified the following pain medications were ordered and administered on 12/11/12: Oxycodone 20 mg at 9:00 a.m., Tylenol 325 mg (7:00 a.m. and 8:00 p.m.), and Dilaudid 1 mg (12:00 p.m. and 8:00 p.m.) intravenously (a new order had been initiated to administer 0.5 - 1.5 mg every 3 hours as needed) on 12/11/12.

On 12/11/12, a nurse ' s note at 1:39 p.m. stated that Pt. #1 had been moaning and mumbling when asking if she had pain and when she was turned, with Dilaudid initiated for pain. At 10:02 p.m. a nurse ' s note stated that Pt. #1 reported discomfort when asked but did not articulate the location of the pain, with Dilaudid administered (1 mg per the Medication Record at 8:00 p.m.). There was no care plan in place related to pain to assure that the patient received the appropriate pain medication at the appropriate dose at the appropriate time.

On 12/12/12, a nurse ' s note at 8:30 a.m. stated, " Last noc (night) shift pt laid in bed with a constant Grimace, as if in pain, unrelieved with tylenol. At one point, did acknowledge that she was in pain so gave tylenol elixir. Pt was unable to state the location of the pain. Tonight pt appears more comfortable with no grimace, had been getting IV dilaudid. 0400 (4:00 a.m.), pt with grimace and very restless and said ' yes ' when asked if she had pain. Gave 0.5mg IV dilaudid, and was repositioned. Pt settled and appeared comfortable within the hour. " There was no care plan in place related to pain until 12/12/12 to assure that the patient received the appropriate pain medication at the appropriate dose at the appropriate time.

Per review of Pt. #1 ' s Medication Record, Dilaudid was given for pain over the remaining course of the patient ' s hospitalization. A nursing care plan addressing pain was not initiated until 12/12/12.

These findings were confirmed per interview with Nurse Manager D on 01/23/13 at 1:25 p.m. Nurse Manager D also confirmed that hospital policy dictates that a care plan for pain be initiated as soon as a pain medication is provided.