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Based on review of Patient Grievance Policy and interview with staff, the hospital failed to provide written response to a grievance filed with the hospital. Findings:

Interview on 9/8/11 at 9:15 AM with S12 RN OB/GYN manager revealed she was responsible for investigating complaints that were voiced while a patient was still hospitalized. S12 stated she immediately met with the complainant for more details and discussed the allegations. Afterwards, S12 speaks with the nurse staff or with PCT (patient care technician) responsible for the individual patient 's care for information relevant to the allegation. If at all possible, S12 indicated the allegation was resolved at the time, but if the patient was discharged, the investigation continued and a follow up letter was sent to the complainant.

Interview with S5 CNO on 9/9/11 at 9:00 AM revealed she was not made aware of patient #1's verbal complaint upon discharge until well after patient #1's discharge on 6/17/11. Patient #1 submitted a written grievance dated 7/11/2011 and a second investigation was launched. There was also a written grievance submitted to the hospital by patient #1's mother that addressed the same issues. This letter was forwarded to Health Standards, Joint Commission, and the Board of Medical Examiners; receipt of this letter by Health Standards was verified by stamp-7/11/11. S5 revealed the hospital staff met on 7/13/11 to review the letters received 7/11/11 and realized S12 did not thoroughly investigate the allegations and document the findings in real time. S12 was reprimanded for not thoroughly investigating patient #1's complaint. S12 stated she typed her conversations with the staff on her computer with nursing staff on 7/19/11 and printed them for surveyor review.

Interview with S12 RN OB/GYN manager on 9/9/11 at 11:15 AM revealed she recalled speaking with patient #1 on 6/17/2011, the day of her discharge. S12 stated patient #1 informed her of her dissatisfaction with her care regarding not receiving her routine home medications, not seeing the surgeon before discharge and not being sure of how to care for her surgical site after discharge. S12 stated hospital staff contacted the surgeon and S4 immediately visited patient #1 and explained how to care for the wound. S12 stated even though she visited with patient #1 every morning, she did not recall patient #1 making any other allegations about her care. S12 also indicated she provided a written follow up letter apologizing to patient #1 that her expectations were not met, that the hospital did strive to provide excellent care, and that she further educated the nursing staff of hospital expectations to provide that care. A copy of the follow up letter dated 6/22/2011 was provided to the survey team for review. The letter failed to address the results of the investigation.

Review of the Patient/Family Grievance/ Complaint Management Policy effective 10/94, reviewed 2/2010 and revised 2/2011 revealed "When a patient/family complains to a direct caregiver regarding care, the immediate supervisor in charge of the department/patient care unit should be notified without delay and every effort made, at that time, to promptly resolve the issue to the patient ' s satisfaction. When the complaint cannot be immediately resolved to the patient's /family's satisfaction, a grievance should be entered into the Risk Management Module using the Meditech Occurrence Reporting System. A Grievance/complaint form should be used during Meditech downtime. The grievance is then entered into the Risk Management Module by the Unit Manager or Department Director when the downtime is complete ". Further review revealed the hospital will "contact the patient/family within 72 hours to acknowledge that the grievance/complaint has been received with concern, even if the investigations are not complete,and agrees to send a follow-up letter for all grievances; Most grievances should be resolved and a follow up letter sent within seven working days. Occasionally, a grievance is complicated and may require an extensive investivation. IF the grievan ce will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be followed u with a written response within 21 days."

On 9/8/11 at 2:30 PM, interview with S17, Risk Manager, revealed when the Joint Commission received the letters from patient #1 and her mother, the Joint Commission notified the hospital and the hospital responded to them about the progress of their investigation. S17 stated information of the investigation was provided to Joint Commission. Review of the Joint Commission letter dated 8/30/11 revealed " based on review of your organization's response to incident number ... the Joint Commission will take no further action at this time " . S17 was questioned if a written response was sent to patient #1's mother and she said there was no written response to the second written grievance since the hospital considered all of this as one complaint. S17 confirmed the policy was not followed.

Based on closed medical record and Home Medication Reconciliation policy review and interview with staff, the hospital failed to enure nursing staff followed the policy to have home medications reconciled and ordered by the physician for 1 of 1 sampled patients in a total of 5 (patient #1). Findings:

Review of the closed medical record for patient #1 revealed an admission date of 6/14/11 at 3:30 PM. Review of the admitting physician orders by S3 general surgeon revealed "patient will give med (ications) list ". Review of the Adult Admission Assessment dated 6/14/11 revealed Home Medication Reconciliation Record was entered at 6:24 PM. Further review of the medical record revealed a computer generated Home Medication Reconciliation dated 6/16/11 that had the medications listed but the record was not signed by the admitting physician. Review of a second Home Medication Reconciliation record that was generated on 6/17/11 revealed it was signed by the admitting general surgeon on 6/20/11, after patient #1 was discharged.

Interview on 9/8/11 at 10:40 AM with S2 Medical Director revealed if a patient was not admitted by his/her PCP (primary care physician), the admitting MD writes the orders. When a patient has home medications, this information was given to the nurse to make a list for the MD to sign as orders. S2 stated if there were medications for pain on the list, the MD may want to change them.

Interview with S14 RN on 9/9/11 at 9:30 AM revealed if a patient was admitted and brought home medications, these would be sent to the pharmacy to be identified and labeled with a bar code. The patient would then be allowed to have their own medications dispensed by the hospital staff or they can elect to send their own medications home, but provide a list to the nurse of what medications they take at home, so the physician can write an order for the medications as he deemed appropriate during the hospital stay.

Interview with S16 RN on 9/9/11 at 9:50 AM revealed if the patient brought home medications, they were taken to the pharmacy for coding and scanning with administration documented. S16 stated if a patient 's Home Medication Reconciliation record was not signed the nurse should call the physician for clarification; if the record was checked and signed, then it was an order. S16 confirmed the Home Medication Reconciliation record for patient #1 was not signed.

Interview with S9 Registered Pharmacist on 9/8/11 at 2:10 PM revealed if patients bring home medications, a list was obtained (and entered in computer under Home Medication Reconciliation), reviewed and signed by the physician which now becomes a physician order and was sent to the pharmacy. Review of the Home Medication Reconciliation record for patient #1 dated 6/16/11 with the pharmacist, confirmed the record was not signed by the physician; therefore, it was not an order and would not be filled. S9 stated the responsibility falls on the nurse staff to ensure the physician sees that list and signs it if the home medications were to be continued during the hospital stay.

Interview with S15 RN on 9/9/11 at 9:55 AM revealed she worked the 7P-7A shift on 6/14/11 and 6/15/11. S15 stated she did not recall seeing the Home Medication Reconciliation record for patient #1 that night so did not know if it was signed or not. S15 confirmed she performed the 24 hour chart check and did not identify the incomplete Home Medication Reconciliation record.

Interview with S13 LPN on 9/9/11 at 10:45 AM revealed she did not recall patient #1 except that she had a draining wound, had orders for dressing changes and was in contact isolation after her surgery. Her wound had been covered prior to surgery. S13 was asked how home medications were addressed and she indicated that home medications were entered into the data base and sent to pharmacy for coding. The home med sheet was on the chart for the physician to reconcile on rounds and order.

Interview with S12 RN OB/GYN manager on 9/9/11 at 11:15 AM revealed the policy indicated that the home medication list was entered into the system for the physician to reconcile and then order, usually within 24 hours. S12 also stated the incomplete Home Medication Reconciliation record should have been found during the 24 hour chart check.

Interview with S3 General Surgeon, the admitting physician, on 9/9/11 at 9:15 AM confirmed the home medications for patient #1 were not ordered. S3 stated he recalled telling patient #1 to bring her list of home medications but did not address the medications that day. S3 confirmed when he visited on 6/15/11, patient #1 was in surgery (along with her chart), so he thought S4 may have addressed the home medications, but that did not happen. S3 indicated he depended on the nursing staff to have that available on the chart for the physician to review and order.