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Based on document review and staff interview, it was determined the hospital failed to adequately investigate and subsequently resolve possible systemic problems in twelve (12) of twenty one (21) grievances reviewed. This has the potential to adversely impact the hospital's grievance process if all grievances are not being investigated. Findings include:

1. The hospital's "Patient Complaint/Grievance Procedure" (revised 10/08) stated (in part):
"All patient complaints are submitted to the Grievance Coordinator or his designee. Upon notification of a patient complaint, information sufficient to identify the individual registering the concern, the name of the patient (if not the individual submitting the information), date of receipt, nature of the concern, patient's attending physician, and hospital location of the patient will be recorded.

The Grievance coordinator or his designee will conduct an investigation of the patient complaint, reviewing the patient's medical record (only if necessary) to obtain information regarding the patient's clinical condition. The coordinator will also query other members of the healthcare team that have been involved in the care of the patient.

After thorough research has been conducted, the Grievance Coordinator or his designee will work in tandem with staff identified as critical to problem resolution for the specifically identified concern. All efforts will be made to effectively and expeditiously resolve the patient's complaint."

2. The hospital's complaint/grievance containing grievances from January 2010 through present were reviewed. Of twenty one (21) complaints reviewed during this time period, nine (9) had been investigated and twelve (12) had not been investigated.

3. The interim Director of Nursing/Director of QA/PI was interviewed at 2:00 p.m. on 7/27/10. She agreed that twelve (12) of the twenty one (21) grievances had not been investigated. She attributed this to staffing issues.

Based on document review and staff interview, it was determined the hospital failed to provide written notice to twenty one (21) of twenty one (21) complainants whom have filed grievances with the hospital. This has the potential to adversely affect the quality of the hospital's grievance process and also fails to include the complainant in the loop relative to what the status of their complaint is. Findings include:

1. The hospital's "Patient Complaint/Grievance Procedure" (revised 10/08) stated (in part):
"Following the resolution (if any), the patient will be provided with written notice of:
The name of the Grievance Coordinator
The steps taken taken to investigate and resolve the complaint
The final result of the complaint
The date of complaint resolution determination."

2. The hospital's complaint/grievance containing grievances from January 2010 through present were reviewed. Of twenty one (21) complaints reviewed during this time period, none of the complainants had been sent written notice of the hospital's decision.

3. The hospital's Administrator was interviewed at 10:15 a.m. on 7/27/10. He agreed there had been no letters sent to these twenty-one (21) complainants. He said this was primarily due to staffing issues.