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Based on review of hospital documents and interviews with staff, the hospital failed to establish a grievance process that includes all required elements, and ensures grievance data is incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program with analysis of the data and implementation of processes to improve patient care.

Findings:
1. The Hospital Wide Grievance policy with a "last update of 10/20/2010" correctly defines "complaint" and "grievance" in the section of the policy "Description". Later in the "Description" section the policy stipulates "if a substantive complaint* is not promptly resolved to the satisfaction of the patient and/or family and complainant wishes to proceed, the complaint may formally become a grievance". The hospital failed to establish a a grievance process/policy which meets all the required elements.

2. On the morning of 1/4/2012 surveyors reviewed the grievance log. Staff G told surveyors grievances were reviewed by risk management and forwarded to the appropriate department manager. Documentation of grievance resolution is handled by the appropriate department manager or physician chairman. Two (Pt#s 32, 35) of the six (32,34,35,37,38,39) grievances did not include a written response with all the required elements to the complainants.

3. Two (Pt#s 33,36) of five variance reports reviewed met the definition of a grievance. There was no evidence the incidents were documented as grievances. The complaints did not go through the grievance process.

4. Review of meeting minutes for 2011 did contain evidence grievances were incorporated into the QAPI program. The documentation did not show the results of the investigations of the grievances had been analyzed with processes for improving problem areas.

Based on a review of policies and procedures, complaint/grievance reports, and a staff interview, the hospital failed to ensure a written notice of the patients' grievance resolutions containing the name of the hospital 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 were provided to the complainants.

Findings:

1. Two (Pt#s 32, 35) of the six (32,34,35,37,38,39) grievances did not include a written response with all required elements to the complainants.

2. Two (Pt#s 33,36) of five variance reports reviewed met the definition of a grievance. There was no evidence the incidents were documented as grievances. The complaints did not go through the grievance process.

3. The above findings were reviewed with administration. No further information was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that all personnel providing patient care are competent and adequately trained to assure quality of care to patients. Six ( N, P, R, T, V & W) of eleven ( H, N, P, Q, R, S, T, U, V, W & X) nursing and auxiliary personnel files reviewed did not have evidence that their competencies were conducted either by a person with knowledge in their field or had competencies totally completed assuring safety of service and quality of care before caring for patients.

Findings:

1. Registered nurse (RN) P's competency for aerosol delivery was completed by another RN not a respiratory therapist.

2. Two RNs' personnel files ( N & R) had incomplete competencies either without dates of successful completion or no documentation of whether the nurse had successfully performed the task.

3. The Nuclear Medicine Technician's (W) competency check list was performed by an advanced practice nurse with the designation CNP-Family.

4. One LPN's (T) competency check list documented she did not have the opportunity to be shown the skill of suctioning and tracheostomy care. This was never followed up on and education provided to complete the nurse's ability to care for a patient with a tracheostomy. This nurse was assigned to care for a patient with a tracheostomy.

5. An RN (V) working in the wound care/hyperbaric department started work on 03/21/10, but the competency check list was not completed until 08/19/10. There were no dates documenting any competencies before 08/19/10.

6. These findings were verified with hospital personnel during review of personnel files on 01/05/12 in the afternoon.

Based on review of patient records and interviews with hospital staff, the hospital failed to ensure the medical record contained information to describe the patient's progress and response to services at the time of discharge. Five of five obstetrical and newborn medical records (Records #12, 13, 15, 16 and 19) reviewed, did not contain complete information/documentation regarding evaluations and discharge notations in the nurses' notes/discharge summaries.

Findings:

1. Obstetrical patient medical records #12, 15 and 19 did not contain information about the patient's condition at the time of discharge, with the time and how the patient left or if the patient was accompanied by anyone. On 01/05/2012 at 1430, Staff Y told they surveyor that nursing should document in the nursing notes when and how the patient left and that an infant car seat was in the vehicle. Staff Y verified the charts did not contain nursing entries describing the above elements.

2. Newborn patient medical records #13 and 16 did not contain information about the time or how the patient left. The medical record did not contain documentation that the infant was placed in an infant car seat to ensure the infant's safety at the time of discharge.

3. The above findings were reviewed and verified with hospital staff, including Staff D and Y, on the afternoon of 01/05/2012. No further documentation was provided.

Based on a review of policies and procedures, medical records, and staff interviews, the hospital failed to ensure the menus were meeting the needs of the patients.

Findings:

1. According to the policy "Assessment/Reassessment of Patients" all patients will be screened to identify patients at nutritional risk who require nutrition assessment plan of care. Upon admission the admitting nurse will complete admission assessment that includes a nutritional screen component. Screening criteria include: diet, number of meals per day, meal assistance needed, appetite: increase, decrease, normal; weight: increase decrease, stable; number of pound change; eating or swallowing problems; dentures; currently breast feeding; non healing wound; nausea/vomiting; diabetes. Later in the section the policy stipulates: "Patients identified as being at nutritional risk are referred to their physician and/or hospital dietitian".

On 1/4/2012 Staff B told surveyors patient records are electronic. Surveyors reviewed the electronic nutrition risk screen. Indicators listed were "no indicators present, unintentional weight loss of 10 lbs (pounds) or more in the past 2 mos (months); tube feeding or parenteral nutrition; large or nonhealing wound, burn or pressure ulcer, reduced oral intake over the last month; dysphagia or difficulty swallowing; vomiting/nausea greater than 3 days prior to admission; presurgical albumin less than 3gm/dl; new diabetes/uncontrolled diabetes; cachectic (severe malnutrition/wasting) anticipated actual length of stay greater than 10 days." The nursing policy indicators do not match the indicators listed in the electronic document.

2. In an interview 1/5/2012, Staff Z told surveyors nursing staff would not look at or select some of the indicators because those indicators are automatically reviewed by the dietary staff. Three of three patient's records selected for nutritional review had diagnosis or symptoms requiring nutritional indicators to be flagged. All of the nutritional risk assessments completed by nursing documented "no indicators". Nursing did not identify patient's "at risk" through the nutritional screen.

3. These findings were reviewed with administration at the exit conference. No further information was provided.

Based on review of infection control data and meeting minutes and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. Infection control meeting minutes for 2011 did not reflect the program contained monitoring, review and analysis of:
a. Employee health and tracking of employee illness to ensure transmissions between staff and patients did not occur;
b. Surgical sterilization practices, including "shortened cycle/flash" sterilization, to ensure practices were performed according to industry standards and manufacture guidelines;
c. Review and analysis of "shortened cycles" to limit or eliminate the need for this practice.
d. Except for handwashing and personal protective equipment (PPE) for isolation, that staff followed established policies and procedures and standards of practice to prevent and control infections and maintain a sanitary environment.

2. Monitoring activities, provided for review, did not include active surveillance of the practices, with the exceptions of handwashing and PPE, to ensure staff adhered to the policies to avoid possible transmission of infections throughout the hospital. On the afternoon of 01/04/2012, Staff J stated she did monitor, but did not keep records.

3. These findings were reviewed with hospital administrative staff during the exit conference on the afternoon of 01/05/2012.

Based on review of hospital documents, medical records, and personnel files and interview with staff, the hospital failed to ensure that respiratory services/procedures, not provided by respiratory therapists, were administered by trained staff, with each respiratory therapy procedure performed by each employee designated in writing, including the amount of supervision required when performing each procedure. One of one emergency room nursing personnel (Staff P), who provided respiratory services and whose personnel file was reviewed, did not have documented training and competencies by the respiratory department.

Findings:

1. A respiratory therapy service (a hand held nebulizer treatment), for Patient #29 was provided by nursing personnel while the patient was seen in the hospital's emergency department (ED).

2. Staff B told the surveyors on 01/05/2012 that nursing personnel routinely performed respiratory therapy treatments in the ED.

3. Review of one ER nurse's personnel file (Staff P) documented the nurse had competency/training for respiratory therapy services, but they were not verified/performed by the a respiratory therapist or the head of the respiratory department.