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Based on record review, and interview, the hospital failed to provide documented evidence of a written grievance resolution that included the steps taken on behalf of the patient to investigate complaints two (2) patients (#1, and #2).of the three (3) sampled.

Findings include:

Three patient grievance records were sampled for review from June 1, 2013 through March 1, 2014.

A grievance was filed on 11-14-2013 on behalf of patient #1 by a family member. The hospital issued a written response on 2-18-2014 with the final investigative decision. The letter failed to include investigative steps taken on behalf of the patient.

A grievance was filed on 12-23-2014 on behalf of patient #2 by a family member. The hospital issued a written response on 3-4-2014 with the final investigative decision. The letter failed to include investigative steps taken on behalf of the patient.

An interview with the Director of Risk Management and Patient Advocacy on 3-6-2014 at 10:00 a.m. confirmed the above findings.

Based on observation and interview, the facility failed to provide a safe setting for care in one (1) of five (5) outpatient care areas.

Findings include:

Observation on 3/4/14 at 11:30 a.m. at the Sleep Study Lab, four (4) of four (4) patient restrooms had no emergency call mechanisms. The restrooms were inside each sleeping suite and there was a door to enter the suite and a door to enter the restroom.

Interview with the Manager of Cardiopulmonary Services (a Registered Respiratory Therapist) confirmed that there were no patient emergency call mechanisms in the restrooms and that while there was an observation camera in each patient room, there were no cameras in the restrooms. The Manager further confirmed that at times patients had chest pain during the night and had to be transported to the Emergency Department in the main facility.

Based on observation and interview, the facility failed to protect the confidentiality of medical records in one (1) of five (5) outpatient areas surveyed.

Findings include:

Observation on 3/5/14 at 1:45 p.m. of the Wound Care Center revealed that hard copy patient medical records were stored in an open area at the admissions desk. The records were kept in open metal racks in this room. The check-in area had unlockable sliding glass windows on the counter . The check-out counter had no windows or barriers. The records were in easy reach of anyone with access to the check-in and check-out counters.

In an interview on 3/5/14 at 1:50 p.m., the supervising Registered Nurse Program Director and the clerical staff confirmed that medical records were not secured and non-licensed housekeeping employees were in the clinic after closing. The Director further stated that the hyperbaric chamber repair technicians do service work in the clinic after closing, and that no professional staff are present during performance of housekeeping or repair duties.