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Based on review of hospital policy, meeting minutes, and interviews with personnel. The hospital failed to correctly identify grievances. The hospital does not ensure all grievances are reviewed by the Governing Body or a Committee appointed by the Governing body. There is no documentation the hospital ensures grievance data is used to improve patient care.

Findings:

On 6/6/2012 surveyors reviewed the grievance policy entitled "Patient Grievance Procedure" with an effective date of July 24, 2009 a patient grievance, as used in this policy, will mean patient concern, complaint, or suggestions for improvement, especially with regard to patient rights. The policy further stipulates, Procedure, Complaints/Grievances of Immediate and Direct Resolution by staff, 1. Patients or patients' family members/representatives may report a grievance concerning the patient's care or the hospital's observation of the patient's rights to any employee of HMC. 2. If that employee is able to resolve the grievance to the patient's or family members' satisfaction, the employee may do so. The patient grievance is considered resolved and no further action is required." The policy then stipulates Complaints/Grievance Not subject to Immediate resolution by staff, 3. The Risk Management Department shall be responsible for reviewing the Grievance Log on a regular basis and forwarding to the appropriate manager/director for follow-up. 4. The manager/director shall initiate an investigation promptly by reviewing the patient's medical record or other pertinent documentation, and contacts knowledgeable or involved staff to obtain any information they may have regarding the patient's grievance/concern. Actions taken will be documented on the Grievance Form. 5. Within 30 days, the manager/director will provide the patient with a written response to the grievance. In the event that a complaint is complicated, an extensive investigation may be required. In this case, a preliminary letter will be sent within 7 days of the complaint/grievance. In the resolution of the grievance, the manager/director will provide the patient with written notice of its decision, 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. 6. The Risk Manager will determine the necessary grievances to be reported to the Corporate Risk Management office. 8. For behavioral Health Services refer to policy 2002-RI-0175 "Grievance Process"

1. The policy does not correctly define grievance with all the required elements. In an interview on the afternoon of 6/6/2012 Staff B and Staff D, Staff D was unable to correctly describe the difference between a grievance and a complaint. Staff B told surveyors the current policy did not correctly define grievance in accordance with current CMS standards.

2. The hospital does not ensure 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:
In an interview on 6/6/11 Staff A told surveyors the risk management reviewed all grievances. Staff A told surveyors the meetings did not have minutes but staff in the department discussed grievances routinely. There was no evidence that grievance and complaint data was reviewed, trended and analyzed with implementation of corrective and/or process changes to improve patient care.

3. There was no evidence the Governing Body reviewed, trended, and analyzed incident, grievance, and complaint data.

4. Multiple grievances entered in the hospital grievance log met the definition of a grievance but were not taken through the grievance process according to the hospital policy.

5. This information was provided to administration at the exit conference. No further information was provided.

Based on review of records and interviews with staff, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent in the hospital's grievance process. Nine of nine ( #'s1, 4, 5,6,7,8,9,10,11) grievances/ complaints reviewed met the definition of a grievance but did not have all required documentation or elements.

Findings:

According to the policy "Patient Grievance Procedure" with an effective date of July 24, 2009 a patient grievance, as uesed in this policy, will mean patient concern, complaint, or suggestions for improvement, especially with regard to patient rights. The policy further stipulates, Procedure, Complaints/Grievances of Immediate and Direct Resolution by staff, 1. Patients or patients' family members/representatives may report a grievance concerning the patient's care or the hospital's observation of the patient's rights to any employee of HMC. 2. If that employee is able to resolve the grievance to the patient's or family members' satisfaction, the employee may do so. The patient grievance is considered resolved and no further action is required." The policy then stipulates Complaints/Grievance Not subject to Immediate resolution by staff, 3. The Risk Management Department shall be responsible for reviewing the Grievance Log on a regular basis and forwarding to the appropriate manager/director for follow-up. 4. The manager/director shall initiate an investigation promptly by reviewing the patient's medical record or other pertinent documentation, and contacts knowledgeable or involved staff to obtain any information they may have regarding the patient's grievance/concern. Actions taken will be documented on the Grievance Form. 5. Within 30 days, the manager/director will provide the patient with a written response to the grievance. In the event that a complaint is complicated, an extensive investigation may be required. In this case, a preliminary letter will be sent within 7 days of the complaint/grievance. In the resolution of the grievance, the manager/director will provide the patient with written notice of its decision, 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. 6. The Risk Manager will determine the necessary grievances to be reported to the Corporate Risk Management office. 8. For behavioral Health Services refer to policy 2002-RI-0175 "Grievance Process"

1. Grievances #4,6, 8, 11 (which required investigation and follow up) did not have evidence of a letter being sent to the complainant.

2. Grievance #5 . The patient complaint letter was dated 8/22/11. The date on the grievance log stipulated 10/31/11. A handwritten notation indicated the complaint was received by the Director of Nurses 9/12/11. There was no documentation as to why the facility delayed reviewing the grievance. The final response letter sent to the patient was documented as 12/2/11. The facility failed to provide a timely response.

3. Grievance #10 was listed and investigated as a grievance. A response letter was sent before all investigations were completed. The letter did not stipulate what was done on behalf of the patient to resolve the grievance and the steps taken to investigate the grievance.

4. Grievance #7 was listed and investigated as a grievance. A response letter was sent but did not include what was done to investigate the grievance.

5. Grievance #8 was submitted by a relative of a patient. The grievance detailed multiple issues with patient care, dietary, and rude staff. There was no response letter to the complainant. Documentation indicated Staff D called the patient to ask permission to call the complainant. No response letter was sent to the complainant.

6. Grievance #9 stipulated multiple complaints regarding care, intravenous (IV) catheter attempts, delay in treatment, and medical staff issues. The response letter did not indicate what was done to investigate the grievance, and steps taken on behalf of the patient to resolve the issue.

7. Grievance #1 was discussed with Staff G by family of patient #1. Staff G did not identify multiple nursing care issues as a grievance. There was no documentation Staff G had been educated and trained on the grievance process.

8. On 6/6/2012 the above information was shared with administration. There was no further documentation.

Based on a review of policies and procedures and staff interviews, the hospital failed to ensure the grievance process was clearly defined with all the required elements.

Findings:

According to the policy "Patient Grievance Procedure" with an effective date of July 24, 2009 a patient grievance, as used in this policy, will mean patient concern, complaint, or suggestions for improvement, especially with regard to patient rights. The policy further stipulates, Procedure, Complaints/Grievances of Immediate and Direct Resolution by staff, 1. Patients or patients' family members/representatives may report a grievance concerning the patient's care or the hospital's observation of the patient's rights to any employee of HMC. 2. If that employee is able to resolve the grievance to the patient's or family members' satisfaction, the employee may do so. The patient grievance is considered resolved and no further action is required." The policy then stipulates Complaints/Grievance Not subject to Immediate resolution by staff, 3. The Risk Management Department shall be responsible for reviewing the Grievance Log on a regular basis and forwarding to the appropriate manager/director for follow-up. 4. The manager/director shall initiate an investigation promptly by reviewing the patient's medical record or other pertinent documentation, and contacts knowledgeable or involved staff to obtain any information they may have regarding the patient's grievance/concern. Actions taken will be documented on the Grievance Form. 5. Within 30 days, the manager/director will provide the patient with a written response to the grievance. In the event that a complaint is complicated, an extensive investigation may be required. In this case, a preliminary letter will be sent within 7 days of the complaint/grievance. In the resolution of the grievance, the manager/director will provide the patient with written notice of its decision, 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. 6. The Risk Manager will determine the necessary grievances to be reported to the Corporate Risk Management office. 8. For behavioral Health Services refer to policy 2002-RI-0175 "Grievance Process"

1. On the afternoon of 6/6/2012, Staff G (mentioned in the complaint as the manager receiving the complaint information) was interviewed. Staff G told surveyors ---------
2. The hospital policy does not include any notification to the complainant a written response will be sent if the complaint is determined to be a grievance.
3. The hospital policy does not clearly explain how the grievance process works. Several complaint/grievances were identified as meeting the definition of a grievance but were not taken through the grievance process.
4. The hospital policy does not correctly define a grievance with all the required elements.

Based on review of hospital policies and procedures and grievances and interviews with hospital staff, the hospital failed to develop and enforce a grievance policy and process with time frames for review, investigation and a provision for a written response to the complainant with the required information.

Findings:

1. Grievance #5 . The patient complaint letter was dated 8/22/11. The date on the grievance log stipulated 10/31/11. A handwritten notation indicated the complaint was received by the Director of Nurses 9/12/11. There was no documentation as to why the facility delayed reviewing the grievance. The final response letter sent to the patient was documented as 12/2/11. The facility failed to provide a timely response.

3. Grievance #10 was listed and investigated as a grievance. A response letter was sent before all investigations were completed. The letter did not stipulate what was done on behalf of the patient to resolve the grievance and the steps taken to investigate the grievance.

4. Grievance #7 was listed and investigated as a grievance. A response letter was sent but did not include what was done to investigate the grievance.

5. Grievance #8 was submitted by a relative of a patient. The grievance detailed multiple issues with patient care, dietary, and rude staff. There was no response letter to the complainant. Documentation indicated Staff D called the patient to ask permission to call the complainant. No response letter was sent to the complainant.

6. Grievance #9 stipulated multiple complaints regarding care, intravenous (IV) catheter attempts, delay in treatment, and medical staff issues. The response letter did not indicate what was done to investigate the grievance, and steps taken on behalf of the patient to resolve the issue.

7. The above information was provided to administration at the exit conference. No further documentation was provided.

Based on review of the hospital's grievance/complaint policy, grievance log and nine grievances and interviews with hospital staff, the hospital failed to develop a policy with all the required elements,provide a timely written notice to the complainant with 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. This occurred for nine of nine incidents in which patients/patients' representatives filed grievances. These findings were reviewed on the afternoon of 06/06/2012 with administration. No further information was provided.

Based on review of hospital documents, quality improvement meeting minutes, medical records, incident reports and grievances, and interviews with hospital staff, the hospital's quality assessment and performance improvement (QAPI) program failed to identify and analyze process of care issues identified by the surveyors, staff and voiced by patients/patient representatives.

Findings:

1. The QAPI program does not ensure all grievances are recorded/identified and placed through the grievance process. Refer to Tags A-0118, A-0119, A-0121, A-122 and A-0123 for findings.

2. Incident reports are not analyzed and processed through the QAPI program for identification or opportunities for improvement of patient care/practices.

3. These findings were reviewed and verified with Staff A, B and E on the afternoon of 06/06/2012.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure nursing staff are adequately trained, oriented and have demonstrated skills competency for their assigned care areas and are competent to provide care to meet the needs of the patients.

Findings:


1. Staff I's personnel file did not have documentation of current competency or current job description. There was no information Staff I had the education and training to perform the duties he was assigned. There was no documentation Staff I had training on the grievance process or incident reporting.

2. Staff H's personnel file did not have documentation of current orientation, training, or competency to the area(s) he is assigned. There was no documentation Staff H had training on the grievance process or incident reporting.

3. This information was provided at the exit conference. No further documentation was provided.