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Based on staff interview and review of facility policies and grievance documentation, it was determined the facility failed to ensure review, investigation, and resolution of grievances within established time frames for 8 of 9 patients (#1, #2, #3, #4, #5, #7, #9 and #10) whose grievance documentation was reviewed. Failure to meet time frames for communication regarding ongoing investigations and resolution of grievances led to extended periods of time between submission and resolution of a grievance without documentation of communication with the complainant. Findings include:

The hospital's "Patient/Family Complaint and Grievance Policy," approved 10/21/11, was reviewed. According to the policy, "Grievances will be addressed by the department director or his/her designee and response made to the complainant within seven (7) calendar days of receipt of the grievance. If the grievance is one that will take longer than seven calendar (7) days to investigated and resolve, the director will contact the complainant within that time frame and let him/her know the grievance has been received and is being investigated and that the director will report back to the complainant within thirty (30) calendar days with a resolution of the grievance." The policy did not guide staff on the process to follow if the grievance took longer than 30 days to investigate and resolve.

Grievances were not responded to in accordance to policy as follows:

1. Patient #2 submitted a grievance to the hospital on 6/19/12 regarding lack of attention from the nursing staff. Grievance documentation indicated the Risk Management and Compliance Coordinator contacted Patient #2 via telephone on 6/19/12 to obtain additional details of the concerns. Additional documentation included a medical record review and results of interviews with involved staff members. A response letter to Patient #2 was present in the documentation and a hand written note at the bottom of the letter indicated the Risk Management and Compliance Coordinator sent the letter to Patient #2 on 8/02/12, 44 days after the receipt of the grievance.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM. She reviewed the grievance documentation for Patient #2 and confirmed that Patient #2 was not notified of the results of the grievance process within 30 days in accordance with hospital policy.

Patient #2's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

2. Patient #3's physician left a voice message for the Director of Nursing on 4/27/12, to let him know Patient #3 had a bad experience at the facility during a recent hospitalization. On 4/30/12, the Risk Management and Compliance Coordinator documented speaking with Patient #3, as well as, a relative of Patient #3's who witnessed several of the events referenced in the complaint. Patient #3's concerns were related to a fall she experienced while at the hospital and several nursing care issues. The grievance documentation included a conclusion summary of the concerns and the decision to financially compensate Patient #3. This document was dated 6/13/12, 47 days after the initial contact with Patient #3.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed grievance documentation for Patient #3. She confirmed that the investigation and response to Patient #3 was not within the specified time frame of 30 days. She stated she submitted her report (the conclusion summary) to the Chief Compliance Officer on 6/13/12 and spoke with Patient #3 at that time to let her know it was going to take some time to obtain the money for her refund. She stated she met with Patient #3 on 7/09/12 and mailed a copy of the conclusion summary to her on 7/12/12.

Patient #3's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

3. Grievance documentation for Patient #4 included hand-written notes, undated and unsigned, that were forwarded to the Risk Management and Compliance Coordinator. The documentation indicated Patient #4 was concerned that she was discharged prematurely while exhibiting symptoms of potential cardiopulmonary dysfunction for which she was readmitted to a different facility for evaluation and treatment. The Risk Management and Compliance Coordinator documented receipt of the grievance on 4/28/12, and that Patient #4 was notified by mail of the resolution of the grievance on 6/15/12, 48 days later. However, her grievance documentation also included a "SETTLEMENT AGREEMENT AND RELEASE" form, signed and dated by Patient #4 on 7/09/12.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed grievance documentation for Patient #4. She explained the Director of Nursing spoke with Patient #4 on 4/26/12. The Risk Management and Compliance Coordinator stated the Director of Nursing supplied his hand-written notes to her on 4/28/12 and she then contacted Patient #4 via telephone to acknowledge receipt of the grievance. She confirmed this phone call was not documented. She also confirmed the investigation and resolution of the grievance did not take place within the 30 day time frame outlined in the hospital policy. She explained that, as a result of the investigation, it was decided to refund money to Patient #4. She stated that the information was sent to the Chief Compliance Officer, who met with Patient #4 on 7/09/12.

Patient #4's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

4. Patient #10, and Patient #10's mother, each submitted grievance letters to the hospital which were documented as received on 5/07/12. The concerns were related to their experience with the technician during a sleep study. Grievance documentation, dated 7/13/12, included a conclusion summary of the concerns, results of the investigation, and the decision to financially compensate Patient #10, 67 days after receipt of the grievance.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed the grievance documentation for Patient #10. She stated Patient #10 was not feeling well so she spoke with Patient #10's mother on 5/08/12 to acknowledge receipt of the grievance. She explained that it took time to complete the investigation but that she spoke with Patient #10 and his mother on 6/12/12. She stated that they were unhappy with the initial resolution and requested monetary compensation. She stated she notified the Chief Compliance Officer and the decision was made to discount Patient #10's hospital bill, which took until 7/13/12. The Risk Management and Compliance Coordinator confirmed the contact with the family regarding the initial resolution was actually 36 days after receipt of grievance, not within the time frame specified in the policy. She stated the hospital policy was not clear regarding the process to follow when it was going to take longer than 30 days to complete an investigation.

Patient #10's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

5. An "Investigation Form" indicated the compliance department was notified of the grievance for Patient #9 on 8/15/11. Documentation on the form indicated Patient #9 received, and subsequently took, a medication he was allergic to and this resulted in additional expenses and time off work for treatment. The grievance documentation included an apology letter sent to Patient #9, dated 11/02/11, 79 days after receipt of the grievance.

The Chief Compliance Officer was interviewed on 8/09/12 at 8:25 AM. He reviewed the grievance documentation for Patient #9 and confirmed the grievance was not resolved within the time frame specified in the hospital's policy.

Patient #9's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

6. Grievance documentation for Patient #1 included an e-mail written by Patient #1, dated 4/26/12. Patient #1 indicated several concerns regarding nursing care and responsiveness to call lights. Documentation in the grievance file indicated the concerns were sent to the Med-Surg [Medical-Surgical] Supervisor and Chief Compliance Officer on 5/04/12. The Med-Surg Supervisor completed a record review and forwarded the results to several individuals, including the Chief Compliance Office and Director of Nursing, on 5/04/12. However, the Risk Management and Compliance Coordinator documented the information was received from the Chief Compliance Officer on 6/19/12. The Risk Management and Compliance Coordinator documented contacting Patient #1 via telephone on 6/19/12. The grievance documentation included a summary of the concerns and the decision to financially compensate Patient #1, dated 8/01/12, 98 days after Patient #1 sent the grievance.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM. She reviewed the grievance documentation for Patient #1. She explained that Patient #1 had sent the original e-mailed letter to the business and the business office forwarded it to the Director of Nursing. She stated the information had been forwarded to herself and the Chief Compliance Officer in May but that both of them failed to notice the e-mail. She stated that on 6/19/12 the information was found and she processed the grievance. The Risk Management and Compliance Coordinator stated that because of the delay in processing, it was decided to reduce Patient #1's bill. She stated this information was sent to the business office on 8/01/12 and that she spoke with Patient #1 on 8/06/12. She confirmed there was no documentation of these two interactions. She also confirmed that hospital staff did not contact Patient #1 within 7 days in accordance with policy, and Patient #1 did not receive additional communication or a resolution to her grievance within 30 days.

Patient #1's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.



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7. Patient #5 submitted a grievance to the hospital on 7/12/12 regarding a long wait for IV antibiotic therapy as well as concern that a nurse caused an infiltrated IV site which resulted in a tender, bruised area. Grievance documentation indicated the Risk Management and Compliance Coordinator attempted to contact Patient #5 on 7/23/12 via telephone but was unable to speak with Patient #5 at that time. Additional documentation by the Risk Management and Compliance Coordinator , undated, included "I spoke w/pt [with patient]. Patient wishes to drop the complaint, because 'I will no longer go there on weekends'." There was no further documentation of communication between the hospital and Patient #5.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM. She reviewed Patient #5's grievance documentation and confirmed the second entry on the grievance form was not dated. She explained that she spoke with Patient #5 during a second phone call, several days after the attempt on 7/23/12. The Risk Management and Compliance Coordinator confirmed she was not able to respond to Patient #5's grievance within seven days and did not report back to Patient #5 within 30 days with a resolution.

Patient #5's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

8. Patient #7 submitted a grievance to the hospital on 7/10/12 regarding multiple negative experiences with IV and IM medication infusions resulting in severe pain. Grievance documentation indicated the Risk Management and Compliance Coordinator left a message for Patient #7 on 7/23/12.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM. She reviewed Patient #7's grievance documentation, and confirmed she did not reach Patient #7 within the time frame established in the hospital policy. She explained that if three attempts to contact a patient by phone were unsuccessful, she would then send a letter. The Risk Management and Compliance Coordinator explained that she was waiting for the Med-Surg Supervisor to review the medical record but that there was no timeline for when that would be accomplished. She confirmed that she was not able to contact Patient #7 within the first 7 days after receipt of the grievance. She confirmed the investigation was not complete and the grievance was not resolved 29 days after receipt of the grievance.

Patient #7's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

Based on staff interview and review of grievance documentation and facility policy, it was determined the facility failed to provide a written response to grievances for 7 of 9 patients (#1, #2, #3, #4, #5, #9 and #10) whose grievance documentation was reviewed. This failure had the potential to result in lack of clarity related to the steps taken to investigate the grievance and resolution of the investigation process. Findings include:

The hospital's "Patient/Family Complaint and Grievance Policy," approved 10/21/11, was reviewed. According to the policy, "All persons with a grievance will receive a written notice of the investigators review, which will include the name of a contact person, steps taken to investigate the grievance, the result of the grievance process and the date of completion." In addition, the policy indicated, "Grievances are considered completed when an approved response has been mailed to the patient/complainant."

Grievances were not responded to with written notice as follows:

1. Patient #2 submitted a grievance to the hospital on 6/19/12 regarding lack of attention from the nursing staff. Grievance documentation indicated the Risk Management and Compliance Coordinator contacted Patient #2 via telephone on 6/19/12 to obtain additional details of the concerns. Additional documentation included a medical record review and results of interviews with involved staff members. A response letter to Patient #2 was present in the documentation and a hand written note at the bottom of the letter indicated the Risk Management and Compliance Coordinator sent the letter to Patient #2 on 8/02/12, 44 days after the receipt of the grievance.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed Patient #2's grievance documentation. She explained Patient #2's medical record was reviewed by herself and the Chief Compliance Officer and staff were interviewed. She stated it was felt that there was no wrong-doing on the part of the hospital and a letter of apology was sent. The Risk Management and Compliance Coordinator confirmed the letter of apology did not include the steps taken to investigate the grievance or the results of the grievance process. She stated the Chief Compliance Officer left it up to her to decide whether to phone the complainant with the resolution of the grievance, or send them a letter. She stated if there was no merit to the grievance, an apology letter will be sent. If the grievance had merit she would contact the patient by phone.

Patient #2 did not receive a written notice of the steps taken to investigate the grievance and the result of the grievance process.

2. Patient #3's physician left a voice message for the Director of Nursing on 4/27/12, to let him know Patient #3 had a bad experience at the facility during a recent hospitalization. On 4/30/12, the Risk Management and Compliance Coordinator documented speaking with Patient #3, as well as, a relative of Patient #3's who witnessed several of the events referenced in the complaint. Patient #3's concerns were related to a fall she experienced while at the hospital and several nursing care issues. The grievance documentation included a conclusion summary of the concerns and the decision to financially compensate Patient #3. This document was dated 6/13/12, 47 days after the initial contact with Patient #3.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed grievance documentation for Patient #3. She stated she met with Patient #3 on 7/09/12 and mailed a copy of the conclusion summary to her on 7/12/12. The Risk Management and Compliance Coordinator confirmed the conclusion summary mailed to Patient #3 did not contain the steps of the investigation process, the results of the grievance process, or the date of resolution of the grievance.

Patient #3 did not receive a written notice of the steps taken to investigate the grievance and the result of the grievance process.

3. Grievance documentation for Patient #4 included hand written notes, undated and unsigned, that were forwarded to the Risk Management and Compliance Coordinator. The documentation indicated Patient #4 was concerned that she was discharged prematurely while exhibiting symptoms of potential cardiopulmonary dysfunction for which she was readmitted to a different facility for evaluation and treatment. The Risk Management and Compliance Coordinator documented receipt of the grievance on 4/28/12, and that Patient #4 was notified by mail of the resolution of the grievance on 6/15/12, 48 days later. Her grievance documentation also included a "SETTLEMENT AGREEMENT AND RELEASE" form, signed and dated by Patient #4 on 7/09/12.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed grievance documentation for Patient #4. She stated the medical record was reviewed and staff were interviewed. She explained the investigation showed a delay in Patient #4's discharge and, as a result, it was decided to refund money to Patient #4. She stated that the information was sent to the Chief Compliance Officer, who met with Patient #4 on 7/09/12. She that Patient #4 was not given a letter of resolution for the grievance.

Patient #4 did not receive a written notice of the steps taken to investigate the grievance and the result of the grievance process.

4. Patient #10, and Patient #10's mother, each submitted grievance letters to the hospital which were documented being received on 5/07/12. The concerns were related to their experience with the technician during a sleep study. Grievance documentation, dated 7/13/12, included a conclusion summary of the concerns, results of the investigation, and the decision to financially compensate Patient #10, 67 days after receipt of the grievance.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM. She reviewed the grievance documentation for Patient #10. She stated the record for Patient #10 was reviewed and the technician was interviewed. She stated that the physician reviewed the filmed footage of the sleep study and was interviewed. She confirmed that as a result of the investigation changes had been made to the sleep study rooms to improve patient care. She explained that it took time to complete the investigation but that she spoke with Patient #10 and his mother on 6/12/12. She stated that they were unhappy with the initial resolution and requested monetary compensation. She stated she notified the Chief Compliance Officer and the decision was made to discount Patient #10's hospital bill, which took until 7/13/12. She confirmed that Patient #10 did not receive a letter indicated the steps taken to investigate the concerns or the results of the grievance process.

Patient #10 did not receive a written notice of the steps taken to investigate the grievance and the results of the grievance process.

5. An "Investigation Form" indicated the compliance department was notified of the grievance for Patient #9 on 8/15/11. Documentation on the form indicated Patient #9 received, and subsequently took, a medication he was allergic to and this resulted in additional expenses and time off work for treatment. The grievance documentation included an apology letter sent to Patient #9, dated 11/02/11, 79 after receipt of the grievance.

The Chief Compliance Officer was interviewed on 8/08/12 at 4:00 PM. He explained that usually complainants were sent an apology letter, especially if the investigation did not reveal substandard care on the part of the hospital. He stated, if it was determined that there was a deficiency in care provided and the resolution involved monetary compensation, he would often meet in person with the complainant. He stated during this meeting he would discuss the investigation process and resolution and if necessary provide them a check. He confirmed that as a routine, no letter regarding the steps taken to investigate a concern and the resolution of the grievance process were provided to complainants.

On 8/09/12 at 8:25 AM, the Chief Compliance Officer reviewed the grievance documentation for Patient #9. He confirmed he did meet in person with Patient #9, however, the apology letter sent to Patient #9 did not include the steps taken to investigate the grievance or the results of the grievance process.

Patient #9 did not receive a written notice of the steps taken to investigate the grievance and the results of the grievance process.

6. Grievance documentation for Patient #1 included an e-mail written by Patient #1, dated 4/26/12. Patient #1 indicated several concerns regarding nursing care and responsiveness to call lights. Documentation in the grievance file indicated the concerns were sent to the Med-Surg [Medical-Surgical] Supervisor and Chief Compliance Officer on 5/04/12. The Med-Surg Supervisor completed a record review and forwarded the results to several individual, including the Chief Compliance Office and Director of Nursing, on 5/04/12. However, the Risk Management and Compliance Coordinator documented the information was received from the Chief Compliance Officer on 6/19/12, and immediately telephoned Patient #1. The grievance documentation included a summary of the concerns and the decision to financially compensate Patient #1, dated 8/01/12, 98 days after Patient #1 sent the grievance.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM. She reviewed the grievance documentation for Patient #1 and explained investigation of the concerns included review of the record by herself and the Med-Surg Supervisor and discussions with the nursing staff involved. She stated she reported back to the Chief Compliance Officer and it was decided that because of the delay in processing, Patient #1's bill would be reduced. She stated this information was sent to the business office on 8/01/12 and that she spoke with Patient #1 on 8/06/12. She confirmed there was no documentation of these two interactions and no letter with her contact information, steps and resolution of the investigation, and the date of completion sent to Patient #1.

Patient #1 did not receive a written notice of the steps taken to investigate the grievance and the results of the grievance process.



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7. Patient #5 submitted a grievance to the hospital on 7/12/12 regarding a long wait for IV antibiotic therapy as well as concern that a nurse caused an infiltrate IV site which resulted in a tender, bruised area. Grievance documentation indicated the Risk Management and Compliance Coordinator attempted to contact Patient #5 on 7/23/12 via telephone but was unable to speak with Patient #5. Additional documentation, undated, included "I spoke w/pt [with patient]. Patient wishes to drop the complaint, because 'I will no longer go there on weekends'. " There was no additional documentation present in the grievance file.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM. She reviewed Patient #5's grievance documentation. The Risk Management and Compliance Coordinator stated she considered the grievance resolved, as Patient #5 wanted to drop the complaint. She stated she did not think a written response to the patient was necessary.

Patient #5 did not receive a written notice of the steps taken to investigate the grievance and the results of the grievance process.

Based on staff interview and review of facility policies and grievance documentation, it was determined the facility failed to ensure review, investigation, and resolution of grievances within established time frames for 8 of 9 patients (#1, #2, #3, #4, #5, #7, #9 and #10) whose grievance documentation was reviewed. Failure to meet time frames for communication regarding ongoing investigations and resolution of grievances led to extended periods of time between submission and resolution of a grievance without documentation of communication with the complainant. Findings include:

The hospital's "Patient/Family Complaint and Grievance Policy," approved 10/21/11, was reviewed. According to the policy, "Grievances will be addressed by the department director or his/her designee and response made to the complainant within seven (7) calendar days of receipt of the grievance. If the grievance is one that will take longer than seven calendar (7) days to investigated and resolve, the director will contact the complainant within that time frame and let him/her know the grievance has been received and is being investigated and that the director will report back to the complainant within thirty (30) calendar days with a resolution of the grievance." The policy did not guide staff on the process to follow if the grievance took longer than 30 days to investigate and resolve.

Grievances were not responded to in accordance to policy as follows:

1. Patient #2 submitted a grievance to the hospital on 6/19/12 regarding lack of attention from the nursing staff. Grievance documentation indicated the Risk Management and Compliance Coordinator contacted Patient #2 via telephone on 6/19/12 to obtain additional details of the concerns. Additional documentation included a medical record review and results of interviews with involved staff members. A response letter to Patient #2 was present in the documentation and a hand written note at the bottom of the letter indicated the Risk Management and Compliance Coordinator sent the letter to Patient #2 on 8/02/12, 44 days after the receipt of the grievance.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM. She reviewed the grievance documentation for Patient #2 and confirmed that Patient #2 was not notified of the results of the grievance process within 30 days in accordance with hospital policy.

Patient #2's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

2. Patient #3's physician left a voice message for the Director of Nursing on 4/27/12, to let him know Patient #3 had a bad experience at the facility during a recent hospitalization. On 4/30/12, the Risk Management and Compliance Coordinator documented speaking with Patient #3, as well as, a relative of Patient #3's who witnessed several of the events referenced in the complaint. Patient #3's concerns were related to a fall she experienced while at the hospital and several nursing care issues. The grievance documentation included a conclusion summary of the concerns and the decision to financially compensate Patient #3. This document was dated 6/13/12, 47 days after the initial contact with Patient #3.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed grievance documentation for Patient #3. She confirmed that the investigation and response to Patient #3 was not within the specified time frame of 30 days. She stated she submitted her report (the conclusion summary) to the Chief Compliance Officer on 6/13/12 and spoke with Patient #3 at that time to let her know it was going to take some time to obtain the money for her refund. She stated she met with Patient #3 on 7/09/12 and mailed a copy of the conclusion summary to her on 7/12/12.

Patient #3's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

3. Grievance documentation for Patient #4 included hand-written notes, undated and unsigned, that were forwarded to the Risk Management and Compliance Coordinator. The documentation indicated Patient #4 was concerned that she was discharged prematurely while exhibiting symptoms of potential cardiopulmonary dysfunction for which she was readmitted to a different facility for evaluation and treatment. The Risk Management and Compliance Coordinator documented receipt of the grievance on 4/28/12, and that Patient #4 was notified by mail of the resolution of the grievance on 6/15/12, 48 days later. However, her grievance documentation also included a "SETTLEMENT AGREEMENT AND RELEASE" form, signed and dated by Patient #4 on 7/09/12.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed grievance documentation for Patient #4. She explained the Director of Nursing spoke with Patient #4 on 4/26/12. The Risk Management and Compliance Coordinator stated the Director of Nursing supplied his hand-written notes to her on 4/28/12 and she then contacted Patient #4 via telephone to acknowledge receipt of the grievance. She confirmed this phone call was not documented. She also confirmed the investigation and resolution of the grievance did not take place within the 30 day time frame outlined in the hospital policy. She explained that, as a result of the investigation, it was decided to refund money to Patient #4. She stated that the information was sent to the Chief Compliance Officer, who met with Patient #4 on 7/09/12.

Patient #4's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

4. Patient #10, and Patient #10's mother, each submitted grievance letters to the hospital which were documented as received on 5/07/12. The concerns were related to their experience with the technician during a sleep study. Grievance documentation, dated 7/13/12, included a conclusion summary of the concerns, results of the investigation, and the decision to financially compensate Patient #10, 67 days after receipt of the grievance.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed the grievance documentation for Patient #10. She stated Patient #10 was not feeling well so she spoke with Patient #10's mother on 5/08/12 to acknowledge receipt of the grievance. She explained that it took time to complete the investigation but that she spoke with Patient #10 and his mother on 6/12/12. She stated that they were unhappy with the initial resolution and requested monetary compensation. She stated she notified the Chief Compliance Officer and the decision was made to discount Patient #10's hospital bill, which took until 7/13/12. The Risk Management and Compliance Coordinator confirmed the contact with the family regarding the initial resolution was actually 36 days after receipt of grievance, not within the time frame specified in the policy. She stated the hospital policy was not clear regarding the process to follow when it was going to take longer than 30 days to complete an investigation.

Patient #10's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

5. An "Investigation Form" indicated the compliance department was notified of the grievance for Patient #9 on 8/15/11. Documentation on the form indicated Patient #9 received, and subsequently took, a medication he was allergic to and this resulted in additional expenses and time off work for treatment. The grievance documentation included an apology letter sent to Patient #9, dated 11/02/11, 79 days after receipt of the grievance.

The Chief Compliance Officer was interviewed on 8/09/12 at 8:25 AM. He reviewed the grievance documentation for Patient #9 and confirmed the grievance was not resolved within the time frame specified in the hospital's policy.

Patient #9's grievance was not reviewed, investigated, and resolved in within time frames specified in hospital policy.

6. Grievance docu

Based on staff interview and review of grievance documentation and facility policy, it was determined the facility failed to provide a written response to grievances for 7 of 9 patients (#1, #2, #3, #4, #5, #9 and #10) whose grievance documentation was reviewed. This failure had the potential to result in lack of clarity related to the steps taken to investigate the grievance and resolution of the investigation process. Findings include:

The hospital's "Patient/Family Complaint and Grievance Policy," approved 10/21/11, was reviewed. According to the policy, "All persons with a grievance will receive a written notice of the investigators review, which will include the name of a contact person, steps taken to investigate the grievance, the result of the grievance process and the date of completion." In addition, the policy indicated, "Grievances are considered completed when an approved response has been mailed to the patient/complainant."

Grievances were not responded to with written notice as follows:

1. Patient #2 submitted a grievance to the hospital on 6/19/12 regarding lack of attention from the nursing staff. Grievance documentation indicated the Risk Management and Compliance Coordinator contacted Patient #2 via telephone on 6/19/12 to obtain additional details of the concerns. Additional documentation included a medical record review and results of interviews with involved staff members. A response letter to Patient #2 was present in the documentation and a hand written note at the bottom of the letter indicated the Risk Management and Compliance Coordinator sent the letter to Patient #2 on 8/02/12, 44 days after the receipt of the grievance.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed Patient #2's grievance documentation. She explained Patient #2's medical record was reviewed by herself and the Chief Compliance Officer and staff were interviewed. She stated it was felt that there was no wrong-doing on the part of the hospital and a letter of apology was sent. The Risk Management and Compliance Coordinator confirmed the letter of apology did not include the steps taken to investigate the grievance or the results of the grievance process. She stated the Chief Compliance Officer left it up to her to decide whether to phone the complainant with the resolution of the grievance, or send them a letter. She stated if there was no merit to the grievance, an apology letter will be sent. If the grievance had merit she would contact the patient by phone.

Patient #2 did not receive a written notice of the steps taken to investigate the grievance and the result of the grievance process.

2. Patient #3's physician left a voice message for the Director of Nursing on 4/27/12, to let him know Patient #3 had a bad experience at the facility during a recent hospitalization. On 4/30/12, the Risk Management and Compliance Coordinator documented speaking with Patient #3, as well as, a relative of Patient #3's who witnessed several of the events referenced in the complaint. Patient #3's concerns were related to a fall she experienced while at the hospital and several nursing care issues. The grievance documentation included a conclusion summary of the concerns and the decision to financially compensate Patient #3. This document was dated 6/13/12, 47 days after the initial contact with Patient #3.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed grievance documentation for Patient #3. She stated she met with Patient #3 on 7/09/12 and mailed a copy of the conclusion summary to her on 7/12/12. The Risk Management and Compliance Coordinator confirmed the conclusion summary mailed to Patient #3 did not contain the steps of the investigation process, the results of the grievance process, or the date of resolution of the grievance.

Patient #3 did not receive a written notice of the steps taken to investigate the grievance and the result of the grievance process.

3. Grievance documentation for Patient #4 included hand written notes, undated and unsigned, that were forwarded to the Risk Management and Compliance Coordinator. The documentation indicated Patient #4 was concerned that she was discharged prematurely while exhibiting symptoms of potential cardiopulmonary dysfunction for which she was readmitted to a different facility for evaluation and treatment. The Risk Management and Compliance Coordinator documented receipt of the grievance on 4/28/12, and that Patient #4 was notified by mail of the resolution of the grievance on 6/15/12, 48 days later. Her grievance documentation also included a "SETTLEMENT AGREEMENT AND RELEASE" form, signed and dated by Patient #4 on 7/09/12.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM and again on 8/09/12 at 8:35 AM. She reviewed grievance documentation for Patient #4. She stated the medical record was reviewed and staff were interviewed. She explained the investigation showed a delay in Patient #4's discharge and, as a result, it was decided to refund money to Patient #4. She stated that the information was sent to the Chief Compliance Officer, who met with Patient #4 on 7/09/12. She that Patient #4 was not given a letter of resolution for the grievance.

Patient #4 did not receive a written notice of the steps taken to investigate the grievance and the result of the grievance process.

4. Patient #10, and Patient #10's mother, each submitted grievance letters to the hospital which were documented being received on 5/07/12. The concerns were related to their experience with the technician during a sleep study. Grievance documentation, dated 7/13/12, included a conclusion summary of the concerns, results of the investigation, and the decision to financially compensate Patient #10, 67 days after receipt of the grievance.

The Risk Management and Compliance Coordinator was interviewed on 8/08/12 at 2:15 PM. She reviewed the grievance documentation for Patient #10. She stated the record for Patient #10 was reviewed and the technician was interviewed. She stated that the physician reviewed the filmed footage of the sleep study and was interviewed. She confirmed that as a result of the investigation changes had been made to the sleep study rooms to improve patient care. She explained that it took time to complete the investigation but that she spoke with Patient #10 and his mother on 6/12/12. She stated that they were unhappy with the initial resolution and requested monetary compensation. She stated she notified the Chief Compliance Officer and the decision was made to discount Patient #10's hospital bill, which took until 7/13/12. She confirmed that Patient #10 did not receive a letter indicated the steps taken to investigate the concerns or the results of the grievance process.

Patient #10 did not receive a written notice of the steps taken to investigate the grievance and the results of the grievance process.

5. An "Investigation Form" indicated the compliance department was notified of the grievance for Patient #9 on 8/15/11. Documentation on the form indicated Patient #9 received, and subsequently took, a medication he was allergic to and this resulted in additional expenses and time off work for treatment. The grievance documentation included an apology letter sent to Patient #9, dated 11/02/11, 79 after receipt of the grievance.

The Chief Compliance Officer was interviewed on 8/08/12 at 4:00 PM. He explained that usually complainants were sent an apology letter, especially if the investigation did not reveal substandard care on the part of the hospital. He stated, if it was determined that there was a deficiency in care provided and the resolution involved monetary compensation, he would often meet in person with the complainant. He stated during this meeting he would discuss the investigation process and resolution and if necessary provide them a check. He confirmed that as a routine, no letter regarding the steps taken to investigat