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Based on document review and staff interview, the facility failed to ensure that the notice of the grievance decision included the required result of the grievance process and the date of resolution of the grievance for 6 (#s 1, 2, 3, 5, 6, and 8) of 8 reviewed complaint/grievances. Findings include:

The surveyor began the review of reported grievances on 1/7/13 beginning at 12:40 p.m. During the review, the surveyor noted 8 grievances that were documented in the log as closed. The surveyor requested the completed documentation and communication for review.

1. Grievance #1 was a complaint about poor care received in the emergency department. The information provided documented the receipt of the complaint/grievance, who handled the investigation, dates and times of contacts with the complainant, and the date the letter was sent. Review of the letter failed to reveal the documentation of the grievance being resolved and the date of the resolution.

2. Grievance #2 was a complaint about care received in the emergency department and the behavior of two employees of the facility. The information provided documented the receipt of the complaint/grievance, who handled the investigation, dates and times of contacts with the complainant, and the date the letter was sent. Review of the letter failed to reveal the documentation of the grievance being resolved and the date of the resolution.

3. Grievance #3 was a complaint about care received in the emergency department and the behavior of two employees of the facility. The information provided documented the receipt of the complaint/grievance, who handled the investigation, dates and times of contacts with the complainant, and the date the letter was sent. Review of the letter failed to reveal the documentation of the grievance being resolved and the date of the resolution.

4. Grievance #5 was a complaint about care received in the emergency department and the behavior of two employees of the facility. The information provided documented the receipt of the complaint/grievance, who handled the investigation, dates and times of contacts with the complainant, and the date the letter was sent. Review of the letter failed to reveal the documentation of the grievance being resolved and the date of the resolution.

5. Grievance #6 was a complaint about care received in the emergency department and the behavior of two employees of the facility. The information provided documented the receipt of the complaint/grievance, who handled the investigation, dates and times of contacts with the complainant, and the date the letter was sent. Review of the letter failed to reveal the documentation of the grievance being resolved and the date of the resolution.

6. Grievance #8 was a complaint about care received in the emergency department and the behavior of two employees of the facility. The information provided documented the receipt of the complaint/grievance, who handled the investigation, dates and times of contacts with the complainant, and the date the letter was sent. Review of the letter failed to reveal the documentation of the grievance being resolved and the date of the resolution.

During an interview with staff member B, the Patient Safety Coordinator, on 1/8/13 at 8:25 a.m., staff member B stated that she was not aware of the requirement for the date of completion of the grievance process.

Based on policy review, document review, and staff interviews, the facility failed to ensure that all patients treated within the facility were protected from all forms of abuse and harassment. Findings include:

On 1/7/13 during the review of the facility grievance log beginning at 12:40 p.m., the surveyor noted that the log included a total of 34 complaints/grievances during the calendar year of 2012. Of the 34 entries, 18 were concerned with care or activities in the emergency department. Of those 18 complaints/grievances, 7 referenced rude or inappropriate behavior or attitude displayed by members of the provider and nursing staff, and one made a direct reference to perceived harassment. The facility investigated the grievances/complaints and responded to the complainants with required response letters. All of the letters to the complainants included an apology for the identified issues.

On 1/7/13 at 12:50 p.m., the surveyor received and reviewed the facility policies and procedures addressing patient rights, including abuse and harassment. The policies and procedures covered all of the required regulatory aspects of abuse training.

On 1/8/13, beginning at 8:25 a.m., the surveyor interviewed staff member B, the Patient Safety Coordinator. During the interview, staff member B stated that there had been multiple complaints of rude or inappropriate conduct from different departments within the facility. Staff member B stated that when a problem was identified, the staff member that was identified was counseled by his/her supervisor and further actions were dependent on recurrences or the severity of the event. Staff member B related that there had been a problem with behavior/attitude identified in the Emergency Department that caused the provision of additional training for the provider and nursing staff, the termination of a provider, and a change in supervision over the staff in the Emergency Department.

On 1/8/13, beginning at 9:35 a.m., interviews were conducted with 10 members of the facility care staff to assess their knowledge of abuse and harassment characteristics, and facility expectations regarding the treatment of patients. All 10 were able to verbalize at least two types of abuse, most commonly, physical and emotional abuse. Half of the staff interviewed had to be reminded of some of the other four forms of abuse, that included verbal abuse, sexual abuse, neglect, and misappropriation of funds. When asked if the staff members were aware of any abuse that had occurred in the facility in the past, 3 of the 10 interviewed staff, staff members A, the Vice-President for Patient Care Services, D, the Medical Director of the Emergency Department, and L, the Director of Critical Care, stated that they were aware of past abuse in the facility. One of the three interviewees, staff member A, acknowledged there had been problems with abusive type behaviors in one department and that there had been changes in supervision to try to correct the problem in October of 2012. The grievance log documented events up through December of 2012. All of the interviews were conducted in the presence of staff member A, the vice president for clinical services.

On 1/8/13, beginning at 12:45 p.m., the surveyor reviewed the employee files of 10 members of the facility nursing staff. All 10 staff had complete files, current licensure, and evidence of completion of annual competencies that included training in Abuse, Neglect, and Exploitation within the last 12 months. The surveyor received evidence that the provider staff had also completed the annual abuse training during the last 12 months.

During an interview with staff member A on 1/8/13 at approximately 3:15 p.m., staff member A stated that staff knowledge of the forms of abuse needed improvement.