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Based on interview and record review the hospital failed to provide written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the resulots of the grievance process, and the date of completion for 3 of 3 patients (patient #11, #12, and #13) who filed a complaint in 2016.

Findings included:

On 5/4/16 the grievance report log reflected Patient #11 returned a comment on a Press Ganey Survey. The grievance log reflected the event reviewed on 5/5/16 and 5/9/16. The grievance log does not reflect a resolution or that any letters were sent to the complainant.

On 6/27/16 the grievance report log reflected Patient #12 spoke with customer service about care she received in the Emergency Room on 6/27/16. The grievance does not reflect a resolution to the complaint or that any letters were sent to complainant.

On 7/9/16 the grievance report log reflected Patient #13 called and stated she had received the wrong discharge information and prescription. The grievance log reflected Patient #13 returned to the hospital and was given her correct discharge information and correct prescription. The grievance log does not reflect that any letters were sent to the patient.

In an interview on 7/26/16 at 3:40 PM, Personnel #4 was informed of the above findings. Personnel #4 confirmed that she could not find any response letters to Patient #11 and Patient #12. Personnel #4 stated she has drafted a response letter to Patient #13, but she is waiting for her director to return to sign the letter. Personnel #4 did confirm that none of the above patients had received an initial verbal or written response to their complaints.

Patient Complaints and Grievances policy revised 5/2016 page 2 required "...The Patient's Grievance may be acknowledged by verbal or written communication within seven (7) business days from the date that the Grievance was received. The complainant is updated, generally, at the end of each thirty (30) business day period until a resolution is reached.

Based on record review and interview, the hospital failed to complete a discharge summary within 30 days following discharge, in that, 1 of 1 patient (Patient #5) did not have a discharge summary completed within 30 days of discharge.

Findings included:

Patient #5's medical record reflected a discharge date of 6/15/16. The discharge summary has not been completed for Patient #5 as of 7/26/16.

During an interview on 7/26/16 at 2:10 PM Personnel #5 and Personnel #6 were informed of the above findings. Personnel #5 and Personnel #6 agreed there is not a discharge summary for Patient #5 in the medical record.