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Based on review of the hospital's grievance/complaint policy, grievance log and seven grievances and interviews with hospital staff, the hospital failed to provide a 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 three of six patients/patients' representatives who filed grievances (Grievance #1 through 6 of Grievances #1 through 7) when the complaint was not resolved at the time of the complaint by staff present or immediately available.

Findings:
1. The hospital's grievance policy, entitled "Patient Complaint/Grievance Resolution," with an issue date of February 2008, on pages 2 and 3, appropriately stipulated that a written response would be provided to the complainant with the "steps taken on behalf of the patient to investigate the grievance; findings of the investigation; results of the grievance process (corrective measures initiated, if any); date of completion of the process; name of the hospital contact person"and this process should be completed within 45 days from the date of receipt of the complaint.

2. The surveyors selected six concerns/complaints/grievances from the complaint, grievance and claim log for September 2009, and March and April 2011. Upon review of the data supplied by the hospital, five of the concerns listed were grievances. The problems/concerns identified by complainants could not be resolved at the time of the complaint and required investigation. This finding was reviewed and verified with hospital administrative staff # A throughout the survey.

3. During the review of the incident reports selected from the incident log for the time period listed in Finding #2, in two of the incidents, the patient/patient representative had also voiced a grievance. For one of these grievances voiced (Patient #3), the hospital could not produce evidence it had investigated and responded to the complainant. For the other one, voiced by Patient #1, the hospital investigated the complaint, but it was not channeled through the grievance process, but was identified as a claim.

5. Three of six grievances/complaints reviewed, not resolved at the time the complaint was issued, did not contain a written response to the complainant with the required information. On the afternoon of 06/22/2011, the surveyors confirmed with administrative staff #A that no additional written response had been provided to the complainants.

Based on record review and interviews with hospital staff, the hospital does not ensure that adverse patient events are investigated and analyzed to assess processes of care and to ensure quality of patient care.

Findings:

1. Patient #4 received burns from equipment used in a procedure.

2. The hospital did not have any evidence that the occurrence had been investigated, analyzed and measures taken to prevent a reoccurrence.

3. Staff A stated on 06/22/11 in the afternoon that there was no documentation of what the hospital did to investigate the incident. Staff A said that according to the radiology department the equipment was sent to the manufacturer, but did not have any documentation of the manufacturer's evaluation. There was also no investigation of whether there were other reasons this incident might have occurred.

4. The occurrence report stated that the radiology department would do a quality assurance ( QA ) investigation of the incident. Review of QA meeting minutes for 2009 which was when the incident occurred did not have any evidence of a review of this incident.