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Based on clinical record review, hospital policy review and staff interview, the hospital failed to ensure the all components of the written grievance resolution notice were present. Six (6) of 8 grievances response letters written by the hospital did not contain results of the investigation nor date of completion of the investigation. This occurred in a total sample 12 patients and has the ability to affect the current census of 210 in patients (28 out-patients and 182 in-patients).

Findings include:

The review of hospital policy on 11/18/13 of the "Complaint and Grievance Resolutions of Patients and Families", documents under "C. Patient /Family Grievance....7. Patient Relations will provide a written notice of the final results of it's investigation to the complainant within 21 business days of the initial complaint including: a. Name of the hospital contact person, b. Steps taken on the behalf of the patient to investigate the grievance, c. An outline of the results of the grievance process, and d. The date of the completion or anticipated completion of the investigation."

The 11/19/13 record review of the following 6 grievance report response letters written to the following complainant's documents no written information on the results of the investigation or the date of completion of the investigations.

1) A grievance received on 9/27/13 on behalf on Patient #8 documents a written response letter written on 11/20/13 by hospital Patient Representative E documents no results of the investigation, and no completion date of the investigation.

2) A grievance received on 7/10/13 on behalf on Patient #9 documents a written response letter written on 9/11/13 by hospital Patient Representative E documents no results of the investigation, and no completion date of the investigation.

3) A grievance received on 9/16/13 on behalf on Patient #10 documents a written response letter written on 10/8/13 by hospital Patient Representative E documents no results of the investigation, and no completion date of the investigation.

4) A grievance received on 7/18/13 on behalf on Patient #8 documents a written response letter written on 8/9/13 by hospital Patient Representative F documents no results of the investigation, and no completion date of the investigation.

5) A grievance received on 7/1/13 on behalf on Patient #12 documents a written response letter written on 7/11/13 by hospital Patient Representative F documents no results of the investigation, and no completion date of the investigation.

6) A grievance received on 10/16/13 on behalf on Patient #7 documents a written response letter written on 10/22/13 by hospital Patient Representative G documents no results of the investigation, and no completion date of the investigation.

In interview with Compliance Manager D on 11/19/13 at approximately 3 p.m. it was stated that there is no additional information to add.

Based on policy review and staff interview, the hospital failed to document an incident report on a newborn unwitnessed fall resulting in injury as per hospital policy, in 1 of 1 incident reports reviewed (Patient #1). This occurred in a total of 12 sampled patients and has the ability to affect 210 patients (182 in-patients and 28 out-patients).

Findings include:

Hospital Policy "Event- Incident Reporting-Patient or Non-Patient" documents "...It is every individual's responsibility to report event/ incidents in order to ensure a safe environment...All reported events will be reviewed and investigated in a timely manner to ensure that patient /family needs are met." This policy gives "Definitions" of events that should be reported, such as "Patient Safety Event: Any identified event that results in patient injury".

The clinical review of Patient #1 on 11/18/13 at approximately 4 p.m. documents a unwitnessed fall resulting in cranial fracture occurring on 11/14/13.

In interview with APN A and CSC B on 11/19/13 at approximately 1:30 p.m., they stated that they were unable to find that a incident report was completed and filed on this patient's unwitnessed fall.

Based on clinical record review and staff interview, the hospital failed to ensure that 2 of 3 patients utilizing restraints (Patient #'s 2 and 4) had physician's orders to implement them. This occurred in a total sample of 12 patients, and has the ability to affect the current census of 210 in patients (28 out-patients and 182 in-patients).

Findings include:

1) Clinical record review of Patient #2 on 11/19/13 at approximately 11:40 a.m. documents that there are no documented medical orders by a physician for the use of the 4 point restraints, used on 10/22/13 at approximately 11:19 a.m. for violent or self-destructive behaviors.

In interview with SSA E on 11/19/13 at 11:40 a.m., it was stated that a written physician's order for the restraint was not found.

2) Clinical record review of Patient #2 on 11/19/13 at approximately 11:40 a.m. documents that there are no documented medical orders by a physician for the use of the 5 point restraints, used on 11/3/13 at approximately 1:21 p.m. for violent or self-destructive behaviors.

In interview with SSA C on 11/19/13 at 11:40 a.m., it was stated that a written physician's order for the restraint was not found.

Based on clinical record review and staff interview, the hospital failed to develop a care plan that met the needs of 1 of 4 comprehensively sampled patients (Patient #1). This occurred in a total sample 12 patients and has the ability to affect the current census of 210 in patients (28 out-patients and 182 in-patients).

Findings include:

The clinical review of Patient #1 on 11/18/13 at approximately 4 p.m. documents a unwitnessed fall resulting in cranial fracture occurring on 11/14/13. Review of the care plan with APN A and CSC B on 11/18/13 at approximately 4:25 p.m. documents no care plan for neurological assessments to evaluate potential adverse neurological symptoms.

APN A and CSC B verified and stated, at the above clinical review, that there was no neurological care plan documented.