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Based on policy review, file review and interviews with key personnel on December 12, 2013, it was determined that the facility failed to follow applicable Federal laws and regulations related to the health and safety of patients.

Findings include:

1. 42 CFR 482.13(a)(2)(ii) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital ' s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.] The grievance process must specify time frames for review of the grievance and the provision of a response.

a. The facility policy 'processing of physician related complaints' , part of the hospital's complaint and grievance policy & procedure, lacked evidence of a time frame for review and response to the patient grievance/complaint against a physician at the hospital.

b. This finding was confirmed by the Quality Manager an the Director of Outpatient Services & Regulatory Compliance on December 12, 2013 at approximately 11:00 AM.

c. The facility 'Complaint and Grievance Policy & Procedure' indicated that 'if for any reason the investigation shall take longer than seven (7) days, the manager shall be responsible for contacting the complainant via telephone to inform them that there will be a delay and this conversation must be documented'.

d. Review of the facility grievance log indicated that the complainant voiced his/her complaint on October 20, 2013, and a response was sent to the complainant with the results of the investigation on November 20, 2013. There was no documentation to indicate that the complainant was notified on day seven to express that the investigation would take longer than seven (7) days.

e. Both of these findings were confirmed by the Quality Manager an the Director of Outpatient Services & Regulatory Compliance on December 12, 2013 at approximately 10:30 AM.

Based on policy review, file review and interviews with key personnel on December 12, 2013, it was determined that the facility failed to immediately notify the State of suspected abuse of a patient.

Findings include:

1. The facility policy 'investigation of suspected abuse/neglect by a staff member', directed staff that "1. the employee suspected of abuse will be immediately removed from direct patient care in order to protect residents from potential abuse while an investigation is in progress". And also, "for cases in the acute house: it is necessary to report the case to the Department of Human Services, Division of Licensing and Certification by calling 207-287-9300 immediately following the incident (or when the incident occurs on a holiday or weekend, leave a message and follow up the next working day)."

2. On November 15, 2013 the person suspected of abuse was removed from direct patient care.

3. On November 18, 2013 a call was placed to Licensing and Regulatory Services to inform the Department of a suspected case of abuse.

4. That the Department was not contacted immediately of suspected abuse of a patient was confirmed by the Director of Outpatient Services & Regulatory Compliance on December 12, 2013 at approximately 10:30 AM.