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Based on review of hospital policies and grievance and complaint log, selected grievances and complaints, and interviews with hospital staff, the hospital failed to ensure the hospital's established grievance process was implemented.

Findings:

1. The hospital's grievance policy, entitled "Patient Complaint/Grievance Resolution," with an issue date of February 2008, appropriately defined the difference between complaints and grievances; provided time frames for investigation and resolution of grievances; stipulated that a written response with the required information would be provided to the complainant; and stipulated data collected from complaints and grievances would be "trended and analyzed for opportunities to improve care and incorporated into the hospital's performance improvement program."

2. The hospital failed to identify grievances: The surveyors selected 16 complaints and 2 grievances from the complaint and grievance log. Upon review of the data supplied by the hospital, fifteen of the concerns listed as complaints were actually 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 # C and G at the time of review on the afternoon of 01/04/2011 and the morning of 01/05/2011.

3. The data provided to the surveyors did not demonstrate the hospital investigated the grievances: For seventeen of the seventeen grievances reviewed, the hospital could not provide data to show the hospital had investigated the all problems/concerns listed by the complainants. This finding was reviewed and verified with hospital administrative staff # C and G at the time of review on the afternoon of 01/04/2011 and the morning of 01/05/2011.

4. The hospital does not ensure all grievances are resolved within the time frames. Seventeen of seventeen grievances reviewed did not contain a date that the grievance was completed/date of resolution. The data supplied to the surveyors did not contain the date the hospital resolved the grievance or evidence the hospital had supplied a written response to the complainant with all the required data, including the date the hospital considered the grievance resolved.

4. The hospital does not ensures grievance data is incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program with analysis of the data and implementation of processes to improve patient care:
a. According to the the complaint and grievance log, six of eighteen complaints and grievances listed for August 2010 concerned Unit 10-West.
b. Staff #F showed the surveyors that she had instituted training and corrective actions for the unit.
c. Review of quality data did not demonstrate that grievance and complaint data was reviewed, trended and analyzed with implementation of corrective and/or process changes to improve patient care. This finding was reviewed with administrative staff on the morning of 01/05/2010.

Based on review of the hospital's grievance/complaint policy, grievance log and five 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 seventeen of seventeen patients/patients' representatives who filed grievances (Grievance #1 through 12, 15, and 18 through 21) and 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 16 complaints and 2 grievances from the complaint and grievance log for August and September 2009, and July and August 2010. Upon review of the data supplied by the hospital, fifteen of the concerns listed as complaints were actually 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 # C and G at the time of review on the afternoon of 01/04/2011 and the morning of 01/05/2011.

3. Seventeen of the seventeen grievances reviewed did not contain a written response to the complainant with the required information. On the morning of 01/05/2011, the surveyors confirmed with administrative staff #C, G and K that no additional written response had been provided to the complainants.

Based on review of the hospital records, the hospital failed to maintain a complete operating room log.

Findings:

Oklahoma State Hospital Standards subchapter 25 requires the facility to maintain a complete and up to date operating room log. The log must include: patient's name, medical record number, name of surgeon, name of assistant(s), type of anesthetic, person administering , circulating nurse, scrub nurse, procedures performed, time surgery began and ended, other persons present. On the morning of 1/5/2010, Staff A and Staff B told surveyors the facility did not record "other persons present".