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Based on review of hospital policy, meeting minutes, and interviews with personnel. The hospital failed to correctly identify grievances. The hospital does not ensure all grievances are reviewed by the Governing Body or a Committee appointed by the Governing body. There is no documentation the hospital ensures grievance data is used to improve patient care.

Findings:

1. On 9/18/2012 surveyors reviewed the facility grievance policy. The policy does not correctly define a grievance with all the required elements. There is no formalized process where all grievances are reviewed through the governing body or a committee appointed by the governing body. There is no documentation the facility uses grievances and complaints to improve care.

2. On 9/18/2012 surveyors reviewed eight grievances (#1,2,3,4,5,6,7,8). Seven of eight grievances did not have initial letters or follow up letters from the facility. There was no documentation any of the grievances were investigated for all of the allegations.

3. On 9/18/2012 surveyors reviewed incident report logs from Jan-2012-current. Eight incident reports were reviewed. Six of the eight incident reports selected required investigation into patient care issues/complaints. These incident reports were not included on the grievance log. There was no documentation the facility treated these incidents as grievances. There was no documentation this complaint was handled as a grievance.

4. The hospital does not ensure 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:
There was no evidence that grievance and complaint data was reviewed, trended and analyzed with implementation of corrective and/or process changes to improve patient care.

5. There was no evidence the Governing Body reviewed, trended, and analyzed all incident, grievance, and complaint data.

6. This information was provided to administration at the exit conference. No further information was provided.

Based on review of records and interviews with staff, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent in the hospital's grievance process. Seven of eight (1,2,3,4,5,6,7,8) grievances/ complaints reviewed met the definition of a grievance but did not have all required documentation or elements.

Findings:

1. Grievances #1,3,4,5,6 (which required investigation and follow up) did not have evidence of a letter being sent to the complainant.

2. Grievance #2,7 are listed and investigated as a grievance. Investigation information was provided.

Grievance #2 was investigated by the facility. The facility stipulated a letter could not be sent as there was no return address for the complainant. Documentation in the patient's chart indicated the patient was married. The documentation also stipulates the patient's wife complained to staff on several occasions. A letter was not sent to the wife although the complaints required investigation.

Grievance #7 was investigated by the facility. An initial letter was sent to the complainant with a stipulation "our investigation may take two to three weeks-we plan to notify you of actions taken". There was no follow up letter.

3. On 9/18/2012 surveyors reviewed facility staff training on patient rights, grievances, and complaints with administrative staff. The administrative staff told surveyors there was no "yearly" training to update staff regarding changes to grievance procedures, complaints, and incidents.

4. On 9/18/2012 the above findings were shared with administration. There was no further documentation.

Based on record review and staff interview, the hospital failed to develop the QA/PI program to include how it would reduce medical errors and adverse events and how QA/PI activities and results would be tracked throughout the organization through committees and leadership entities.

Findings:

1. On 9/18/2012 surveyors reviewed meeting minutes from governance, quality, and infection control. There was no documentation all incidents, grievances, and complaints were analyzed and utilized to improve processes and improve patient safety.

2. There was no documentation of QA/PI activities designed to respond to identified causes of events and how preventive actions would be implemented. Meeting minutes did not stipulate actions to be taken and responsible parties.

3. There was no evidence of widespread staff training related to any changes in grievance, incident reporting, complaint procedures as processes changed. Review of policies stipulated the incident reporting policy was last revised 2/2004. The policy letterhead did not have the current hospital's name listed. Processes listed in the policy included routing information to former owners. Three of the charts reviewed by surveyors included documentation of patient's or family complaining to staff member's about care. Three of three charts did not have a grievance, complaint, or incident report submitted as stipulated in policy.

4. Several complaints/incidents reviewed by administrative personnel and department managers were not appropriately classified as grievances or not followed up on according to the facilities policies. Seven of eight of the grievances reviewed by the surveyors either did not go through the grievance process or were not followed up on.

5. Governance meeting minutes included only the number of complaints. There was no analysis of the complaints. There was no information on trends or processes developed for improvement.

6. These findings were reviewed with administration at the time of the exit conference. No further documentation was provided.

Based on review of policies and procedures and medical records and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient. Care/needs cannot be identified without complete baseline and ongoing assessments and evaluations.

Findings:

1. The unit's initial nursing assessment had a section that prompted nurses to answer Y (yes) or N (no) to the question skin assess WDL (within defined limits). If the nurse answers Y in skin assess they are assessing the skin is uniform color and texture, good turgor, no lesions; absence of xerosis (dryness of skin). Another documentation prompt prompts for "wound" Y or N. If the nurse answers Y to the wound prompt an automatic consult will be triggered to the wound nurse and dietitian. Patient #1's medical record included a"Y" on initial skin assessment 1/16/12. There was no documentation of wounds or skin tears. On 1/17/12 the assessment was unchanged. On 1/18/2012 documentation indicated the patient had scrotal edema, 4 plus pitting ededma, small pink pressure sore on left gluteal area. On 1/19/12 there was no documentation of scrotal edema, pitting edema, or pressure sores. On 1/20/12 nursing documented multiple skin tears, open sore to left buttock. The initial wound nurse assessment was 1/23/12. At that time the wound nurse documented wounds on the buttocks and heels bilaterally. The heel wounds were documented as deep tissue injury. Nursing assessments did not consistently contain documentation of this skin problems or progression of the skin impairment. Nursing staff failed to consistently document a complete skin assessment.

2. Review of incidents/occurrences included instances of heel pressure ulcer developement during patient stays. There was no documentation of patient #1's ulcers.

3. These findings were reviewed with at the time of at the exit conference on the afternoon of 9/18/2012. .

Based on review of infection control data, surveillance activities, and meeting minutes, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. The surveyors reviewed meeting minutes and surveillance activities provided for January 2012 through July 2011 containing Infection Control.

2. Meeting minutes containing infection control, did not reflect the program contained review and analysis with plans of action and follow-up of monitoring. Infection Control information was reported in multiple committees. There was no information in the committees regarding analysis and recommendations for change.

3. The Infection Control Plan 2012 includes a statement "surveillance activities which monitor infections among patients, staff, licensed independent practitioners, students/trainees, visitors, and volunteers. Surveillance activities for outlying facilities (ASC). " There was no information regarding what was to be included in surveillance and expectations for compliance. Infection control surveillance activity did not delineate what the practitioner was actually reviewing.

4. The infection control program did not contain a review of all departments and follow up of problems, complaints regarding infection control practices. For instance, meeting minutes indicate on a patient satisfaction survey hospital cleanliness was rated low. There was no information in the infection control minutes of surveillance of housekeeping and housekeeping practices.

5. The above information was reviewed at the exit conference. No further documentation was provided.

Based on review of hospital documents and meeting minutes concerning infection control, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, through Quality Assessment and Performance Improvement (QAPI):
1. Were monitored, reviewed and analyzed;
2. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and
3. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

1. Meeting minutes that contain infection control data reported reported rates. There was no analysis of data with recommendations for improvement. The QAPI meeting minutes did not contain analysis or plans of action taken to reduce infections there were no recommendations to governance or medical staff from the analysis of the data.

2. The infection control data is presented in multiple committees. None of the committees have all of the departments or services in attendance as required by State regulation. None of the meeting minutes include all of the areas with surveillance activities, analysis, and plans for improvement.

3. Review of infection control data showed surveillance activities. Meeting minutes did not contain evidence the hospital analyzed the data; developed a plan of action to reduce and/or prevent transmission of organisms; and provide follow-up to ensure corrective actions taken were effective.