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Based on document review, policy and procedure review and staff interview, it was determined the hospital failed to address allegations of patient abuse as a grievance.

Findings:

1. A hospital policy, titled, Opportunities For Improvement (OFI) Patient Complaint Resolution, documented, "... All verbal or written complaints regarding abuse, neglect patient harm or hospital compliance with CMS requirements, are to be considered a grievance..."

2. On 11/20/13, the surveyors reviewed written allegations of two sexual abuse/assaults. The hospital investigated the allegations but did not define the events as grievances and did not respond to them them as such.

The findings were reviewed with the hospital director. No comment was made.

Based on document review, policy and procedure review and staff interview, it was determined the hospital failed to respond to all grievances in writing. When a written response was provided, the hospital did not inform the complainant of the results of the grievance process.

Findings:

1. A hospital policy, titled, Opportunities For Improvement (OFI) Patient Complaint Resolution, documented, "... A written complaint is ALWAYS considered a grievance... regarding the patient care provided, abuse or neglect, or the hospital's compliance with Conditions of Participation... Patient complaints that become grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding their patient care or with an allegation of abuse or neglect, or failure to comply with one or more of the Conditions of Participation, or other Centers for Medicare and Medicaid Services (CMS) requirements... All verbal or written complaints regarding abuse, neglect patient harm or hospital compliance with CMS requirements, are to be considered a grievance..."

The policy further documented, "... Written response letters to a grievance include... a brief summary of the complaint, the results of the investigation..."

2. On 11/20/13, the surveyors reviewed documentation of grievances received by the hospital.

Two written reports of sexual assault were investigated by the hospital. The complainants were not responded to in writing.

3. Two other grievances had documentation of a written response to the complainant. However, the written responses did not address all issues identified in the allegations. The responses did not include the hospital's decision and the results of the investigation.

The hospital director was informed of the findings. No comment was made.

Based on medical record review and interview it was determined the hospital failed to ensure that the nursing staff provided ongoing evaluation of patient care provided. This occurred in seven of ten records reviewed.

Findings:

Patient #2 had a documented fever by the physician on several occasions. The nursing notes did not reflect a fever and did not contain any interventions related to the fever.

The medical record for patient #2 contained documentation from the physician that the patient had mouth sores. There was no nursing assessment that documented mouth sores and interventions.

The medical record for patient #2 documented high blood pressures on several occasions. There was no nursing documentation of interventions.

The medical record for patient #1 documented high heart rates on several occasions. There was no nursing documentation of interventions.

Patient #1 had a documented fever by the nurse on several occasions. There was no nursing documentation of interventions.

The medical record for patient #7 documented abnormal lung sounds on several occasions. There was no nursing documentation of interventions.

Patient #9 had several abnormal blood pressures documented from the nurse on several occasions. There was no nursing documentation of interventions.

Patient #10 had documented high blood pressures on several occasions. There was no nursing documentation of interventions.

The medical record for patient #5 documented increased respiratory rates for several occasions. There was no nursing documentation of interventions.

The medical reocrd for patient # 6 documented poor skin turgor, skin color pale, increased respiratory rate on several occasions. There were no nursing interventions documented.