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Based on review of hospital documents and staff interviews the hospital failed to grant specific privileges to medical staff through the governing body processes. This occurred in two (Staff M and N) of two physician credential files reviewed.

Findings:

Review of physician roster documented that physician N's specialty is psychiatrist and Staff M's specialties are hospitalist and emergency room physician. Specific medical staff privileges had been requested by both Staff N and M, there was no documentation the governing body approved the specific requested privileges.

This was verified on 11/06/13 in the afternoon with Staff B and C.

Based on review of the hospital's grievance and complaint policy, grievance log and interviews with hospital staff, the hospital failed to follow its grievance process and respond to grievances in a timely manner. This occurred in three of three grievances reviewed from the hospitals grievance log.


Findings:

The hospital's grievance policy stated the administrative assistant will contact the patient within three days of receiving the grievance; the grievance will be forwarded to the risk manager who will investigate and respond to the grievance within fifteen days. The risk manager will maintain the grievance log, investigations and findings

The grievance policy identified Staff E as the person responsible for part of the grievance. Staff E was interviewed regarding her role in the grievance process. Staff E was not aware she was responsible for the investigation and written response of each grievance.

On 11/06/13 Staff B was asked to explain the hospitals grievance process, she stated, once she receives the grievance, it is sent to the department manager of where the grievance occurred. The department manager is responsible for the investigation and notifying Staff B of the results. Staff B stated the hospital did not mail any written response to the complainant, telephone notifications are conducted.

Grievances #1 was received on 01/22/13 by Staff B. The grievance documented the patient did not receive a bath while an inpatient. The grievance was sent the unit manager the same day. There was no documentation of the action taken by the unit manager until the resolution date, 07/05/13. There was no evidence of the steps taken to investigate the grievance or written response sent the complainant with all the required elements.

Grievance #2 was received on 03/15/13. The grievances documented that the patient fell while an inpatient and the family was not notified. There was no documentation of the action taken by the unit manager until the resolution date, 07/05/13. There was no evidence of the steps taken to investigate the grievance or written response sent the complainant with all the required elements.

Grievance #3 was received on 9/18/13. The grievance documented the staff on the HOPE unit was unprofessional. At the time of review on 11/06/13, the grievance log did not contain a resolution date. There was no evidence of the steps taken to investigate the grievance or written response sent the complainant.

Staff B said she had not received any information from the unit manager regarding Grievance #3. When asked on the afternoon of 11/06/13, Staff D brought a copy of the Patient Grievance Form documenting interviews and discussions Staff D had with the unit staff.

On the afternoon of 11/06/13, staff confirmed there was no evidence of the steps taken to investigate the grievances and verified that no written response had been sent/provided to any of the complainants.

Based on policy and procedure review, document review and staff interview, the hospital failed to show over site of the grievance process and ensured grievances were processed through the quality assessment and improvement (QAPI) program.
Findings:

Review of the Governing Body meeting minutes did not contain documentation the governing body reviewed the hospital's grievances.

The hospital grievance policy had no reference to the governing body responsibilities or documentation of a requirement to include complaint and grievance information through the QAPI process.

A review of the QAPI committee meeting minutes for 2013 had no documentation of a review of complaints and grievances. This was verified by Staff E on the afternoon of 11/06/13.

Based on review of the hospital's grievance/complaint policy, grievance log and interviews with hospital staff, the hospital failed to ensure a written response with all the required elements was sent/provided to each 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 three of three grievances reviewed.

Findings:
The hospital's grievance policy correctly identifies that grievances will be investigated and a written response with all the required information on investigation, resolution and contact information will be mailed to the complainant.

Three of three complaints (Complaints #1, 2 and 3) reviewed did not show evidence a written response, with the required elements, had been sent to the complainants.

On the afternoon of 11/06/13, staff confirmed no written response had been sent/provided to the complainants

Based on review of medical records and hospital documents and interviews with hospital staff, the hospital failed to ensure the patient's representative was kept informed of the patient's health status, plan of care and treatment. This occurred in two of three medical records (#2 and 3) reviewed.

Findings:

The hospital's patient rights include the right of the patient to have a representative involved in their care planning.

Review of the clinical record for Patient #2 revealed the patient had a designated power of attorney (POA) and fallen on the following dates; 02/22/13, 02/23/13, 02/24/13, 03/04/13, 03/05/13 and 03/08/13. There was no evidence in the clinical record the POA had been notified regarding the patient falls.

Review of the clinical record for Patient #3 revealed the patient had a designated POA and fallen on 02/19/13; there was no evidence in the clinical record the POA had been notified of the patient fall.

These findings were reviewed and verified with hospital staff in the afternoon of 11/06/2013.

Based on review of hospital documents, quality improvement meeting minutes, medical records, incident reports and grievances, and interviews with hospital staff, the hospital's quality assessment and performance improvement (QAPI) the hospital failed to ensure care was provided in a safe setting.

Findings:

Review of the clinical record for Patient's #1, 2 and 3, documented all three patients had fallen on the HOPE Unit.

On the afternoon of 11/06/13, Staff E stated the hospital has identified where falls are occurring. Review of the QAPI meeting minutes for 2013 did not analyze the number of falls documented. There was no evidence the hospital had developed a plan of action to reduce the falls and prevent patient injuries.See Tag A-283 for further details.

Based on review of hospital documents, quality improvement meeting minutes, medical records, incident reports and grievances, and interviews with hospital staff, the hospital's quality assessment and performance improvement (QAPI) program failed to:
a. Include grievances and restraints as part of the QAPI program and
b. Analyze and develop actions to improve patient care.

Findings:

Grievances was placed through the QAPI program and analyzed with possible identification of opportunities for improvement. Three of three grievances reviewed did not follow the hospital's grievance policy and provide a written response with the required information. On 11/06/13, this was verified by Staff B and E.

Incident reports (falls) are not analyzed through the QAPI program to improvement patient care/practices. The hospital did not evaluate the

Restraints usage is not identified and analyzed through the QAPI program for identification or opportunities for improvement of patient care/practices.

These findings were reviewed and verified with Staff E on the afternoon of 11/06/13.

Based on review of hospital documents, Governing Body Meeting Minutes, quality assessment and performance improvement (QAPI) meeting minutes and interviews with staff, the Governing Body failed to be accountable for the hospital ' s QAPI program. The Governing Body did not ensure the hospital QAPI program implemented and evaluated actions to improve patient care and outcomes.