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Based on staff interview and review of the hospital's grievance policies the facility's governing body failed to approve all procedures for grievance investigations. The facility failed to complete the investigation of a complaint by patient #3. The facility census was 125 patients.

Findings included:

Review of the facility's policy titled: "Customer Satisfaction/Complaint/Grievance Process" effective 09/2012 revealed no evidence of specific timelines to investigate complaints. Interview of Staff B on 07/09/13 at 2:47 PM revealed there are timelines internally established and followed by the complaint department. Interview further revealed these timelines followed by the complaint department were not in the Grievance policy and had not been approved by the facility's Governing Body.

Review of Patient #3's medical record and complaint on 07/08/13. The "customer service worksheet revealed the patient had made a complaint of being treated rudely by a specific nurse in the emergency department on 02/27/13.

The report revealed Patient #3 left against medical advice due to how she perceived her treatment. The hospital follow up was a plan to apologize to the patient and a follow up with the specific nurse alleged as being rude.

Interview of Staff C on 07/08/13 at 3:00 PM revealed there was no documented evidence the specified nurse was ever counsled to in order to prevent further occurrences.

These findings were confirmed by Staff C on 07/08/2013 at 3:00 pm.

Based on staff interview and medical record review, the facility failed to notify a complainant of the investigation and results of a grievance investigation and completion date for one of ten sampled medical records which complaints had been made. (Patient #9) The facility census was 125.

Findings included:

Review of the complaint files on 07/09/13 at 2:47 PM revealed a complaint had been filed by a patient representative on 05/17/13 regarding emergency room care for Patient #9 on 05/16/13. Review of the complaint investigation revealed that there was no evidence the complainant was notified as to the investigation findings.

Interview of staff A further revealed that there was no evidence Patient #9 was ever questioned regarding the patient's representative's complaint regarding his/her care although this patient had been an inpatient at the facility since the 05/17/13 the complaint was filed.

Review of documentation dated 05/20/13 of the complaint information provided, revealed the complainant was not called because he/she was not the husband or family member. The only contact made by the facility in regard to the complaint was a letter of apology sent to Patient #9 on 05/30/13.

These findings were confirmed by Staff A on 07/09/2013 at 3:00pm.