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Based on a review of policies and procedures, complaint/grievance reports, and a staff interview, the hospital failed to ensure the written notice of the patients' grievance resolutions included 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. Four or four grievances reviewed did not contain all the components required in the letters to the complainants. Hospital staff verified on 06/07/10 that the letters to the person submiting the grievance did not contain the steps taken to investigate the grievance, the contact person, the results and the date of completion.

Based on record review and interviews with hospital staff, the governing body does not ensure that all services performed under contract are provided in a safe and effective manner. Dialysis services provided to the hospital by contract are not monitored and evaluated by the hospital's quality assessment and performance improvement (QAPI) program to ensure that they are provided in a safe and effective manner.

Findings:

1. Review of the hospital's Quality Council meeting minutes of various hospital departments for the previous six months of 2010 did not have evidence that adult acute dialysis services provided by a contracted provider were evaluated and reviewed.

2. According to hospital staff on 06/07/10 in the afternoon, the method the hospital used to evaluate the acute adult dialysis services provided by a contracted service is by the contracted service itself. The contract dialysis provider provides an evaluation report annually to the Quality Council. The hospital has not directly evaluated the adult acute dialysis service.

3. Patient # 1 was supposed to receive dialysis three times a week on Monday, Wednesday and Friday. Patient #1 according to the record was taken to dialysis on 02/05/10, but did not get dialyzed due to a mechanical problem with the dialyzers. The hospital had recently changed dialysis providers and the previous provider came in and took all the machines and removed all the piping and water connections. The new provider had replaced all equipment. There was no documentation provided in Patient #1's record that explained what occurred in the three hours that the patient was in supposed to be receiving dialysis. There was no evidence in the QA/PI documentation provided for review that any evaluation of the contracted dialysis service's equipment malfunction.

4. Dialysis staff is provided by the contracted provider not the hospital. 5 of 5 contracted personnel records reviewed did not have evidence of annual competency training, unit orientation, or annual evaluation. Refer to Tag 0398.

Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure the Director of Nursing, or designee, provided orientation and evaluation of contract hemodialysis nursing personnel. This occurred for five of five contracted hemodialysis personnel (Staff # A-E) whose files were requested for review.

Findings:

1. On 6/8/2010 during the opening conference the Chief Nursing Officer (CNO) stated Hemodialysis was provided by a contract service and in February of 2010 the facility changed companies. The contract prior to February 2010 had been with Company A and the first week of February 2010 Company B began providing services. The CNO also stated hemodialysis nursing personnel were also provided through the contracted services and the contracted service is responsible for orientation and training of hemodialysis personnel. The CNO also stated all contracted services are given a general contractor orientation to the facility handout.

2. On 6/8/10 the surveyors requested five hemodialysis nursing personnel files (A,B,C,D, E) The documents initially produced for staff #A, B, C, D,E contained annual competency forms dated 10/08 through 2/09. These forms were labeled "Company A Orientation". The company documented at the top of the competency training files was not the company currently contracted to provide hemodialysis services and equipment. When reviewed in the exit conference with the CNO and the Director of Nursing (DON) additional hemodialysis personnel paperwork (A, B, D, E) was provided. The paperwork provided had competencies for "Company B". There was no documentation provided establishing the hospital had trained or evaluated the contract personnel in their specialty area.

3. On 6/8/10 documents produced for Staff # C contained only "Company A Orientation" paperwork and the general contractor orientation to the facility handout. There was no documentation Staff #C had been trained or was competent to operate the hemodialysis equipment currently under contract. There was no documentation Staff #C had been oriented, trained, or evaluated by the hospital.The patient mentioned in the complaint's chart contained entries by Staff #C providing hemodialysis care.

4. The above findings were reviewed with the administrative team during the afternoon of 6/08/2010.