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Based on review of the grievance log, medical record review, staff interview and facility policy review it was determined the agency failed to investigate all of the areas of concern and failed to follow their policy in their investigation of and written response to the formal grievance. This affected one of two patients (#4) whose medical record and grievance files were reviewed out of a total of 10 medical records reviewed. The facility census was 305.

Findings include:

Review of the medical record completed on 03/13/14 revealed Patient #4 was admitted to the facility on 08/13/13 after sustaining a traumatic fall. Review of the facility grievance log on 03/11/14 revealed a verbal complaint was lodged by the wife on behalf of Patient #4 on 08/21/13. During interview with Staff B on 03/11/14 at 2:25 P.M., Staff B stated Patient #4's wife had approached her stating her concerns were "not a grievance yet, but would let them know if the patient had any complications." Review of the document which identified the concerns noted an additional concern was added on 08/26/13 related to the patient's discharge.

The formal complaint identified concerns with a hospital acquired infection; the quality of care particularly in regard to the patient's shoulder; lack of response to family/patient request for medical attention; a nurse's use of her personal cell phone to text a colleague about the patient's admission to the facility; family notification; housekeeping practices; infection control practices; staff education; patient rights and privacy practices; and notification of admission to the primary care physician.

The letter of resolution stated the facility had reviewed Patient #4's medical record and had spoken with pertinent staff and physicians; and stated they utilized current best practices in patient care and infection prevention to reduce or eliminate risk for all patients and suggested they speak with their physician to provide clarification on this issue. The facility stated that the patient's symptoms in regard to the shoulder were consistent with his diagnosis. The facility responded to nursing care concerns and family notification by stating that if there had been a deterioration or serious change in the patient's condition that the family would have been immediately notified and went on to state that the "other issues have also been addressed with each individual nurse." The letter then stated that concerns with housekeeping and social work had been "addressed at the highest level, internal processes followed, and when indicated, process improvements implemented." The letter was signed by the patient representative. The resolution letter failed to specifically state the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the facility's decision.

Review of the facility policy, "Patient Complaint and Grievance Procedure," dated as last revised 07/03/12 revealed at item 4 the policy directs, "Grievances require timely resolution with a written response. The hospital must provide the patient a written notice of its decision that contains the name of the hospital contact, the outcome of the grievance review and investigation, steps taken on behalf of the patient/patient's representative to investigate the grievance, the results of the grievance process and the date of completion."