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Based on interview record review and policy review, the facility failed to protect and promote the rights of its patients in 4 of 4 charts reviewed (Patient ' s #1, #12, #13 and #14) as evidenced by:

The facility failed to follow an established process for prompt resolution of patient grievances (A118); failed to follow the established process for prompt resolution of patient grievances (A119); failed to respond in writing in its resolution of a grievance (A 123); failed to protect the confidentiality of patient information (A147) and failed to obtain a completed physician order for restraints (A 168)

Based on interview, record review and policy review, the facility failed to follow the process for prompt resolution of patient grievances in 4 of 4 charts reviewed (patient ' s #1, #12, #13 and #14). Findings include:

During record review on 12/14/10 at 1830 of patient #1 it was found that she had called the facility on 11/05/10 to inform Human Resources of her concerns. When the phone call was made she got a voice mail box, she left a message, but was so upset about the situation that she went to the facility to speak face to face with someone.

She met with Executive Assistant #1 and explained her concerns. Executive Assistant #1 informed her of the fact that no one from that department was available at that time and the investigation would be started the following Monday (11/08/11).

As of 11/16/10 when the State of Michigan hotline was called by patient #1 she had not received any response from the facility. As of 12/14/10 upon the surveyors' entrance into the facility for investigation of this complaint, the investigation was still pending action.

During policy review on 12/15/10 at approximately 1000, the policy titled "Grievance Resolution Process" states "Based on the substance of the grievance, within two (2) weeks of receipt of the grievance, a written report of the status of the investigation or a status report stating when the report will be expected to be given to the patient."

During interview on 12/15/10 at approximately 1115 these findings were confirmed by Executive Assistant #1.

Patient #12, #13, and #14, entered the grievance process, and the hospital process was not followed. There were no letters sent, no documentation that confirmed that the patient was contacted and nothing documented that contained the elements that the grievance was investigated and considered "closed".

During review of the policy titled "Grievance Resolution Process" on 12/15/10 it states "It is the responsibility of the Health System Board of Trustees to ensure the effectiveness of the grievance process" with bi-annual reports regarding the grievance process "will be provided by Risk Management to the Quality and Outcomes committee officers". During record review of patient's #1, #12, #13, and #14, it was determined that the grievance process was not followed per policy and the Governing Body did not follow up to determine that a resolution letter that contained the necessary elements, were sent to the complainant.

Executive Assistant #1, the Chief Financial Officer, and the Director of Patient Financial Services confirmed these findings on 12/15/10.

Based on a focused record review, interview and policy review, the facility's Governing Body failed to be responsible for the effective operation of the grievance process which includes prompt resolution. Findings include:

During record review of patient's #1, #12, #13, and #14, it was determined that the grievance process was not followed per policy and the Governing Body did not follow up to determine that a resolution letter that contained the necessary elements, were sent to the complainant.

During review of the policy titled "Grievance Resolution Process" on 12/15/10 it states "It is the responsibility of the Health System Board of Trustees to ensure the effectiveness of the grievance process." with bi-annual reports regarding the grievance process "will be provided by Risk Management to the Quality and Outcomes committee off."

Executive Assistant #1, the Chief Financial Officer and the Director of Patient Financial Services confirmed these findings on 12/15/10.

Based on interview and record review, the facility failed to provide written notice of its decision in the resolution of a grievance for 3 of 3 (#1, #12, and #13) grievances reviewed. Findings include:

During an interview with Executive Assistant #1 on 12/14/10 at 1730 it was determined that the facility "has not had any grievances. We logged them as complaints. "

According to the policy titled "Grievance Resolution Process" a "Grievance: Shall be defined as a verbal or written appeal expressing dissatisfaction with resolution of a complaint at the unit or department level." (A "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient or a patient's representative, regarding the patient's care [when the complaint is not resolved at the time of the complaint]).

During record review on 12/15/10 at 1000 it was determined that the facility did receive a grievance in writing, and 2 grievances by phone calls but did not follow the policy steps to investigate the grievance; there was no written notice sent to the patient that contained 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 the completion.

Executive Assistant #1 confirmed these findings on 12/15/10 at 0830.

Based on record review and interview the facility failed to protect the patient #1 s confidentiality of her clinical records. Findings include:

During an interview with the Director of Patient Services it was determined that Billing Associate #1 logged into "Diagnosis/Misc" screen on 08/31/10 at 1047. Billing Associate had "no reason" to be in this screen according to the Director of Patient Financial Services.

Record review on 12/15/10 at approximately 1000 confirmed that Billing Associate #1 had accessed the "Diagnosis/Misc" screen on 08/31/10 at 1047.

The Director of Patient Services confirmed the findings on 12/15/10 at 0900.

Based on record review and policy review the facility failed to ensure that restraint orders were being authenticated in a timely manner by a physician in 3 out of 4 (#8, #9, #11) resraint medical records reviewed.

During record review on 12/14/10 at 1800 it was determined that patient #8 was placed in soft wrist restraints on 11/09/10 at 1550 by verbal order from the physician. Authentication of this order by the physician was not completed until 12/4/10 at 1100. During record review of patient # 11 it was found that the patient was placed in soft restraints on 8/4/10 at 1700 by verbal order from the physician. Authentication of this order by the physician was not completed until 8/26/10 at 1240. When this patient #11 had a continuation of orders for restraints on 8/5/10 at 1315 by verbal order from the physician, the physician authentication was not completed until 10/23/10.

During record review on 12/15/10 at 0900 it was determined that patient #9 was placed in Left soft restraints on 11/01/10, 11/02/10, 11/03/10, and 11/0410. On 11/05/10 patient #9 was placed in both Left and Right soft wrist restraints. The only restraint order that was documented was dated 11/06/10 at 0840 for "soft wrist" .

During review of the policy titled "Restraint Use" it is stated "Within 24 hours, physician performs a face-to-face- assessment of patient and documents findings on the [Restraint Order Form]" ... "If need for continuous restraint persists past 24 hours each recurrent episode of restraint application requires: a new physician order which outlines rationale and time restraints are applied must be obtained from the physician, and physician performs a face to face assessment of patient and authenticates the need for restraint use. This is captured on the [Restraint Order Form]."

Based on record review and interview, the facility failed to ensure that unauthorized individuals cannot gain access to confidential patient records. Findings include:

The facility has an established policy in place to protect the confidentiality of medical record information. The facility failed to follow their policy titled "HIPAA Complaint Process" when Patient #1 came to the facility on November 5, 2010 to report the "Breech of Confidentiality". Billing Associate #1 completed the mandatory in-services that the facility provided regarding "Confidentiality of Patient Information" and "HIPAA".

During interview with the Director of Patient Financial Services on 12/15/10 at 0900 it was determined that an access report was run on November 10, 2010 at 0859 by data processing/Information System associate #1. This report showed that Billing Associate #1 accessed the "Diagnose/Misc" screen on 08/31/10 at 1047. According to the Director of Patient Financial Services, Billing Associate #1 "should not have been in this screen" .

This was confirmed on 12/15/10 at approximately 1300 by the Director of Patient Financial Services.

Based on observation, record review and interview, the facility failed to ensure that all patient medical records were completed with in 30 days of discharge of the patient. Findings include:

During record review it was determined that there were 127 incomplete (closed) medical records according to the record titled "Health Information Services Incomplete Chart Statistics". The policy titled "Completion of Medical Records" states that the patient record will be completed 30 days from the day of discharge.

The Director of Health Information confirmed these findings on 12/15/10.