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Based on review of grievance log, grievance policy and interview, it was determined the facility failed to assure four patient (Pt. #11-#14) of eight grievances reviewed were resolved or contact was made with the Complainant within seven days of receipt of the complaint. The Complainant could not be assured of the status of the grievance without notification by the facility that the investigation was resolved or ongoing. The failed practice affected Pt #11-#14 and had the potential to affect all patients who filed a grievance. The findings follow:

1. A review of the facility grievance log on 11/19/12 revealed:
A. Patient #11 had a "date concern received by Quality Management" listed as 11/05/2012. The grievance log did not have a resolution date and there was no documentation the patient or representative was notified of the status of the grievance. The Additional Comments Section stated "Per (named) Guest Relations not to call patient because he has gotten an attorney."
The findings were confirmed by interview with Patient Safety Coordinator #1 from 1530 - 1550 on 11/20/12.

B. Patient #12 had a "date concern received by Quality Management" listed as 10/01/12. The Grievance log documentation revealed the date Guest Relations mailed the follow up letter to the patient/family on 11/06/12. The Additional Comments Section stated "Pnd (pending) Manager response. Patient called and made aware. Crystal emailed and aware of the importance of the response. Letter to (named) still pending review 10/23/12."

C. Patient #13 had a "date concern received by Quality Management" listed as 08/23/12. The Grievance Log documentation revealed the date Guest Relations mailed the follow-up letter to the patient/family on 11/19/12. The Additional Comments Section stated "11/07/12 called patient's daughter".

D. Patient #14 had a "date concern received by Quality Management" listed as 09/14/12. The Grievance Log documentation revealed there was no date Guest Relations mailed the follow-up letter to the patient/family. The Additional Comments Section stated "Administrative Phone Call to take place. Per (named) do not call patient granddaughter. Per (named) in Risk Management."

2. Review of policy "Patient Complaints and Grievances", Section 3.5 revealed 3. All grievances will be entered in the Global Reporting System and communicated to the Guest Relations Department. The Guest Relations Representative will contact the complaining party and explain the steps that will be taken during the investigation of the grievance. In the event that someone other than the patient makes a grievance, (facility named) will obtain the patients' permission prior to discussing medical record information with the person making the grievance.

A. Item #4, "When the Quality Management Department receives the Global Report, it will be forwarded to the appropriate management staff for review and follow-up of the grievance. The Management member will promptly review the grievance, develop and implement a solution plan and communicate the action/resolution to the Quality Management Department in writing. This information will be forwarded to Guest Relations for the written response."

B. Item #5. "All grievances will be processed within seven calendar days from the date of receipt and a written response will be provided to the patient/representative by Guest Relations. The response will include: who to contact at (facility named) regarding the grievance, a brief explanation of the steps taken on behalf of the patient to investigate and resolve the grievance, results of the grievance process and date of completion of the grievance process. If the grievance is not resolved within seven days, if the investigation is not complete, or if the corrective action is still being evaluated, Guest Relations will contact the patient/representative by phone to provide an update, and will inform the patient/representative that a written follow-up response will be sent within an outlined timeframe. In the unlikely event that a grievance cannot be resolved within that time frame, an interim report will be provided to the patient/representative."

C. Item #7 "A grievance is considered resolved when the patient is satisfied with the actions taken on his/her behalf. However, there may be situation where the hospital has taken appropriate and reasonable actions on the patient's behalf in order to resolve the patient's grievance and the patient or the patient's representative remains dissatisfied. In this situation, (facility named) may consider the grievance closed. Facility will maintain documentation of its efforts to resolve the complaint/grievance.

The findings were reviewed and confirmed by Safety Coordinator #1 on 11/20/12 at 1550.

Based on observation, review of staff schedules, assignments, policy and procedures and interview, it was determined the facility failed to assure patient care assignments for clinical staff were based on acuity and patient needs. Failure to provide assignments based on acuity of patients created the potential for unmet patient care needs. The failed practice affected the inpatient hospital census of 179 at the time of the survey and had the potential to affect all patients admitted to the facility. The findings were:

A. The facility policy 501.23 Staffing Guidelines was reviewed on 11/19/12 at 1000. There was no documentation of a process to consider the acuity of patients in the assignment and scheduling of staff.

B. The Clinical Nurse Manager of the Rehab Unit was interviewed on 11/20/12 at 0830 and reported the unit was staffed based on the "Staffing Grid".

C. On 11/20/12, a copy of the Rehab "Staffing Grid" was provided. The information included on the grid was: number of patients, indirect hours, hours per patient day. The next sections listed the number of Registered Nurses, Licensed Practical Nurses, and Patient Care Technicians for the number of patients.

D. The Vice President of Patient Care Services stated in an interview on 11/19/12 at 1015, that "staffing is not based on an acuity system. It is based on Hours Per Patient Day."

Based on clinical record review and interview, it was determined the facility failed to assure physician orders for scheduled bladder training were provided for one (Patient #1) patient and failed to follow the skin care policy/protocol for two, Stage I pressure ulcers (Patient #4) of eight inpatient clinical records reviewed. Patient Care needs were unmet for Pt #1 and Pt. #4. The failed practice affected patient #1, #4, and had the potential to affect the 25 patients on the rehab unit at the time of the survey. The findings were:

A. Patient #1 was admitted to the Rehab floor on 11/09/12. An order for "bladder training" was documented 11/09/12. Review of the clinical record on 11/20/12 revealed the clinical record lacked documentation bladder training was performed. The findings were confirmed after review by the Clinical Nurse Manager of Rehab on 11/20/12 at 1045.

B. Patient #4 was admitted on 11/14/12. Review on 11/20/12 at of the admission nursing assessment revealed the patient had two, Stage I pressure ulcers. The admission Braden score was 19 and the patient was incontinent. Documentation on 11/14/12 by Charge Nurse #1 revealed "Stage I ulcer to coccyx, ulcer base is reddened, extra Protective cream applied." "Ulcer two, Stage I of the left heel outer ankle. The ulcer base is reddened. Elevated heel." The Clinical Nurse Manager of Rehab stated in an interview at the time of observation the "Stage I skin breakdown protocol should have been implemented."

C. A copy of the Stage 1 Skin Breakdown policy/protocol was provided 11/20/12 at 1700. The document identified the following: Notify physician, and report any changes to M.D.; Assess wound each shift; Measure wound initially and then weekly; Document wound; Care Plan Wound; Consult ET nurse if area worsens; consult Dietician; Turn every two hours. Heel or Foot "Bridge with pillows if inactive." "Trunk (coccyx) for incontinent patients, clean with soap and water. Apply Extra protective Cream BID (two times daily)." Clinical record review for 11/15-19/12 with the Director of Rehab revealed intervention documentation was not evident and the clinical record did not include documentation that the Stage I skin breakdown policy/protocol was implemented.

The findings were confirmed on 11/20/12 by the Clinical Nurse Manager of Rehab.