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Based upon review of the Grievance Policies and Procedures, Grievance Log, complaint investigations, and staff interviews, the governing body failed to ensure the grievance policy was followed related to: 1) The establishment of the Grievance Committee to review and resolve grievances, and 2) The data collected regarding patient grievances were incorporated into the hospital's performance improvement program. Findings:

Review of the policy titled "Patient Complaint and Grievance" Policy Number Adm.005, revealed "Grievance Committee - An ad hoc committee consisting of members defined by Administration as appropriate to the grievance type. The committee must consist of more than one person and may include members of Administration, Case Management, physician Representative, Patient Advocate, Risk Management and appropriate department managers. The committee is responsible for reviewing and resolving grievances that may require additional input, or that cannot be resolved by the Patient Advocate alone."

Interview with Risk Manager S10 on 12/07/11 at 8:50 AM, revealed she received all patient complaints, conducted the investigations, and responded back to the patient with the results. When asked if there was input from the Grievance Committee, S10 responded the last committee meeting was "a few years ago".

Further review of the Grievance Policy and Procedure revealed "6. Complaint Log and Performance Improvement. b. Data will be collected regarding patient grievances, as well as complaints that are not defined as grievances and incorporated into the organization's performance improvement program."

Review of the Quality Assurance/Performance Improvement data revealed there failed to be documented evidence the grievance process was reviewed and analyzed through the hospital's QA/PI program. Interview with the Quality Assurance Director S9 on 10/06/11 at 10:50 AM, confirmed the grievance process was not reviewed through the Quality Assurance Program.

Based upon review of the grievance policy and procedure, grievance log, 1 of 10 sampled patients (#6), and staff interview, the hospital failed to ensure the written notice of the outcome of the complaint investigations contained 1) the steps taken on behalf of the patient to investigate the grievance, the results of the process and the date of completion. Findings:

Review of the policy titled "Patient Complaint and Grievance", policy #Adm.005 revealed 4. Grievances/Significant complaints...5. The Grievance Committee will respond to the grievance with written notice by Certified Mail to the patient and/or their legal representative within seven (7) days of receipt of the grievance. The notice shall include: The name of the hospital contact person; The steps taken on behalf of the patient and/or legal representative to investigate the grievance; The results of the grievance process, and ; The date of completion of the process.

The grievance log was reviewed and a sample of patient complaints were selected. On 01/02/2011, pediatric patient #10 presented to the hospital's Emergency Department accompanied by the mother and grandmother. According to the complaint, the patient was administered an adult dose of an antibiotic instead of a pediatric dose. According to Risk Manager S10, the incident was investigated and a letter was sent to the complaint on January 5, 2011. Review of this letter revealed the notice failed to include 1) the steps taken on behalf of the patient and/or legal representative to investigate the grievance, the results of the grievance process, and the date of completion.

Based upon reviews of medical records, Infection Control data/log, Quality Assurance/Performance Improvement Program/meeting minutes, and interviews the hospital failed to ensure the established indicators for Infection Control were captured and reported as evidenced by a patient (#7) who had a positive Methicillin Resistant Staphylococcus aureus (MRSA) sputum culture and the failure of the Infection Control Personnel to capture and report this to the hospital's Quality Assurance Committee. Findings:

Review of patient #7's medical record revealed a physician's order, dated 01/04/11, for a sputum culture. Review of laboratory reports revealed the sputum culture was reported as positive for MRSA and Stenotrophomonas maltophilia.

Review of Infection Control data/log revealed patient #7's sputum culture, that was positive for MRSA, failed to be captured by Infection Control.

Interview, 12/07/11 at 1:00pm, with S6 Infection Control Registered Nurse (RN) confirmed the above information was correct. When S6 was questioned as to why the MRSA positive sputum culture was not captured through the established indicators for MRSA, she replied that she had assumed the role of Infection Control RN in September 2011; therefore she could not answer why the previous Infection Control RN did not capture all the infections including the one on patient #7 (positive sputum culture for MRSA).

Interviews, 12/07/11 at 1:00 pm, with S2 Director of Nursing and S6 Infection Control RN confirmed patient #7's sputum culture results were positive for MRSA and were not captured and reported through Infection Control.

Based upon reviews of medical records (#7), Infection Control data/log and interviews the hospital failed to ensure all infections were captured and monitored by Infection Control as evidenced by the failure of Infection Control to identify a patient (#7) with a sputum culture which was positive for Methicillin Resistant Staphylococcus aureus (MRSA). Findings:

Review of patient #7's medical record revealed a physician's order, dated 01/04/11, for a sputum culture. Review of laboratory reports revealed the sputum culture was reported as positive for MRSA and Stenotrophomonas maltophilia.

Review of Infection Control data/log revealed patient #7's sputum culture, that was positive for MRSA, failed to be captured by Infection Control.

Interview, 12/07/11 at 1:00pm, with S6 Infection Control Registered Nurse (RN) confirmed the above information was correct. When S6 was questioned as to why the MRSA positive sputum culture was not captured through the established indicators for MRSA, she replied that she had assumed the role of Infection Control RN in September 2011; therefore she could not answer why the previous Infection Control RN did not capture all the infections including the one on patient #7 (positive sputum culture for MRSA).

Interviews, 12/07/11 at 1:00 pm, with S2 Director of Nursing and S6 Infection Control RN confirmed patient #7's sputum culture results were positive for MRSA and were not captured and reported through Infection Control.

Based upon reviews of Medical Records (#7), the hospital's Infection Control Plan/data/meeting minutes, Quality Assurance/Performance Improvement Program/meeting minutes, and interviews the hospital failed to ensure all infections were reported to the Quality Assurance (QA) program as evidenced by a lack of documented evidence Infection Control data was reported to the QA committee to ensure corrective interventions were implemented and monitored. Findings:

Review of patient #7's medical record revealed results of a sputum culture, dated 01/04/2011, was positive for Methicillin Resistant Staphylococcus aureus (MRSA).

Review of Infection Control (IC) data, dated 1st Quarter May 5, 2011, revealed there failed to be documented evidence the IC officer/s had identified a MRSA positive sputum culture on patient #7; even though they documented blood cultures, performed on 01/05/2011, were positive for Staphylococcus epidermidis and Staphylococcus haemolyticus.

Review of the indicators that were monitored and trended included MRSA infections and central line blood stream infections; however IC failed to identify and document the positive MRSA sputum culture on patient #7.

Review of the hospital's QA meeting minutes, dated 01/2011 to present, revealed IC data was not included in the meeting minutes.

Interview, on 12/07/2011 at 12:45pm, with S6 Infection Control RN (Registered Nurse) revealed she assumed this position on 09/09/2011. The previous IC RN was no longer employed by the hospital and therefore could not be reached for interview in regard to the lack of documented information related to the positive MRSA sputum culture on patient #7.

Continued interview with S6 revealed she could not state why the sputum culture had not been reported and included in the IC data. She further stated she could not state why information had not been reported to QA; and since she took over IC (09/09/2011) she had recorded all infections and made reports monthly. S6 also stated that the end of the 4th quarter, 12/31/2011, a report would be made to QA as IC was to report quarterly to QA. S6 further stated she could only respond to incidents of infections since 09/09/11 when she began to monitor IC issues.

Interview, 12/07/11 at 1:00pm, with S2 Director of Nursing (DON) confirmed IC data had not been reported to QA.

The hospital failed to ensure Infection Control data/infections were reported to Quality Assurance for inclusion in reports.