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Based on record review and interviews with hospital staff, the governing body does not ensure that services performed under a contract are provided in a safe and effective manner. Multiple contracted services/personnel are not evaluated by the QAPI program to assure the services are performed in a safe and effective manner by qualified personnel.

Findings:

1. Contract personnel providing care during dialysis are not evaluated by the hospital to ensure the contractor follows hospital policies, and are competent. Documentation in Staff F (a registered nurse) file included documentation a licensed practical nurse representing the dialysis company validated competency with the contractors equipment. There was no documentation hospital personnel evaluated the contractors competency.

2. On the morning of 6/27/2012 and the afternoon of 6/28/2012 contract dietary personnel told surveyors they followed the contracted services policies regarding incident reporting and grievances. Review of the contractor's policies did not include a policy for grievance, incidents, or complaints. Contracted dietary personnel files did not include current training on the hospital's complaint, grievance, or incident reporting. There was no documentation all food service personnel had been oriented and trained to the facilities policies and procedures.

.3. These findings were reviewed at the exit conference. No further documentation was provided.

Based on review of hospital policy, meeting minutes, and interviews with personnel. The hospital failed to correctly identify grievances. The hospital does not ensure all grievances are reviewed by the Governing Body or a Committee appointed by the Governing body. There is no documentation the hospital ensures grievance data is used to improve patient care.

Findings:

On 6/28/2012 surveyors reviewed the grievance policy entitled "Complaint/Grievance Process" with an effective date of August 2010; Policy Statement: "The Risk Manager shall operate and maintain the hospital's grievance mechanism designed to process and resolve patient complaints and formal grievances while maintaining a comprehensive record of complaints presented to Midwest Regional Medical Center. The policy further stipulates: II. Receipt of Complaints A. Processing of verbal complaints: 1. Receipt of a verbal complaint is to be addressed promptly by the staff present (staff present includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e. nursing, administration, nursing supervisors, patient advocate, etc.) to resolve the patient's complaints. 2. The customer patient feedback report form should be completed immediately stating facts of the complaint and the resolution provided (A complaint /grievance is considered resolved when the patient is satisfied with the actions taken on their behalf.) 3. The unit director should receive the completed patient/customer feedback form and take necessary actions to achieve resolution. The unit director will then forward the completed report to the Risk Manager who will review and maintain the data. 4. Patients choosing not to voice complaints to unit staff providing their care may choose to call the Risk manager. In the absence of the Risk Manager the House Supervisor may be called. B. Complaints not resolved on the spot by staff present are grievances. 1. Grievances made about situations endangering the patient (neglect/abuse), given the seriousness of the allegations and potential to harm patients, require immediate investigation and review. 2. Grievances require written notice (response) to the patient within seven (7) days. The written response will contain the name of the hospital contact person and identify the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. the written notice of the hospital's determination regarding the grievance must be communicated to the patient or patient's representative"

1. The policy does not correctly define grievance with all the required elements. In an interview on the afternoon of 6/6/2012 Staff B and Staff D, Staff D was unable to correctly describe the difference between a grievance and a complaint. Staff B told surveyors the current policy did not correctly define grievance in accordance with current CMS standards.

2. The hospital does not ensure grievance data is incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program with analysis of the data and implementation of processes to improve patient care:
In an interview on 6/28/1 Staff A told surveyors the risk management, Quality, and the Chief Nursing Officer reviewed all grievances. Meeting minutes provided to surveyors 6/27/2012 did not have any breakdown of the grievances. There was no evidence that grievance and complaint data was reviewed, trended and analyzed with implementation of corrective and/or process changes to improve patient care.

3. There was no evidence the Governing Body reviewed, trended, and analyzed incident, grievance, and complaint data.

4. Grievances entered in the hospital grievance log met the definition of a grievance but were not taken through the grievance process according to the hospital policy. Three of three grievances (Records #4, 5 and 5) reviewed for March and April 2012 contained patient care issue concerns. The information contained on the forms and additional data provided to the surveyors did not contain evidence the grievances had been taken through the grievance process.

5. During the interviews with Staff A, E and I, the surveyors learned a patient representative for Patient #1 had voiced a grievance. This grievance was not identified on the patient grievance log and was not taken through the hospital's grievance process.

6. This information was provided to administration at the exit conference. No further information was provided.

Based on review of hospital policies and procedures and grievances and interviews with hospital staff, the hospital failed to enforce their grievance policy and process with time frames for review, investigation and a provision for a written response to the complainant with the required information.

Findings:

1. The surveyors reviewed the grievance log for March and April 2012 and selected three grievances for review. The surveyors requested all information concerning the three selected grievances, including investigation and the written response to the complainants.

2. Grievances #4, 5 and 6 contained clearly stated patient care concerns. The information/data provided did not contain evidence of investigation of the patient care issues addressed in the grievances. On 06/28/2012 at 1410, Staff A stated she had referred Grievance #4 and 6 to the emergency department manager for review. Staff A stated because the manager could not contact the complainants, no investigation was undertaken. Concerning Grievance #5, Staff A stated because she did not know the patient's name, she could not investigate the grievance. Grievance #5 clearly addressed patient care issues and identified the unit.

3. During the interviews with Staff A, E and I on the afternoons of 06/27 and 28/2012, the surveyors learned a patient representative for Patient #1 had voiced patient care issue complaints. A grievance for concerning this patient and the patient care issues identified was not contained on the patient grievance log and was not taken through the hospital's grievance process. Although Staff A and E told the surveyors the process that was performed to investigate the dietary issue provided by the patient representative, no evidence or documentation of investigation was provided. Although Staff A told the surveyors that she had reviewed the staffing for the unit and time period for Patient #1, no evidence was provided of the investigation.

4. The hospital's policy stipulated that a written response with the hospital's decision would be sent to the complainant within seven days and would contain the name of the hospital contact person, the steps taken on behalf of the complainant to investigate the grievance, the results of the grievance process, and the date of completion. At the time of review, on 06/28/2012, this had not been completed for Grievances #4, 5, and 6 and for Patient #1's representative's grievance.

5. These findings were reviewed with administrative staff on the afternoon of 06/28/2012. No additional information was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that patients receive care in a safe setting. The hospital failed to investigate, take action or have a method to identify incidents or patterns to protect patients.

Findings:

1. Review of Quality Assurance and Performance Improvement Committee Meeting minutes for 2012 and Governing Body Meeting Minutes did not include analysis of all incidents to identify patterns which might impact patient safety. There was no analysis of incidents so that corrective action plans are developed to improve patient safety.

2. Review of Governing Body Meeting Minutes 2012 did not include documentation complaints, grievances, and incidents reviewed for trends or patterns so that corrective action plans are developed to improve patient safety.

3. Surveyors reviewed personnel files on 6/28/12. There was no documentation all employees were educated on the current complaint/grievance policy. There was no documentation all employees were educated on incident reporting.

4. Surveyors reviewed Grievance Committee Minutes 2012. There was no documentation in the minutes indicating the types and numbers of grievances, complaints and what actions and follow up were recommended or taken.


5. This finding was discussed at the exit conference. No further documentation was provided.

Based on review of medical records, policies and procedures, dietary consultation reports, and interviews with staff, the facility failed to ensure dietary services were provided in an organized manner and policies, procedures, and processes were reviewed, approved and implemented.

Findings:


1. On the afternoon of 6/28/2012 Staff C and D told surveyors if they received a complaint they would report the information to their supervisor. Staff C and D told surveyors they would follow the contracted services policies. Staff C could not recall any specific training on current grievance and incident reporting policy. Staff C and D's personnel files did not include any documentation of training on current incident and grievance reporting.

2. On the afternoon of 6/28/2012 Staff E the food services director told surveyors about a incident regarding moldy food during March of 2012. Staff E told surveyors no incident or complaint form had been completed as he spoke to Staff A. Surveyors reviewed the complaint and grievance log for March 2012. There was no complaint/grievance or incident report generated for this incident. Staff E told surveyors the dietary department takes care of the complaints regarding dietary. Staff E told surveyors the department did not document the complaints but they were handled at the time of the report. Staff E told surveyor the department did not attend quality assurance/performance improvement There was no documentation clinical nutritional services submitted quality data for review and analysis.

3. On 6/28/2012 surveyors reviewed dietary test tray reports. The policy indicated test trays would be performed on weekly basis. March 2012 included two test trays. April 2012-current did not have any test trays documented. Staff E did not know why the test trays had not been done during those weeks.

4. On the morning of 6/27/2012 Staff C told surveyors dietary service was provided through a contracted agency. There was no documentation indicating the policies had been reviewed and approved through the hospital's medical staff or governing body. There was no documentation the hospital's governing body evaluated the contracted service through the QAPI process.