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A. Based on Hospital policy, a complaint investigation, a review of incident/unusual occurrence reports, and patient and family interviews, it was determined the Hospital failed to ensure all grievances were processed as per policy and included into any type of resolution process with quality control which has the potential to effect 14 of 14 patients as of 12/29/11.

Findings include:

1. Policy # H-PC- 05-007 titled "Patient Complaint/Grievance Process" (last revised 12/2008) was reviewed on 12/28/11 at 12:00PM. The policy indicates that the grievance process will provide a process to help identify, investigate and resolve systematic problems through identification and analysis of trends and resolve a complaint within a reasonable time frame.

2 A complaint investigation was conducted on survey dates 12/28/11 & 12/29/11. The allegations included a complaint that Pt. #1's family had contacted the "head nurse and physician" regarding the quality of care issues with their mother. Clinical record documentation indicated that Pt. #1 had not been properly assessed for decubitus ulcers on admission.

3. A phone conversation with Pt. #1's daughter was conducted on survey date 12/28/11 at 8:00am. The family informed this writer that during Pt. #1's two month stay at this Facility, Pt. #1 was not turned and repositioned as required, had developed decubitus ulcers and some nurses and a physician had "given the family the brush off." The family member indicated to this writer that after consultation with the head nurse regarding Pt. #1's care, she was told that the issues would be placed in writing and resolved. Pt. #1's family indicated the family had not been provided with proper channels for filing grievances and issues regarding quality care.

4. The grievance logs at the Hospital were reviewed on 12/29/11 for a period of 1 year. Several complaints existed regarding the quality of care received, "harsh" "rude" nurses, patients not being turned and repositioned as required and other scenarios of concerns expressed. There was no documented Hospital evidence regarding Pt. #1 as described by the family was reviewed or that any complaint or grievance was filed into the Hospital occurrences.

5. During a staff interview conducted with the Chief Clinical Officer (CCO) and the Director of Quality Assurance (QA) on 12/28/11, it was verbalized that quality issues are incorporated into their plan of correction. "We have been here 3 mos, there have been a lot of changes and some staff have been relieved of duties because of it."

6. The above findings were confirmed with the CCO and the Director of QA on 12/29/11 at 3:00PM.

A. Based on Hospital policy, clinical record review and staff interview, it was determined in 1 (Pt. #1)of 6 clinical records reviewed, the Nursing staff failed to ensure the admission assessment reflected the patients current condition to ensure accurate nursing care could be provided.

Findings include:

1. The Hospital policy #H-PC- 04-009 titled "Assessment/Reassessment-Interdisciplinary Patient" (last revised 11/2010) was reviewed on 12/28/11 at 12:20PM. The policy indicates that goal of the Assessment process is to provide the patient the best care and treatment possible, that care provided will be based on each patient's specific needs to outline a systematic process for gathering pertinent information about each patient. Furthermore, the policy indicated at #1. Nursing Department: "An assessment is performed by a RN and is recorded in the patient medical record, within 12 hrs of admission, the assessment is based upon actual observation.....the initial assessment of the patient's nursing care needs will include: Wound Risk Assessment."

2. The clinical record of Pt. #1 was reviewed on survey date 12/28/11. Pt. #1 was admitted to the Hospital on 3/08/11 following a hip arthroplasty, femoral neck fracture with developing respiratory distress and expired on 05/05/11 after 2 months of care. At 8:00 pm on 03/08/11 the admission assessment performed by the admission nurse indicated that Pt. #1 had no skin deterioration or breakdown. "dry, warm, normal for patient, shiny, pressure ulcer-none signs or symptoms- none." "Braden scale risk documented as 14/23." The clinical record reflected that Pt. #1 was turned and repositioned every two hours while hospitalized throughout her stay until expiration on 05/05/11. On 03/10/11 documentation in the clinical record indicated Pt. #1 was consulted by a wound care nurse who described and documented a wound as "right gluteal wound and coccyx wound measuring 4.29Lx2.99wx0.2dx with an area of 10.07 and volume of 2.01." The wound nurse had documented that this "wound onset was 03/01/11 (Pt. admitted on 03/08/11) POA- present on admission, although transfer records conflicted with this assessment indicating was no skin impairment. Wound treatment protocol dated 03/07/11 from a preadmission screening indicated wounds, not applicable. The initial assessment on 03/08/11 failed to identify any wounds. It was also noted on the wound care assessment, that the wounds discovered on 03/10/11 were "community acquired." A "class III coccyx pressure ulcer that was selectively debrided with patient discomfort" was described in a physician's progress not dated 03/14/11, with date of visit as 03/10/11.

3. The above findings were confirmed with the CCO and QA Director on 12/29/11 at 2:40pm.

A. Based on review of Hospital policy, a complaint investigation, quality care data, grievance log, and staff and patient interviews, it was determined the Hospital failed to ensure patient grievances and result outcomes were monitored to ensure patient safety and quality of care that could potentially effect 14 of 14 patients as of 12/29/11.

Findings include:

1. Hospital Policy # H-PC- 05-007 titled "Patient Complaint/Grievance Process" pg. 2 of 6 (last revised 12/2008) was reviewed on 12/28/11 at 12:00PM. The policy indicates that if a verbal complaint cannot be resolved at the time of complaint by the staff present, then the complaint is a grievance. The Quality council monitors complaints and grievances to ensure compliance with procedures to review trends to improve patient care and services and ensure customer satisfaction.

2. A complaint investigation was conducted on survey dates 12/28/11 and 12/29/11. The allegations consisted of improper care, quality of care, staffing requirements, turning and repositioning patients and answering call lights in a timely manner and "rude" care were substantiated. The grievance logs indicated similar care issues were submitted in the past and this was an ongoing problem.

3. A phone conversation with Pt. #1's daughter was conducted on survey date 12/28/11 at 8:00am. The family informed this writer that during Pt. #1's two month stay at this Facility, Pt. #1 was not turned and repositioned as required, had developed decubitus ulcers and some nurses and a physician had "given the family the brush off." The family member indicated to this writer that after consultation with the head nurse regarding Pt. #1's care, she was told that the issues would be placed in writing and resolved. Pt. #1's family indicated the family had not been provided with proper channels for filing grievances and issues regarding quality care.

4. The grievance logs at the Hospital were reviewed on 12/29/11 for a period of 1 year. Several complaints existed regarding the quality of care received, "harsh" "rude" nurses, patients not being turned and repositioned as required and other scenarios of concerns expressed. There was no documented Hospital evidence regarding Pt. #1 as described by the family was reviewed or that any complaint or grievance was filed into the Hospital occurrences.

5. Pt. # 3 was interviewed on survey date 12/29/11 at 10:15 AM. Pt. #3 was admitted on 12/21/11 with extensive abdominal surgery. Pt. #3 indicated that self care needs were not being addressed in a timely manner. Pt. #3 indicated during an interview that she had never been turned and repositioned since her admission with a large abdominal wound on 12/21/11 and that she had to wait sometimes over 20 minutes for the call light to be answered.

6. There was no documented quality care data to reflect the effectiveness and quality of care regarding nursing assessments or of patients who complained of not being turned and repositioned even though turning and repostioning is documented.

7. The above findings were confirmed with the CCO and the Director of QA on 12/29/11 at 3:00PM.