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Based on a review of policies and procedures, complaint/grievance reports, and staff interview, the hospital failed to ensure a written notice of the patients' grievance resolutions containing 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 completion were provided to the complainants. Two of two grievances did not include a written response with all required elements to the complainants. This finding was reviewed and verified with Staff A at the time of the review on 06/26/2012.

Based on review of hospital documents, quality improvement meeting minutes, medical records, incident/occurrence reports and grievances, and interviews with hospital staff, the hospital's quality assessment and performance improvement (QAPI) program failed to identify and analyze process of care issues identified by the surveyors, staff and voiced by patients/patient representatives.

Findings:

1. The medical record for Patient #1 identified the patient received a hospital acquired skin interruption. Although this occurrence was documented by two staff and a physician, none of the individuals followed the hospital's policies and the event was not processed through the QAPI program for analysis and possible opportunities for patient care improvement. Staff E stated on 06/26/2012 that she thought the nurse would be responsible since it "was a skin issue."

2. Incident reports are not analyzed and processed through the QAPI program for identification or opportunities for improvement of patient care/practices.

3. Grievances are not placed through the grievance process and analyzed with possible identification of opportunities for improvement. Two of two grievances reviewed did not follow the hospital's grievance policy and provide a written response with the required information.

4. These findings were reviewed and verified with Staff A and B on the afternoon of 06/26/2012.