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Based on review of submitted complaints/grievances and staff interview, it was determined there was no evidence the facility gave written notice to the complainant containing the hospital contact person, the steps taken to investigate the complaint/grievance, the result of findings of the investigation and the date of completion for three (#1-#3) of seven (#1-#7) complains. The failed practice prevented the complainants from receiving resolution to the submitted complaint/grievance and had the potential for all complainants who submit a complaint/grievance from receiving resolution to the submitted complaint/grievance. The findings were:

Review of Complaint #1-#3 revealed there was no written follow-up to the complainant after the investigation was completed to inform them of the outcome. Interview on 03/22/11 at 1030, the Director of Nursing confirmed the findings.

Based on clinical record review and staff interview, it was determined nursing staff failed to document the monitoring of the bed or wheelchair alarm to assure the alarms were operational for three (#8-#10) of four (#7-#10) current in-patients. The failed practice affected patients #8-#10 and had the potential to affect all patients in which a bed or wheelchair alarm was used. The findings were:

1. Patient #8 was admitted on 03/18/11. Review of the Nurse's Notes Daily Shift Assessment from 03/18/11 to 03/21/11 revealed the bed alarm was turned on when the patient went to bed. Review of the Close Observation Flowsheet from 03/18/11 to 03/21/11 revealed the 7P-7A shift did not record the alarm was activated and monitored to assure the alarm was operational throughout the night.
2. Patient #9 was admitted on 03/13/11. Review of the Nurse's Notes Daily Shift Assessment from 03/13/11 to 03/21/11 revealed the bed alarm was used from 03/19/11 to 03/21/11 and was turned on when the patient went to bed. Review of the Close Observation Flowsheet from 03/19/11 to 03/21/11 revealed the 7P-7A shift did not record the alarm was activated and monitored to assure the alarm was operational throughout the night.
3. Patient #10 was admitted on 03/19/11. Review of the Nurse's Notes Daily Shift Assessment from 03/19/11 to 03/21/11 revealed the bed alarm was on turned when the patient went to bed. Review of the Close Observation Flowsheet from 03/19/11 to 03/21/11 revealed the 7P-7A shift did not record the alarm was activated and monitored to assure the alarm was operational throughout the night. Review of the Close Observation Flowsheet for the 7A-7P shift revealed a wheelchair alarm was to be used but there was no evidence when the patient was in the wheelchair that the alarm was activated and monitored.
4. Interview on 03/22/11 at 1030, the Director of Nursing confirmed the clinical record findings for Patient #8-#10.