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Based on review of the hospital's grievance/complaint policy, grievance log and six grievances and interviews with hospital staff, the hospital failed to establish and maintain a grievance process that recognized and investigated all patient care concerns/grievances that were not resolve at the time the complaint was voiced and provided written notice to the complainant with all the required elements. This occurred for four of six grievances (Grievances #1, 2, 3, 4) that were not resolved at the time by the staff present.

Findings:

1. Grievances #1, initiated 03/01/13, documented a complaint that a patient rang for assistance and was told someone would be there, but no one came. The result was the patient had an episode of incontinence. The grievance report documented the issue was closed on 3/5/13. The report contained no documentation of investigation or written response to the complainant. Staff D stated on the afternoon of 03/07/13 that he talked with staff and the patient once he became aware of the complaint.

2. Grievance #2, initiated 09/18/12, documented a complaint was voiced about competency of staff. A staff member did not know how to get a patient up and as a result the patient experienced an incontinent episode in the bed. The grievance report documented the issue was closed on 11/28/12. The report contained no documentation of investigation or written response to the complainant. Staff D stated on the afternoon of 03/07/13 that he talked with staff.

3. Grievance #3, initiated 12/22/12, documented a patient was left in a chair alone and was found exposed and incontinent. The grievance report documented the issue was closed on 12/31/12. The report contained no documentation of investigation or written response to the complainant. Staff C stated on the afternoon of 03/07/13 that she got the message the next day and talked with staff.

4. Grievance #4, initiated 11/24/12, documented a concern with nursing staff's knowledge about a patient and care. The grievance report documented the issue was closed on 11/27/12. The report contained no documentation of investigation or written response to the complainant. Staff D stated on the afternoon of 03/07/13 that he tried to call the complainant three times and then closed the complaint.

Based on review of the hospital's grievance/complaint policy, grievance log and six grievances and interviews with hospital staff, the hospital failed to develop a policy with all the required elements to recognize all grievances, and provide a timely written notice to the complainant with 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. This occurred for four of six complaints/grievances that were not resolved at the time the grievance was initiated. These findings were reviewed on the afternoon of 03/07/13 with administration. No further information was provided.