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Based on review of hospital documents and interviews with staff, the hospital failed to establish a grievance process that ensures 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.

Findings:

1. Review of QAPI meeting minutes for 2009 and 2010 did not contain evidence grievances were incorporated into the QAPI program. On the afternoon of 09/27/2010, Staff B stated grievance was kept separate and that Staff A was responsible.

2. On the afternoon of 09/27/2010, Staff A told the surveyors that the grievances were sorted according to area and patient floor and a report was given to the Executive Officers and then forwarded to the Board. She showed the surveyors a sample of the documentation. The documentation did not show the results of the investigations of the grievances had been analyzed with processes for improving problem areas.

Based on review of records and interviews with staff, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent as required by the hospital's grievance process. Three of five grievances/complaints (Grievances # 1, 3 and 4) listed on the hospital's 2010 grievance log did not have evidence of an investigation and resolution of all the complainants's grievances. This finding was reviewed and verified with hospital staff on the afternoon of 09/27/2010.

Based on review of the hospital documents and interviews with hospital staff, the hospital failed, after investigation and resolution of the grievance, to provide a written notice to the complainant with the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. In four of four grievances reviewed (Grievances 1, 2, 3, and 4), that could not be resolved at the time of the complaint, did not have evidence a written response with the required information had been provided to the complainant once the hospital had finished its investigation. This finding was reviewed and verified with hospital staff on 09/27/2010