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Based on medical record review, facility policy review, and interview, the facility failed to ensure timely written responses to patient grievances were met for one patient (#5) of five patients reviewed.

The findings included:

Patient #5 was admitted to the 500 south hall of the facility on May 29, 2010, with diagnosis to include Colitis.

Medical record review revealed the patient had an intermittent IV catheter (INT) placed in the right wrist on May 29, 2010. Medical record review of the Patient Care Notes, dated May 29, 30, and 31, 2010, revealed the IV site was documented as being assessed every twelve hour shift. The INT was used for every eight hour IV antibiotic pushes only and not utilized for continuous IV fluids. Medical record review revealed the Patient Care Notes: Focus Narrative Note, dated May 31, 2010, at 8:00 a.m., revealed the patient complained of the IV site burning when the nurse flushed the INT with sterile saline followed with a Heparin dose to maintain patency of the INT, as was ordered to be done every 8 hours. Continued review revealed at 8:28 a.m., the IV team (a dedicated team of nurses with the sole responsibility of initiating or addressing problem IV) was at the patient's bedside and had assessed the site to have phlebitis infiltration (inflammation of the vein and fluid going into the tissue rather than the vein) with a scale of 1 (on a scale of 0-4, with 4 being the worst and 1 indicating the skin blanched, less than 1 inch edema, and cool to touch). Continued review revealed the IV team attempted to start a new IV in another site but the patient refused saying she was going home. Review of the Focus Narrative Notes revealed no prior documentation of complaints of problems with the INT IV site.

Review of facility documents revealed the patient had filed a complaint with the facility on July 9, 2010 related to the hospitalization of May 31, 2010. Continued review of the documents revealed the facility took action to contact the complainant by phone on July 21, 2010 (12 day after the patient complained). Continued review revealed the information documented on July 21, 2010 was a continued list of complaints by the patient.

Interview by phone on October 28, 2011, at 9:50 a.m. with the Director of Accreditation, Service Excellence Representative, the Nurse Manager on 5 North, Director of Human Resources, Chief Nursing Officer, the Director of IV Access Quality, Director of Service Excellence, and two Registered Nurses revealed the 5 North Nursing Manager investigated the complaint allegations on July 9, 2010 and responded via email to the Service Excellence Representative. Continued interview revealed the Nurse Manager of 5 North was already aware of the patient's complaint and thought they had been addressed while the patient was hospitalized. Interview with the Nurse Manager confirmed the facility response from the time of the call in complaint from the patient on July 9 was delayed for 12 days; and the facility had no documentation it had responded to the patient in writing.

Medical record review revealed patient #5 was re- admitted to the hospital's 100 south hall on October 30, 2010, with diagnosis to include Pleuratic Chest Pain with Syncopy.

Medical record review of facility documents revealed on October 31, 2010, the patient filed a complaint with the facility which was entered by the House Supervisor at 7:10 p.m. The patient indicated being "very upset" with attitude of the nurse caring for her, complained about the responsiveness of the staff, complained about the staff not having her lunch tray after returning from an MRI causing the patient to leave the unit for her meal in the facility cafeteria, and complained about not receiving pain medications when requested. The House Supervisor apologized and assured the patient that the patient's complaints would be reported to the nurse manager of the unit for follow-up. Continued review revealed a notation in the Progress Note, dated November 1, 2010, indicating the Service Excellence Representative "attempted" to follow-up with the patient per the patient request. Continued review of the undated facility documents revealed the concerns identified by the patient were investigated by the Director of Nursing Services. Continued review revealed there was no documentation the facility provided a formal response in writing to the patient related to the complaint.

Review of the facility policy Patient Complaint and Grievance, #RI-03239, dated as revised February, 2009, revealed " ...a process for prompt resolution of patient grievances and complaints ...Grievance - a written or verbal complaint (when the complaint about patient care is not resolved at the time of the complaint by staff present ...the grievance process may be invoked when a complaint cannot be resolved promptly to the patient's satisfaction by the staff present ...examples of complaints that will invoke the patient grievance process: Patient Care ...The Department Manager will, within seven (7) business days of the communication of a patient grievance, begin an investigation by contacting the patient either in writing or orally acknowledging receipt the patient grievance ..."

Interview, by phone, on October 28, 2011, at 10:45 a.m., with the Director of Service Excellence, confirmed the facility had not formally responded in writing to the May or October 2010 complaint made by the patient.

Interview, by phone, on November 3, 2011, at 11:45 a.m., with the Director of Accreditation, confirmed the facility failed to ensure the facility's grievance process was followed.