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Based on record review and interview the hospital failed to ensure a written notice was provided to the complainant upon resolution of the grievance that contained 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 for 1 of 3 grievances reviewed (Patient #3). Findings:

Review of the grievance log from 12/01/09 through 11/01/2010 revealed no documented evidence of a complaint intake or grievance for Patient #3.

S5, RN was interviewed face to face on 11/05/10 at 8:45am. S5 indicated she remembered Patient #3 and her daughter and had reviewed the patient's record before the interview. S5 indicated she was the Charge Nurse at the time of Patient #3's death on 12/04/09. Further she indicated the patient's daughter had made no complaints and had thanked the staff for the care. Further she indicated she rounds every shift and she was not made aware of any complaints.

S4, RN Divisional Director of Medical/Oncology (includes 5 east) was interviewed face to face on 11/05/10 at 8:25am. S4 indicated she had reviewed the record for Patient #3 but she did not remember the patient or the family. Further she indicated she had not received a complaint of neglect for Patient #3 but if she had she would have investigated it further and entered the issues into the on line complaint tracker system. Further there was no documented evidence in the patient's record of complaints of staff not providing comfort care.

S11, RN Director of Mission Services was interviewed face to face on 11/05/10 at 9:10am. She confirmed she is responsible for tracking grievances. Further there was no documented evidence of a complaint/grievance filed for Patient #3. Further the complaint would have been expanded depending on the circumstances involving the issues. Further if she had received a complaint/grievance regarding care services it would have been referred to the Nurse Manager and investigated. Further a letter would have been sent to the complainant within 7 working days of receipt of the complaint.

S7, Risk Manager was interviewed face to face on 11/05/10 at 9:20am. S7 indicated she is responsible for risk issues and works with staff and family and patient safety department and does the work for legal claims. Further she is not the first contact person to handle complains/grievances but the complaint/grievance usually gets to her by another system. S7 further indicated she did receive a direct call, put through by the secretary, from Patient #3's daughter around 05/2010. Patient #3's daughter had indicated she had concerns because there was no physician's order for a DNR and her mother was not resuscitated. Further she had pulled the chart, verified the physician's order for the DNR and called S8, MD Patient #3's Primary Physician, and he also confirmed the written order. Further she had called the Complainant again after her investigation and informed her there was a DNR order and she could request Patient #3's medical record. Further she had considered the concerns to be a complaint and not a grievance so it was not documented and entered into the complaint/grievance tracking system. Further a letter was not sent to the complainant within 7 working days of receiving the grievance.

Review of the hospital policy entitled " Patient Rights, Complaints, and Grievance Process " Reference #: OrgClin/020 revealed in part, " E. A grievance is defined as: * A verbal complaint by a patient or the patient's representative, regarding the patient's care when the complaint has not been resolved at the time given by staff present. "Staff present" includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location; * All verbal and written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements. Grievance Review Process: The Grievance Committee or designee will notify the patient filing the grievance in writing of the steps taken to investigate the grievance, the results of the investigation, and the date the investigation was completed. Investigation of Grievances: The Referral Department Director/Manager will complete the investigation and identify all actions taken and any additional recommendations and follow up with the patient in writing within a average of seven working days from receiving the grievance."