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BAYFRONT HEALTH BROOKSVILLE 17240 CORTEZ BLVD BROOKSVILLE, FL 34601 March 16, 2011
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on record review and interview, the facility failed to they followed their own policies and procedures to review, investigate, and resolve patient grievances within a reasonable time frame for 1 of 5 (#2) patients' grievances.

Findings:1. Review of the Patient Rights and Responsibilities policy and procedure revealed it became effective 03/31/2009 and was last reviewed on 08/2010. Further review of this policy and procedure revealed the following:
Grievance: A Grievance: A "grievance" is a written or verbal complaint made to the hospital by a patient, or patient's representative, regarding the patient's care, abuse or neglect.
Upon receipt of a concern (written or verbal) from the patient, family or staff, a Patient Grievance/Complaint Management Report is generated.
The hospital will send a written notice of acknowledging the receipt of the grievance. If the grievance will not be resolved, or if the investigation is not or will not be completed with 7 days, this correspondence will advise that the hospital is working to resolve the grievance and will follow-up with a written response within 30 days.

2. Review of the Verbal and Written Complaint (Grievance) log revealed that there was not a filed a complaint from patient #2's family member regarding the development of a pressure ulcer.

3. Interview at 7:30 PM with the complainant revealed the she/he had complained to nursing staff of his/her mother having a pressure ulcer to his/her buttocks. The complainant further stated that she/he had visited patient #2 at this facility and found that their family member had not been receiving any baths while she was in this facility. Also patient #2 had a bloody gauze on his/her neck for about 3 days.

3. Interview on 03/16/2011 at 2:30 PM with the Director of Risk Management revealed that they were unable to locate a complaint/grievance form written regarding patient #2. Also there was not a grievance documented with a resolution or neither was it in the grievance log.

4. Further interview on 03/16/2011 at 3:00 PM the Risk Manager and the Director Critical and Clinical Information revealed that they have not investigated a grievance voiced by Patient #2's daughter.

5. Interview with the Director of the Intensive Care Unit (ICU) on 03/16/2011 at 3:30 PM revealed that she had received a phone call from the family member of patient #2, who had complained of her/his mother, and stated to this surveyor, "I did do a complaint form, responded to the complaint and left it in the mail room for Risk Management."