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Based on record review and interview, the hospital failed to provide the patient with written notice of its decision for 1 of 1 patient grievance (Patient #1), in that, the hospital did not provide Patient #1 a written response for her 8/14/14 verbal, unresolved complaint.

Findings Included


There is no investigation, follow-up or response letter noted for the 8/14/14 complaint from Patient #1.

During an interview on 11/07/14 ending at 1:06 PM, Personnel #1 was asked about the 8/14/14 patient complaint/grievance resolution. Personnel #1 was asked if she investigated the complaint/grievance. Personnel #1 stated, "I did not follow up with the charge nurse speaking to the patient. I did not consider it a grievance."

The September 2012, revised "Grievance, Patient/Family" policy required, "To provide a mechanism for patients and their families/representatives for prompt resolution of grievances...A "patient grievance" is a written or verbal complaint (when the verbal complaint about care is not resolved at the time of the complaint, by staff present)...The patient or patient representative will be given a written response within 7 days...written notice of the hospital's decision in the resolution of a grievance..."

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) evaluated the nursing care of 4 of 10 patients, in that, Patient #1, Patient #2, Patient #3, and Patient #4 did not have a documented RN assessment every 24 hours during their admission.

Findings Included

Patient #1 did not have a documented RN assessment for 8/15/14 and 8/17/14.

Patient #2 did not have a documented RN assessment for 9/10/14 and 9/12/14.

Patient #3 did not have a documented RN assessment for 8/10/14 and 8/18/14.

Patient #4 did not have a documented RN assessment for 10/18/14 and 10/24/14.


During an interview on 11/10/14 ending at 10:45 AM, Personnel #2 was asked to verify there were no RN assessments documented for the above listed dates. Personnel #2 confirmed there was no RN assessments documented for the listed dates.


The March 2011, revised "Nursing Assessment, Initial" policy required, "A RN must perform the initial nursing assessment and at least one of the shift reassessments in a 24 hour period and as the patient's condition warrants..."

Based on record review and interview, the hospital failed to ensure the completion of a discharge summary for 1 of 10 patients, in that, Patient #1 had no documented physician discharge summary for the 8/18/14 discharge.

Findings Included


Patient #1's record did not document a physician discharge summary.


During an interview on 11/07/14 at 2:55 PM, Personnel #1 was asked for the discharge summary for Patient #1. Personnel #1 stated, "there isn't one."