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Based on review of hospital policies and the grievance and complaint log, selected grievances and complaints, and interviews with hospital staff, the hospital failed to ensure the hospital's established grievance process was implemented.

Findings:

1. The hospital's grievance policy, entitled "Complaint/Grievances Process," with an issue date of12/01/98, last revision date 7/01/10 defined a patient grievance as "a formal or informal written or verbal complaint by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS hospital Conditions of Participation". The policy provided time frames for investigation and resolution of grievances; stipulated that a written response with the required information would be provided to the complainant; and stipulated the Director of Quality Management and/or Director of Clinical Services will investigate the grievance and review with the Chief Executive Officer . The policy further provided for complaint and grievance review through the governing body. The hospital failed to follow policy.

2. The hospital failed to identify grievances: The surveyors reviewed the grievance/complaint log for 2011. Four of seven grievances were not correctly identified as grievances as stipulated by the hospital policy. Four (15,16,17,19) of seven (3,15,16,17,18,19,20) grievances did not have letters to the complainants.

3. The above findings were reviewed with administration in the exit conference. No further documentation was provided.

Based on a review of policies and procedures, complaint/grievance reports, and a staff interview, the hospital failed to ensure a written notice of the patients' grievance resolutions containing 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 were provided to the complainants. Four (Pt#s 15, 16, 17, 19) of the seven (3, 15,16, 17, 18,19, 20 )grievances did not include a written response with all required elements to the complainants.

Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure the Director of Nursing (DON), or designee, provided orientation and evaluation of agency personnel and contract hemodialysis nursing personnel.

Findings:

1. On 4/12/11 the surveyors requested one agency nurse's personnel file (Staff H). Staff H's personnel file did not document orientation, training or competency evaluation for the facility.

2. On 4/12/2011 the surveyors requested two contract hemodialysis personnel files. One (Staff D) of two (Staff D,E) contract hemodialysis personnel did not have documentation establishing the hospital had trained or evaluated the contract personnel in their specialty area. The documents provided for staff A did not contain current skills assessment, competencies, or evaluations for the facility.

3. The above findings were reviewed with the administrative team during the afternoon of 4/12/2011.

Based on review of infection control data and meeting minutes and patient medical records and interviews with hospital staff, the hospital failed to ensure the infection control practitioner maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases.

Findings:

1. Infection control data and meeting minutes did not demonstrate review and analysis of infections present on admission or employee illnesses. On the morning of 4/12/11, Staff B, the infection control officer, told surveyors the hospital only tracked/reported for review HAI central line blood stream infections, ventilator acquired pneumonias, catheter related uninary tract infections and clostridium difficile.

2. Infection control data and meeting minutes did not demonstrate review and analysis of all HAI. According to Staff B's tracking sheet, Patient #1's sacral wound cultured out an infection on 02/22/2011. This was not recorded on the infection control log. Staff B stated they did not follow wound cultures in infection control. She stated that Staff W was responsible for wounds and might report his findings to Medical Staff or Quality. Review of meeting minutes for these committees did not demonstrate review and analysis of wounds for infections or corrective action when needed.

3. On the morning of 04/11/2011, Staff A told the surveyors that although the hospital did not have an organized surgery department, the hospital performed bronchoscopies and colonoscopies on site at the hospital. Infection control data and meeting minutes did not reflect Staff B monitored the equipment to ensure appropriate measures were taken regarding the cleaning of the scopes to avoid potential sources and transmission of infections. This was reviewed with Staff B on the afternoon of 04/12/2011.

Based on record review and interviews with hospital staff the hospital does not ensure that a log of all infections and communicable diseases is maintained that identifies incidents of infection and communicable diseases in both patients and staff that would enable the hospital to evaluate the data contained in the log to determine whether the infections were either present on admission or health-care associated and to protect both the patients and staff from infections.

Findings:

1. The original log, presented for review on the morning of 04/11/2011, did not contain all of the patient's identified as having infections present on admission. Staff B stated on the morning of 04/11/2011 that the log only contained hospital acquired infections/nosocomial infections, because those were the ones the committee reviewed. Staff B brought her work sheets. She stated she filled out a data sheet for every patient admitted to the facility, but only logged and reported on those patients who had hospital acquired infections (HAI).

2. The log presented for review did not contain all patient's identified as having HAI. Three (Pt#'s1,2,4) of twenty two patient's medical records reviewed contained documentation of hospital acquired infections. Of these hospital acquired infections three of three were not found on the infection control log. Staff B stated she had pulled Patient #4's data sheet because she needed it to report in infection control as a HAI. Patient #2's name was not on the infection control log either. Staff B stated she updated the log on the computer every day and the copy given to the surveyors was not the most current. Patient #1 developed a positive wound culture during hospitalization. Staff B told surveyors hospital acquired wound infectionss were not tracked by infection control.

3. On the morning of 4/12/11, Staff B told surveyors the hospital only tracked/reported for review HAI central line blood stream infections, ventilator acquired pneumonias, catheter related uninary tract infections and clostridium difficile. This was verified by meeting minutes containing infection control.

4. On 04/12/2011 at 1415, Staff B also stated they did not follow wound cultures in infection control. She stated that Staff W was responsible for wounds and might report his findings to Medical Staff or Quality. Review of meeting minutes for these committees did not demonstrate review and analysis of wounds for infections or corrective action when needed.

5. The above findings were reviewed with administration in the exit conference on 4/12/11.