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Based on review of documents and staff interview, the hospital failed to follow hospital policy to provide the complainant with a written response regarding the resolution of the complaints for nine (9) of thirty-five (35) complaints reviewed. This has the potential for the record of the hospital's inhouse investigation to be incomplete and precludes the patient/complainant from having the right to receive a written response according to hospital policy.

Findings include:

1. A review of the hospital's complaint policy revised 7/20/11 revealed a statement under the heading "POLICY" that indicates: "if the grievance is not yet resolved within the initial written response of 7 days, ....... that a follow-up (letter) will be provided ...... but not to exceed 30 days until the grievance is resolved".

2. During interview with the Chief Nursing Officer on 3/12/12 at approximately 10:30 a.m. he indicated the hospital did not send the complainant a follow-up letter (for patient #1 on the identifier list) as required per hospital policy.

3. A review of thirty-five (35) grievances generated over the past six (6) month period revealed:

- Five (5) letters were written to complainants with-in the time frames as outlined per hospital policy.

- Six (6) grievances were still on-going with an acceptable "window" of time remaining for a written response to the complainant.

- Twelve (12) grievances had letters written to the patient/complainant but all were sent late and were sent beyond the hospital's time frame per hospital Complaint Policy.

- Two (2) complaints were resolved on-site.

- One (1) complaint resulted in the patient expiring before the hospital could locate the address of the patient's sister.

- Nine (9) complaints failed to generate a written response from the hospital per hospital policy (the complaint patient - number one (1) on the identifier list was included in this list of nine (9)complainants).

4. These findings were reviewed with the QA/PI Coordinator on 3/12/12 at approximately 3:15 pm and she agreed with these findings.

Based on interview, intravenous policy and education documentation the hospital failed to put in place a corrective action plan for a patient developing thrombophlebitis following the intravenous (IV) placement . This affected one (1) of one (1) patients (patient #1). Failure to implement a corrective action plan has the potential to affect all patient's receiving IV therapy.

Findings include:

1. The medical record for Patient #1 was reviewed for his hospitalization from 01/05/12 through 01/16/12. The medical record had conflicting information as to where the IV site was located. The nurse documented 01/11/12 at 0755 the IV was located in the left arm and at 2000 another nurse documented the IV in the right arm with no documentation to support the IV had been restarted in a new location.

2. Findings were reviewed with the Director of Nursing (DON) for 3S at 1430 on 03/14/12 and she agreed with the findings.

3. The hospital's IV policy was reviewed at 1300 on 03/12/12 and it states IV site locations will be restarted in ninety-six (96) hours. The medical record for patient #1 had documentation that the IV in the right forearm with a date to restart as 01/12/12 was discontinued on 01/13/12 and restarted in the left wrist which was beyond the ninety-six (96) hours.

4. Findings were reviewed with the DON for 3S at 1430 on 03/14/12 and she agreed with the findings.

5. The DON for the 3S unit was interviewed on 03/13/12 at 1300 and she stated the IV policy for re-education had been placed in the staff lounge the first week of February. The sign in sheet was reviewed at the same time and only had three (3) signatures of staff out of twenty (20).

6. The findings were reviewed with the DON on 03/13/12 at 1315 and she concurred that all staff on her unit had not been re-educated. The Chief Nursing Officer (CNO) concurred at 0830 on 02/15/12 that only the staff on 3S were re-educated.