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Based on review of records and interview, the hospital failed to follow and enforce their policy to ensure patients rights were being met by providing written notice to the complainant according to its Grievance Policy in that 5 of 5 grievances received from patients (Patient #15, #16, #17, #18 and #19) dated between 04/28/10 - 01/03/11 did not receive a written notice of its decision, steps taken, results of the investigation and date of completion.

Findings included:

Patient #15's sister complained on 06/05/10 that Patient #15 choked and could not get anyone to respond and when they did respond, they did not know how to use the equipment. She complained that the call bell was not being answered in a timely manner. She also complained that she had requested a suppository and did not get it until the next day and the room was not being cleaned.

Patient #16's daughter complained on 12/23/10 that one of the night shift nurses took the call light away from him and put it where he could not reach it because he was bugging her too much.

Patient #17's daughter complained on 04/28/10 that the toilet was stopped up, the Certified Nurse Aide was short with her and she was worried about too much fluid being removed in dialysis.

Patient #18's son complained on 01/03/11 about the wound care. The dressing on the donor site was dry and the tape had stool on it.

Patient #19's sister complained on 10/03/10 the hospital allowed a woman in her brother's room that claimed to be his wife sign a consent form for a feeding tube. The sister stated she was the Power of Attorney and refused to allow the procedure to be done and requested the physician to be taken off the case.

Administrative Policy, "Patient and Family Grievance Policy," dated, 08/2010, required "To provide a mechanism for patient and their families for prompt resolution of grievances to comply with applicable regulations...the patient or patient representative will be given a written response within 7 days of the grievance notification. If the grievance is still in the process of being resolved, this will be communicated in the notification as well as an anticipated date of resolution...the written notice of the hospitals decision in the resolution will include...the name of the 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..."

In an interview at 10:00 A.M. on 03/22/11 with the Director of QA/RM (Personnel #4), she was asked if a written notice of the hospitals decision that contained the required components of the grievance process was provided to Patient's #15, #16, #17, #18 and #19. She stated, "No."