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Based on medical record reviews and interviews, the hospital failed to follow the hospital grievance policy for one of two patients (#1) when a concern brought to the hospital's attention was not addressed according to the hospital grievance policy. Findings include:

Employee (D)/administration stated during an interview on April 29, 2010, at 10:15 a.m. that she received information of a telephone call message from nursing home staff voicing a concern. She contacted the nursing home staff regarding the concern about Patient #1. The main concern was about bruises and scratches, although scratches were not new for the patient. She stated the bruises were small and on the upper chest. Employee (D) states she needed to speak with staff who cared for Patient #1. She spoke with them that same day and followed up with the nursing home staff a couple of days later. She found out that the area of bruises was small and staff did not feel the areas were significant. She also stated she did not consider this to be a grievance but rather a professional concern since it came from the nursing home and not a family member. The hospital completed no documentation and there was no response in writing.

According to the hospital grievance policy "a patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care.....If a complaint is not resolved on the spot....., the complaint becomes a grievance and must be responded to in writing.

Based on medical record reviews and interviews, in its resolution of the grievance, the hospital failed to provide a written notice to one of one verbal grievance received by the hospital. Findings include:

During an interview with Employee (D)/administration, she stated she received a telephone message from the nursing home regarding a concern in relation to Patient #1's hospital stay. The nursing home was contacted the next day to discuss the concern of bruises, bathing and dentures. Employee (D) spoke with the nursing home representative the next day. That same day she spoke with nurses who cared for Patient #1 during her hospital stay regarding the issues of the concern. Follow up to the concern was addressed to the nursing home representative by telephone a couple of days later. there was no written documentation regarding the complaint. According to the hospital grievance policy "a patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care....If a complaint is not resolved on the spot...., the complaint becomes a grievance and must be responded to in writing."

Follow up to the concern was addressed to the nursing home representative by telephone a couple of days later. There was no written documentation regarding the complaint.