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Based on review of Patient Grievance Policy and Procedure, Complaint/Grievance Log and interview, it was determined the Facility failed to assure a process was in place to provide the patient with written notice of the investigation of the grievance that included the name of the hospital, contact person, steps taken on their behalf, results and date of completion. The Facility could not be assured patients were informed of the outcome of the grievance investigation and that the grievance was resolved. The failed practice affected the current census of 21 patients and was likely to affect all patients admitted to the facility

A. Review of the facility policy "Patient Grievance (Patient Complaint Procedures)" on 10/20/14 revealed, "If a response is requested by the patient, the patient shall receive a response from the Patient Advocate upon review by the Hospital Administrator. The patient shall receive the response within three working days." The policy did not stipulate a written notice of the Facility's decision would be provided to the patient. The policy did not state that in the written response, the patient would be provided the Facility contact person, steps taken on their behalf in the investigation of the grievance, the results of the grievance process and the date of completion.

B. The Facility Grievance/Complaint Log was reviewed on 10/20/14 at 1000 and investigation documentation and follow-up was reviewed with the DON (Director of Nursing). The documentation did not include a written response to patients or resolution of grievances. The DON confirmed the findings at the time of review.

Based on review of the visitation policy and interview, it was determined the Facility failed to: have written policies that addressed the patient's right to have visitors; assure that any restrictions or limitations to visitation are clinically necessary and include the reason for any limitations and failed to address how hospital staff would be trained in the visitation policies and procedures. The Facility could not assure patient's visitation rights would be protected and that unnecessary restrictions and limitations would be prevented. The failed practice affected 11 (#1-#11) clinical records reviewed and likely all patients in the hospital at the time of the survey. The findings were:

A. The Facility visitation policy and admission rights provided to the patient were requested on 10/20/14. Review of the Facility policy "Visitation Policy" revealed " Objective, To prevent and/or control the transmission of disease or infection between visitors and patients by following established policies for hospital visitation and by instituting special restrictions when necessary." The Guidelines listed under "General Visitation Policies" listed "Visitation hours are from 8:00 a.m. to 9:00 p.m., Visitation should be limited to two (2) visitors per patient at a time, the visitors should be free of communicable disease (fever, rashes, etc.), Children under the age of 12 are not allowed to visit without consent of the patient's physician or nurse in charge, the nurse in charge may ask a visitor to leave if he becomes disruptive or hampers the medical well-being of our patients or the operation of the hospital. "

B. The Facility policy did not include the patient's right to have visitors; assure that any restrictions or limitations to visitation are clinically necessary and included the reason for any limitations and failed to address how hospital staff would be trained in the visitation policies and procedures.

C. On 10/20/14 clinical records #1 - #11 were reviewed for notification of visitation policy. A copy of the Facility "Visitation Policy" was signed by the patient or their representative and included in the clinical record.

D. The Director of Nursing was interviewed on 10/20/14 at 1145 and confirmed the findings and that the policy provided was the current policy.