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Based on review of the hospitals grievance policy, log and individual grievances, the hospital failed to provide a written response to the complainant with 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. This occurred for two of two patients/patients' representatives who filed grievances (Grievance #'s 1and 2) and the complaint was not resolved at the time of the complaint by staff present or immediately available.

Findings:

1. The hospital's grievance policy, #911.0, provided to the surveyors on the afternoon of 04/11/12 and identified by the administrator as the current policy, stipulated that grievances would be investigated and the complainant would be provided a written response with the required information within 7 days. The policy stated that if the investigation was not completed within the 7 days, a written response would be sent to the complainant stating the hospital was still investigating and then another written response, with the required information, would be sent when the investigation was complete.

2. From the grievance/concern log, two (Grievances #'s1 and 2 ) were selected and the surveyor requested all documentation the hospital had concerning the grievance, including investigation and any written correspondence. Two of the grievances were not resolved at the time of the grievance/concern. The material supplied did not contain documentation a written response had been provided to the complainant as required. The surveyor again asked Staff A if the hospital had any additional documentation. None was provided.

Based on review of the hospital's policies and procedures, meeting minutes, and personnel files, and interviews with staff, the hospital failed to designate the Infection Control professional in writing and the Infection Control program is not under the direction of a qualified professional trained in the principals and methods of infection control.

Findings:

1. Upon entrance to the facility on 04/11/2012, Administrative staff told the surveyors that Staff C was now the hospital's Infection Control Coordinator/Preventionist/Nurse since the first of February 2012.

2. Review of the hospitals's meeting minutes, Governing Body, Medical Executive Committee and Committee of the Whole, did not show the hospital had designated Staff C as the practitioner to direct the hospital's infection control program. Administrative staff stated the committees had not met since Staff C had been appointed.

3. Review of Staff C's personnel file contained a change of status form that documented Staff C had changed job status to the infection control preventionist and employee health nurse on January 30, 2012. The file did not contain a job description for infection control nurse/preventionist. The file did not contain documentation that Staff C had any training on the principals and methods of infection control.

4. Staff A stated on 04/11/2012 and again on 04/12/2012 that Staff C had not received any training in infection control.

5. These findings were reviewed and verified at the exit conference on the afternoon of 04/12/2012 with administrative staff.