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Based on document review and interview, the governing board failed to ensure the facility grievance/complaint policy was followed.

Findings include:

1. Review of the patient medical record for P#1 on 4-04-12 indicated the family was upset and wanted the patient transferred; documentation indicated nursing attempted to reach the physician on 3-22-12 from 0800 hours to 1600 hours without success to have the patient transferred to a facility where a PICC line could be placed; the facility documents lack evidence that a complaint form, including investigation and follow-up to the patient and/or family, was completed.
2. Review of facility policy titled COMPLAINT POLICY on 4-04-12 indicated the following: Verbal and written patient complaints will be given to the Chief Nursing Officer or the Chief Executive Officer. All employees are responsible for reporting complaints/concerns of customers by use of the Formal Complaint Form. If a complaint is received via phone call, on site visit, verbal, or letter, refer the complaint to the Department Director/Manager; the Director/Manager will inform the Chief Executive Officer of any complaint involving threats of legal action, patient injury, safety or severe risk immediately.
3. Interview with B#1 on 4-04-12 at 1415 hours confirmed there is no documentation of the family complaint/grievance form being completed from the patient/family of P#1 related to the concerns voiced to nursing and noted in the patient medical record.
4. Interview with B#1 on 4-04-12 at 1500 hours confirmed the medical record of P#1 indicated the family was upset and wanted the patient transferred to another facility, the physician could not be reached to discuss transferring the patient on 3-22-12 from 0800 hours to 1600 hours, and the nurse did not follow the facility policies related to grievances.

Based on document review and interview, the Director of Nursing failed to ensure the policy for notification of physicians was followed for 1 of 5 (P#1) patient records reviewed.

Findings include:

1. Review of the patient medical record for P#1 on 4-04-12 indicated the family was upset and wanted the patient transferred; documentation indicated nursing attempted to reach the physician on 3-22-12 from 0800 hours to 1600 hours without success; the facility documents lack evidence that the facility policy related to physician notification was followed.
2. Review of facility policy titled PHYSICIAN NOTIFICATION on 4-04-12 indicated the following: Should it be required of the hospital staff to reach a physician by his/her personal beeper, that physician will be responsible to contact the hospital within 45 minutes of the first contact. Should the physician fail to respond after 2 attempts to reach him the nursing supervisor will be notified. The nursing supervisor will then contact the Administrator on Call. At that time, the Administrator on Call will give the nursing supervisor authorization to contact the Chief of Staff as per Medical Staff ByLaws/Rules and Regulations. In the event that the Chief of Staff cannot be contacted promptly, the Vice Chief of Staff will then be called.
3. Interview with B#1 on 4-04-12 at 1415 hours confirmed the medical record of P#1 indicated the physician could not be reached to discuss transferring the patient on 3-22-12 from 0800 hours to 1600 hours with attempts being documented at 0800 hours, 0900 hours, 1400 hours, and 1500 hours; B#1 confirmed the nurse did not follow the facility policy related to notification of the physician.

Based on observation and interview, a condition is being maintained which is conducive to the harborage of insects, rodents, and other vermin thus compromising the safety and well-being of patients.

Findings included:

1. While touring the Emergency Department (ED) on 4-4-12 at 1300 hours with B#1, 4, 5, and 7, it was observed that the back entrance exterior door to the ED was propped open due to the temperature of the department and the lack of air conditioning in the ED area; rooms 5, 4, and 3 temperature were 82 degrees, 82 degrees, and 78 degrees respectively.
2. Interview with B#5 on 4-4-12 at 1305 hours confirmed the doors are being propped open due to the heat and lack of air conditioning in the ED; B#5 confirmed insects have entered the ED and the staff kill them.