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Based on a review of policies and procedures, complaint/grievance reports, and staff interview, the hospital failed to ensure a written notice of the patients' grievance resolutions containing 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 were provided to the complainants. Six of seven grievances did not include a written response with all required elements to the complainants.

Based on review of policies and procedures, hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure nurses supervised and evaluated patient care for one of three patients (Patient #1 of Patients #1 7, and 10), who had specific weights ordered and whose medical records were reviewed.

Findings:

1. On admission, 12/14/2011, the physician ordered Patient #1's weight to be taken and recorded every three days. No weights were recorded on 12/22 and 28/2012. On 01/02/2012, the order was changed to daily weights. Patient #1's weight was only taken and recorded on 01/02, 05 and 18/2012. This was confirmed with staff at the time of review.

2. The nurses did not supervise to ensure the nursing care and weights were provided as ordered.