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Based on review of documents and staff interview the hospital failed to provide patients with an appropriate written response to a grievance. This deficient practice affected one (1) of one (1) patients (patient #1). This has the potential to limit the rights of patients to have their concerns addressed in a reasonable period of time and may also limit the quality of patient care. Findings include:

1. The hospital's patient complaint file was reviewed. For patient #1, the hospital had received a complaint made on behalf of the patient dated 7/5/10, after the patient was discharged from the hospital. The hospital had received the complaint on 7/12/10.

2. A review of the in-house investigation file revealed there was no evidence that an appropriate written response was sent to the patient. The hospital's only written response was a brief letter dated 7/16/10 (4 days after receipt of the patient's letter) stating they had received his letter and that they would be investigating his concerns.

3. A review of the Patient Grievance Policy dated July 2008 indicated patient abuse complaints require a written response to be sent to the patient. However, when a patient is still hospitalized, non-abuse complaints are investigated and documented on an Adult Protective Services form and reviewed and signed by the patient. The policy failed to indicate how complaints are processed when they are received after the patient has been discharged. During interview with the acting administrator on 8/25/10 in the a.m., she agreed the grievance policy does not include a process for dealing with complaints (including the need to provide a written response) when they are received after the patient has been discharged.

4. The Acting Administrator stated during interview on 8/25/10 in the a.m. that she agreed with the above findings.

Based on review of documents and staff interview it was determined that the hospital failed to allow a patient to participate in the planning of his care by not being given his medication as requested and by not being given adequate information relative to medical decision making regarding his medication. This deficient practice affected one (1) of ten (10) patients (patient #1). This has the potential to affect the care provided to all patients who have the right to participate in the planning of their care. Findings include:

1. Review of the medical record for patient #1 revealed that for the first six days of the patient's admission, it was documented by nursing staff, the physician assistant and physician involved in his care that the patient was repeatedly asking for medication that he was taking prior to admission on 6/19/10. The first dose of the medication was given to the patient on his sixth day of hospitalization, on 6/25/10. There were no progress note entries by the medical staff relative to the medication other than notes indicating the medicaion would be obtained and given to the patient. There were no entries to explain why there was a delay in providing the medication to the patient.

The Medical Director was interviewed in the afternoon on 8/25/10. He stated he reviewed the medical record and spoke with the physician who was involved in the care of the patient. He stated there were medical reasons for not providing the patient his medication as the patient had requested. He concurred the progress notes entered by the medical staff failed to reflect there had been a decision made to not provide the medication and/or why that decision had been made or that the decision had been discussed with the patient.

2. There was inadequate documentation to show the patient was given the opportunity to participate in the initial treatment plan formulated on day two of the admission, on 6/20/10. The Utilization Review Nurse was interviewed in the afternoon on 8/24/10. She stated the patients are verbally informed of the initial treatment plan. She concurred there was no documented evidence the patient did participate in the initial treatment plan.