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Based on record review and interview the hospital failed to ensure all components pertaining to the resolution of the grievance were included in the response letter by failing to provide written notice of the steps taken on behalf of the patient to investigate the grievance for 1 of 2 sampled patients with grievance in a total sample of 12. Findings:

Review of the hospital's current "Patient and Customer Complaint/Grievance Policy" reflected "........7. In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains 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."

Review of the hospital's "Complaint Log Qtr 2.. "reflected patient #5's spouse submitted a written grievance (postmarked 5/12/12) to the facility. Further review of the log reflected there were multiple issues. Under the "Investigation" section documentation reflected "through staff interview [and] record review] copy attached". Under the "Action" section it was noted "letter received [no] follow-up requested treated as complaint". Documentation reflected a letter was sent on 5/18/12.

Review of the information noted in the hospital's "Complaint Log" regarding patient #5 revealed a letter, dated 5/18/2012, which was addressed to the patient's wife. Further review of the letter reflected there was no documentation to reflect the steps that were taken to investigate the complaint/grievance.

There was no written evidence to reflect an investigation had been conducted concerning the allegations/concerns submitted by patient #5's spouse.

During an interview with S3, Director of Quality, on 6/7/12 at approximately 2:05 p.m., she revealed the staff were attentive to the "things" that were brought to their attention by patient #5's spouse. S3 stated they made the letter "general" but they let her know that they looked at the concerns.

Further interview with S3, Director of Quality on 6/8/12 at 11:55 a.m. confirmed the letter was not specific. S3 further confirmed there was no written evidence to reflect the complaints/grievances submitted by patient #5's spouse were investigated.

Based on record review and interview the hospital failed to ensure medical record entries were legible by failing to ensure the physician's progress notes and/or evaluations were written legibly. Findings:

Review of physician progress notes and/or post admission physician evaluations completed by S4, Medical Doctor (MD) for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 reflected documentation that was not legible.

During an interview with S2, Director of Quality and S3, Director of Nursing (DON) on 6/7/12 at approximately 10:00 a.m., they confirmed that there was a problem with S4, (MD), completing legible documentation in the records.