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Based on record review and interview, the hospital failed to ensure the grievance process was implemented according to policies and procedures for 1 (#3) of 1 (#3) records reviewed for grievances by failing to respond appropriately to a verbal grievance initiated by a family member. Findings:
Review of the documented intake information provided by the Complainant revealed, in part, the Complainant stated two days (04/03/15) after Patient # 3's discharge (Wednesday, 04/01/15), she contacted the nurses' station at the hospital where Patient #3 was an inpatient (from 03/26/15 through 04/01/15) to voice a complaint about Patient #3's care during her hospitalization. The Complainant indicated a male answered the telephone, but she did not know the name of the person. The Complainant indicated she reported to the staff member Patient #3's name and the nature of the complaint regarding Patient #3. The Complainant indicated the staff member advised her to contact administration to report her concerns. The Complainant indicated she placed several calls to the administrator over the next couple of days and again approximately three days after her first call, and left multiple messages with the hospital's operator. The Complainant stated she never received a call back from the administrator or any other hospital personnel to discuss the grievance.
Review of the policy and procedure entitled Grievance-Procedure Patient and Family, NO: RI-010A, presented as current by S3RM (Risk Manager) revealed, in part: "2.0: It is the responsibility of each staff member to respond promptly to any concern or grievance voiced by patients and their families ...The staff member receiving the complaint should notify his/her supervisor when the issue cannot be immediately resolved. 3.0: If the staff member who receives the verbal concern is unable to resolve the concern promptly, his/her supervisor is notified ....17.0: Any grievance received after a patient is no longer in the facility's system should be documented by the staff member receiving the complaint and forwarded to the Patient Advocate."
Review of all of the Incident Reports from 01/15 to current revealed no documentation of an incident, complaint, or grievance regarding Patient #3.

Patient #3
Review of the medical record for Patient #3 revealed she was an 18-year-old female admitted to the hospital on 03/26/15 and discharged on 04/01/15. Admitting diagnoses included Depression, Suicidal and Homicidal Ideations (with no plans). Other diagnoses included Schizoaffective Disorder, Obsessive Compulsive Disorder, and Asperger's Disorder (Autism). Patient #3 was admitted under a Formal Voluntary Admission. Patient #3 had not been interdicted.
In an interview on 08/17/15 at 12:13 p.m., S3RM (Risk Manager) indicated there were no grievances received at the hospital since 01/15. (He indicated he had been out on medical leave for the period surrounding the hospitalization of Patient #3.) S3RM also indicated if a complaint or grievance is called in directly to the nursing unit and it is after business hours, the staff would be expected to contact the Administrator on call, and from there, the Administrator would contact the family and try to resolve the issue with the family. S3RM confirmed the receiving staff member would be expected to complete an Incident Report.
In an interview on 08/19/15 at 10:00 a.m., The Complainant indicated she thought she had contacted the nurses' station "sometime after noon, maybe around 6:00 p.m. or 7:00 p.m.," but was not absolutely sure because she did not have any documentation. She also confirmed that she did not know or document the name of the staff member she spoke with regarding the complaint. The Complainant confirmed, to date, she had not received any contact from anyone at the hospital regarding her complaints/ grievance she voiced to the staff member on 04/03/15.
In an interview on 08/20/15 at 4:15 p.m., S3RM confirmed the hospital staff did not follow the policy and procedures for the complaint/grievances related to Patient #3, and the staff should have followed the policy and procedure.

Based on record review and interview, the hospital failed to ensure that all documents were completed for 1 (#3) of 3 (#1, #2, #3) records reviewed for complete and accurate medical records. Findings:
Review of the policy and procedure entitled, "HIM (Health Information Management) Policy 004, Documentation Protocol" revealed, in part: Policy: Facility records, reports, charts, and documents are to be accurate, truthful and complete ....Purpose ...To assure accurate and timely documentation ...Procedure: 1. All patient medical record entries are to be legible, complete, timed, and authenticated .... "

Patient #3
Review of the medical record for Patient #3 revealed she was an 18-year-old female admitted to the hospital on 03/26/15 and discharged on 04/01/15. Admitting diagnoses included Depression, Suicidal and Homicidal Ideations (with no plans). Other diagnoses included Schizoaffective Disorder, Obsessive Compulsive Disorder, and Asperger's Disorder (Autism). Patient #3 was admitted under a Formal Voluntary Admission. Patient #3 had not been interdicted.
A further review of Patient #3's medical record revealed Patient #3's General Consent for Admission and Treatment Form, the Advance Directive Acknowledgment Form, and the Consent to Release Verbal Information Form had been signed by Patient #3, but did not contain a date and time documented by Patient #3, and and did not contain documentation of staff signatures with dates and times.
In an interview on 08/20/15 at 9:30 a.m., S4Director (Admissions) confirmed the above-referenced forms were not completed correctly and did not contain the required staff signatures, dates, and times and should have contained the appropriate documentation.