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Based on interview, record review, and policy review, the facility failed to follow their policy of notification of the results of investigation of grievances as evidenced by 10 of 12 sampled Grievance Record forms (#3, #4, #5, #6, #7, #8, #9, #10, #11, #12) not having written confirmation of the results of the investigation being shared with the complainants. Findings:

A review of 12 grievance reports dated since 7/1/10 until 12/20/10 revealed the nature of complaints, who initiated the grievance, and the results of the investigation.

On 12/21/10 at 10:30 a.m. in an interview with S1, Administrator, he stated if a family member calls after the patient was discharged from the facility, he (S1) would initiate the complaint by making a written report on the Grievance Record form, then he would delegate to the appropriate person to investigate or resolve the complaint. After the investigation was complete, S1 would then verbally notify the complainant of the results of the investigation by telephone. S1, Administrator confirmed there were no written confirmations to the complainants about the results of the investigations.

Record review of the facility's policy titled "Patient Complaint Management" revised 12/11/08, (pg 3) reads: "A written response to the formal grievance will be provided to the patient within 30 days of receipt of the written grievance."

Based on interview, record review and policy review, the facility failed to track, trend, and analyze incident reports as a quality indicator of hospital services as evidenced by the lack of incident reports being logged and submitted to the Performance Improvement Team. Findings:

On 12/21/10 at 10:40 a.m. in an interview with S2, Health Information Manager (HIM)/Performance Improvement Coordinator (PIM)/ Medical Staff Coordinator (MSC)/ Regulatory Officer (RO), she confirmed the incidents cited in the grievance reports were not placed in a log, not trended, and not analyzed. She confirmed that who ever receives a complaint was responsible to take care of the complaint and attempt to resolve it. S2 added that grievances were not reported to the Performance Improvement Committee by S3, Social Worker. (S3, Social Worker was the person responsible for reporting the findings from the Patient/Family Satisfaction surveys, which were completed after the patient was discharged, to the Performance Improvement Committee.) S2 also added that the Social Worker functions as the Case Manager.

Record review of the facility's policy titled "Patient Complaint Management" (pg 3), reads: "The Case Manager will generate Quality Reports on a quarterly basis summarizing the nature of patient complaints received to assist the Performance Improvement Committee in organizational monitoring and quality management activities."

Record review of the facility's Organizational Performance Improvement Plan's Goals (pg. 4) included: "To utilize internal and external customer feedback to improve the services necessary to excel on a competitive healthcare environment." Under B. Dimensions of Performance (pg. 18), one of the monitoring and evaluation processes included "Evaluation of the needs, expectations, and satisfaction of patients."