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Based on review interview and document review, the facility failed to establish a grievance procedure for specifying timeframes for review, investigation and response of a patient's written or verbal grievance.

This failure resulted in written grievances not being processed by the facility, as well as patients not receiving communication their grievances were received and investigated.

Findings:

POLICY

The facility's policy titled, Patient Grievance Resolution Process, effective 04/25/12, stated how and when a grievance would be submitted to the Patient Care Advocate (PCA). It stated a unit staff member would meet with the patient to attempt to resolve the issue. If resolution was not achieved, the staff member would refer to the PCA within three (3) days after the patient presented the grievance form. Further, the policy states a Clinical Team Lead or Charge Nurse may extend the time frame to seven (7) before referral to the patient care advocate. If the grievance was resolved at the unit level, the PCA would enter a summary into the database with "no further action required." If the PCA determined the unit staff took appropriate and reasonable action, the PCA may close the grievance without further investigation. If the PCA determined the grievance would need further investigation, the PCA would meet with the patient and review documentation. If the grievance would be unable to be resolved, both the patient and PCA would sign and date the back of the grievance form and the patient provided information on how to request further review of the grievance.

1. The facility failed to ensure patient care concerns expressed were appropriately and timely investigated by the patient care advocate at the facility.

a) On 01/14/15 at 10:19 a.m., an interview with the Patient Representative (PR) was conducted. The PR discussed the grievance process and how s/he would "try" to address all the grievances. Upon receipt of the grievance form from the unit, the PR would put a date stamp on it, turn it over to see if unit staff had already addressed the grievance. If it had not been addressed, s/he would go to the unit and speak with the patient. The PR stated s/he would only send an acknowledgement letter if the grievance had been resolved at the unit level. Otherwise, a written response would not be provided to the patient.

The PR further stated s/he was in and out of the facility from July 2014 to November 12, 2014, with no coverage provided for the patients' grievances to be investigated. There had been a staff member put in place to take care of issues that were deemed as "imminent" or "dangerous", which consisted of a phone call to the Director of Quality (DQ). When asked if patients received notification of his/her absence or a letter informing the patients there would be a delay in the investigation, the PR stated "I should have." In response to missing documentation from the grievances, the PR stated s/he does not always write letters, but "2015 is off to a much better start."

c) A review of 175 grievances, dated 06/10/14 to 12/24/14, submitted by 29 different patients was conducted. Focus Sample Patients A-D expressed patient care concerns multiple times with no evidence of investigation or written response to the patient.:

Review of Focus Sample Patient A revealed, 16 grievances were submitted by the patient between the dates of 11/05/14 to 11/13/14 including 3 grievances with no dates regarding dietary issues. The grievances did not contain a date stamp of when the PR received them. The only written response to the patient was dated 11/13/14, which stated "I have sent an email to dietary regarding your concerns and hope that you will be able to meet soon." There was no evidence the grievance was investigated or the patient received a response in writing regarding the findings.

Review of Focus Sample Patient B revealed, 4 grievances were submitted by the patient between the dates of 09/30/14 to 10/10/14 regarding conflict on the unit between patients. Two grievances did not contain a date stamp of when the PR received them. The grievance dated 10/10/14 was dated 10/14/14 by the PR, 4 days after submission. The grievance dated 09/30/14 was dated 10/02/14, 3 days after submission. There was no evidence of acknowledgement, investigation, or written response to the patient for any of the grievances reviewed.

Review of Focus Sample Patient C revealed, 3 grievances were submitted by the patient between the dates of 09/13/14 to 11/04/14 regarding unit rules, suspected racial slurs while on the telephone, and safety on the unit. Two of 3 grievances did not contain a date stamp of when the PR received the grievance. The grievance dated 09/29/14 was dated as received on 10/06/14, 7 days after submission of the grievance. There was no evidence that either unit staff or the PR acknowledged the grievance, investigated or provided the patient with a written response.

Review of Focus Sample Patient D revealed, 3 grievances were submitted by the patient between the dates of 10/12/14 and 10/20/14 regarding use of hygiene products, patients answering telephone calls, and cleanliness on the unit. All date stamps by the PR were within 3 days of submission. The patient disagreed with the outcome of the resolution efforts of the unit staff in all 3 of the grievances. There was no evidence of investigation by the PR or written response to the patient in all 3 grievances reviewed.

d) An interview with the Director of Quality (DQ) was conducted on 01/14/15 at 3:09 p.m. The DQ discussed how the PR was overwhelmed and needed assistance. S/he stated the patient representative just became a direct report as of mid year 2014 and s/he has requested an additional full-time person. The DQ confirmed the grievance policy needed to be updated and process has not been followed according to regulations.

e) On 01/15/15 at 9:56 a.m. an interview with a Licensed Psychiatric Technician (LPT) was conducted. The LPT discussed the grievance process at the unit level. A patient would submit a grievance form to a unit staff member who would then date and sign the form. The staff member would try to resolve the grievance at the unit level first and would then forward it to the PR. The LPT stated even if s/he were able to resolve the grievance at the unit level, it would still be forwarded to the PR so a letter could be sent to the patient.