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Based on interview and record review, the facility failed to implement the established grievance policy for one (1) of fourteen (14) sampled patients. (Patient #9). The facility failed to investigate the grievance, provide a written notice of the facility's findings of their investigation and/or the ability to complete the investigation within the facility's established timeframe of seven (7) days.

The findings include:

Review of facility policy for Patient Concerns/Grievances revealed any patient and/or representative has the right to file a concern/grievance regarding any issue. The policy stated that concerns/grievances would be reviewed, investigated, resolved, and a written response would be made in a timely manner. The policy further stated the Patient Advocate "will respond in writing to all grievances within seven (7) calendar days of receipt of the grievance". The written response includes a statement of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. "Should the matter not be resolved within seven (7) days of receipt of the grievance, the Patient or Patient's representative will be notified in writing that the investigation has not concluded and the hospital was still working to resolve the grievance and that a written response would be made within thirty (30) calendar days of receipt of the grievance." The facility's failure to follow their grievance policy, Patient #9's representative concerns/complaints were not investigated and did not receive notification of the results of the facility's investigation within the seven (7) day timeframe.

Review of the closed record for Patient #9 revealed the patient was admitted to the hospital on October 20, 2009 and was discharged on November 5, 2009 to the hospital's skilled unit. The record revealed the patient sustained a fall at home and was brought to the emergency room. The patient was initially admitted with a right 7th rib fracture. However, two days after admission, the patient experienced an acute stroke. The patient had left hemiparesis affecting the upper extremities greater than the lower. A newly diagnosed paroxysmal atrial fibrillation with rapid ventricular response was noted. The patient was treated and discharged to the skilled nursing unit on 11/05/09.

Interview with Patient #9's representative (complainant) on 02/09/11 at 8:30am revealed he/she filed a grievance with the hospital but never received a response. He/She stated the President/CEO found out about the concerns through a mutual acquaintance of the family. The CEO called the complainant and requested a copy of the letter the complainant had drafted to forward to the Division of Health Care. This letter included concerns that occurred during Patient #9's hospital stay. The CEO told the complainant that those concerns would be investigated. The drafted letter was sent to the President/CEO via email on December 18, 2009 as requested. However, as of March 25, 2010, the complainant had not received any correspondence from the hospital relating to the grievance filed. The complainant requested a status report regarding this issue on this date. The complainant never received a response from the hospital to date (02/09/11).

Interview with the Vice President/CEO on 02/09/11 at 3:00pm revealed there was no evidence a grievance investigation in response to the complainant's concerns was ever conducted. She presented the letter the complainant had sent the hospital on 12/05/09 regarding the concerns he/she had for Patient #9's care. She stated the previous CEO indicated there was a telephone conversation with the complainant prior to the letter received but he had not considered it a grievance. She stated she was unaware the grievance had not been investigated according to the facility's policy, therefore, no steps were taken to provide the the Patient's representative with results.

Review of the letter sent to the hospital on 12/05/09 revealed the first statement, "this is a complaint regarding the treatment of my mother" to be a request for a grievance to be filed. In addition, the complainant forwarded an email on 03/25/10, three months later requesting information regarding the status of the grievance. He/She received no response.

Interview with three (3) Patient Advocates who are members of the hospital's grievance committee on 02/09/11 at 4:00pm revealed this was a grievance and the hospital failed to investigate and respond to the complainant's concerns.

Review of six (6) additional grievances files revealed the hospital investigated those grievances and a written letter with the results included was sent to each person who filed a grievance within the seven (7) day timeframe.