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Based on document review, interview, and policy review the facilty failed to complete and finalize the complaints and grievance process in three of four complaints reviewed resulting in the potential of patient's complaints/grievances not being responded to in a timely manner. Findings include:

During document review of the complaints and grievance log on 7/12/2021 at 1600, a complaint was logged from patient #1. A review of the complaint occurred on 7/13/2021 at 1100. According to the complaint notes, the patient stated she was concerned with the violence of other patients on the unit and the lack of care for other patients. Review of the documentation did not include any information of physical aggression towards the patient, nor any information of sexual inappropriateness directed towards the patient by other patients. The documentation stated that the patient was concerned about medications other patients were taking, nursing care of other patients, and privacy of other patients.

On 7/13/2021 at 1400 an interview was conducted with Staff R, the former Officer of Recipient Rights. Staff R was queried about her role in handling complaints and grievances for the facility and as the Officer of Recipient Rights. Staff R stated that in mid-March she had notified the facility that she could no longer handle a dual role of being the program coordinator of the Family Medicine / Psychiatric residency program and being the Officer of Recipient Rights / complaints and grievances contact. Staff R stated that she helped when asked but that two interim people had been assigned the role of responding to ORR/complaints and grievances. She also added that the Director of Quality and Risk, Staff A, had been involved in addressing complaints and grievances. Staff R was asked if was aware of how complaints and grievances were being responded to during the time period of mid-March and currently. Staff R stated she provided some guidance to the new employee in the position that was hired in June, but that Staff A was providing most of the oversight. Staff R was asked who was in charge of complaints and grievances when Staff A was on vacation for 10 days from late April until the second week in May. Staff R stated one of the managers (Staff S) was in charge of complaints and grievances during that time.

On 7/14/2021 at 0800 an interview was conducted with Staff S, the Director of Surgical Services, and Infection Control. Staff S was queried about her oversight of ORR/complaints and grievances while Staff A was on vacation, specifically relating to patient #1. Staff S explained that while she was helping cover some of the responsibilities of Staff A during that time period that she would receive complaints from patients. Staff S stated that she would go and meet with patients if a concern or complaint was identified. Staff S was queried about the complaint from patient #1. Staff S stated that she had met with patient #1 on 5/4/2021. She stated that much of the items of patient #1's complaint had to do with the patient's observations while she was a patient on the 4South psychiatric unit. She further stated that patient #1 was overtly concerned with other patients' medications, nursing staffing, and safety issues. She also stated that patient #1 was asking to be moved to another facility. When asked about the investigative process of handling the complaint, Staff S stated that she felt that the concerns had been addressed and that the investigation was completed. Staff S was then asked if she had detailed notes about what had been done to investigate the concerns/complaint lodged by patient #1. Staff S stated that she did not have detailed notes but that she had talked with both the patient and the patient's husband in detail.

On 7/13/2021 at 1315 a review of four complaints from the complaints and grievance log was conducted. Three of four complaints failed to have documentation for investigation and finalization of the complaint process. Staff A, the Director of Quality and Risk was queried if the three complaints had been finalized. Staff A stated that there had a been a lapse in having a dedicated person in the role of handling complaints and grievances since Staff S had resigned from ORR/complaints and grievances. Staff A stated that a contracted employee was providing assistance in March and April. Staff A also stated that the facility had hired a person for the role of ORR/complaints and grievances but did not stay very long. Staff A stated a new employee in the role was hired in late June but had not been fully trained. She added that the employee was scheduled for state training for ORR within the week. Staff A was then asked if she could provide any further follow-up regarding a response to the complainants. Staff A stated she was aware that some of the complaints had not been formally closed within a timely period but was working on getting things finished.

On 7/13/2021 at 1400 a document review occurred of the policy titled, "Patient Complaint Policy," dated 6/05/2018. According to the policy under subtitle "Procedure," #4, it states, "Investigation and documented response are expected within 7 days after the complaint is received, or a notification letter that investigation is ongoing and follow-up communication will be sent when concluded."