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Based on interview and record review the facility failed to follow its policy and procedure related to prompt response of grievances for 1 (#1) of 3 patients reviewed for grievances resulting in untimely resolution of Pt #1's grievance. Findings include:

On 11/17/20 at 1310 a review of the medical record, management investigation notes and internal emails revealed the following:

Patient (Pt) #1 was a 26 year old male that requested emergency services on 09/22/20 at 1157 and, after receiving stabilizing treatment, was discharged in stable condition from the emergency department (ED) on 09/22/20 at 1412. The nursing progress notes written by the ED registered nurse (RN I) indicated Pt #1 was discharged home and left the ED "ambulatory".

Review of investigation notes written by the ED Manager (RN C) (undated) indicated on 09/22/20 at 1610 Pt #1's representative left a voice mail message with complaints related to Pt #1's discharge from the ED on 09/22/20 at 1412. These notes indicated RN C contacted Pt #1's representative via phone on 09/23/20 at 0950 to discuss the complaint with a suggested follow-up plan, including having medical records staff (Staff J) contact Pt #1 on 09/27/20. These notes dated 09/27/20 indicated Pt #1's representative "agreed" with this solution.

Review of a formal grievance sent to the hospital by Pt #1's legal representative dated 10/01/20, specific to the ED visit on 09/22/20, indicated Pt #1 requested the hospital "investigate this incident immediately and provide a sufficient and adequate response" to a specific address in writing.

Review of internal email dated 10/08/20 at 1348 from the acting patient advocate (RN L) addressed to the ED manager (RN C), compliance officer (K), public relations staff (M), and medical records officer (J) indicated, in response to the events involving Pt #1 on 09/22/20, Pt #1 would "need to be contacted" and to log such information "into the grievance log".

During an interview with RN L on 11/17/20 at 1305, RN L said he felt Pt #1 concerns were a grievance, however he had not provided Pt #1 with a written response to the patient's grievances. RN L could not produce any evidence showing the hospital provided Pt #1 with a written notice or response to the patient's grievances or that a final resolution had been provided.

During an interview with RN C on 11/17/20 at 1400, RN C acknowledged Pt #1 voiced complaints during his discharge from the ED on 09/22/20 and the complaints were not promptly addressed by staff present at that time. RN C felt the complaint was resolved when contact was established with Pt #1's representative via phone on 09/23/20. RN C said she approached this as a complaint that had been resolved, not a grievance.

An unsuccessful attempt was made to interview RN I on 11/17/20 at 1500. Hospital leadership (RN C, RN B) made arrangements for RN I, on a leave of absence, to be interviewed via phone however RN I failed to make contact.

During an interview with Staff J on 11/18/20 at 0815, Staff J said medical records staff called Pt #1 on 09/28/20 but could not make direct contact and a voice message was left, however Pt #1 did not respond back. Staff J said she approached this as a complaint, not a grievance. Staff J said she did not provide Pt #1 with a written response to the patient's grievances.

During an interview with the Vice President of Clinical Services (RN B) on 11/18/20 at 0825, RN B said the hospital was in the process of providing Pt #1 with a written response to the patient's grievances.

Review of facility policy and procedure titled, "Complaint Management and Resolution Management", last revised February 2020, indicated under Definitions section, a grievance was "Any formal or informal, verbal or written complaint [hereafter termed "complaint"] that CANNOT be resolved at the time of the complaint by staff present.", "Any complaint referred to staff for later resolution", "Any complaint that requires investigation or further actions for resolution", or "Any written complaint ...", as well as other definitions. This policy also indicated, under Complaints Review, Resolution, and Response section, "a. For complaints falling into the grievance category, a written response will be provided to the complainant within 7 days of receipt of the complaint" and "If complete resolution of the complaint is not possible within this timeframe ...the department manager will notify the Compliance and Risk Officer and the patient advocate the complainant will be contacted in writing that the complaint has been received and is being actively investigated and that a final resolution will be provided within 30 days.".