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Based on record review and interview, the facility failed to they followed their own policies and procedures to review, investigate, and resolve patient grievances within a reasonable time frame for 1 of 5 (#2) patients' grievances.

Findings:1. Review of the Patient Rights and Responsibilities policy and procedure revealed it became effective 03/31/2009 and was last reviewed on 08/2010. Further review of this policy and procedure revealed the following:
Grievance: A Grievance: A "grievance" is a written or verbal complaint made to the hospital by a patient, or patient's representative, regarding the patient's care, abuse or neglect.
Upon receipt of a concern (written or verbal) from the patient, family or staff, a Patient Grievance/Complaint Management Report is generated.
The hospital will send a written notice of acknowledging the receipt of the grievance. If the grievance will not be resolved, or if the investigation is not or will not be completed with 7 days, this correspondence will advise that the hospital is working to resolve the grievance and will follow-up with a written response within 30 days.

2. Review of the Verbal and Written Complaint (Grievance) log revealed that there was not a filed a complaint from patient #2's family member regarding the development of a pressure ulcer.

3. Interview at 7:30 PM with the complainant revealed the she/he had complained to nursing staff of his/her mother having a pressure ulcer to his/her buttocks. The complainant further stated that she/he had visited patient #2 at this facility and found that their family member had not been receiving any baths while she was in this facility. Also patient #2 had a bloody gauze on his/her neck for about 3 days.

3. Interview on 03/16/2011 at 2:30 PM with the Director of Risk Management revealed that they were unable to locate a complaint/grievance form written regarding patient #2. Also there was not a grievance documented with a resolution or neither was it in the grievance log.

4. Further interview on 03/16/2011 at 3:00 PM the Risk Manager and the Director Critical and Clinical Information revealed that they have not investigated a grievance voiced by Patient #2's daughter.

5. Interview with the Director of the Intensive Care Unit (ICU) on 03/16/2011 at 3:30 PM revealed that she had received a phone call from the family member of patient #2, who had complained of her/his mother, and stated to this surveyor, "I did do a complaint form, responded to the complaint and left it in the mail room for Risk Management."

Based on record review and interview, the facility failed to they followed their own policies and procedures to review, investigate, and resolve patient grievances within a reasonable time frame for 1 of 5 (#2) patients' grievances.

Findings:1. Review of the Patient Rights and Responsibilities policy and procedure revealed it became effective 03/31/2009 and was last reviewed on 08/2010. Further review of this policy and procedure revealed the following:
Grievance: A Grievance: A "grievance" is a written or verbal complaint made to the hospital by a patient, or patient's representative, regarding the patient's care, abuse or neglect.
Upon receipt of a concern (written or verbal) from the patient, family or staff, a Patient Grievance/Complaint Management Report is generated.
The hospital will send a written notice of acknowledging the receipt of the grievance. If the grievance will not be resolved, or if the investigation is not or will not be completed with 7 days, this correspondence will advise that the hospital is working to resolve the grievance and will follow-up with a written response within 30 days.

2. Review of the Verbal and Written Complaint (Grievance) log revealed that there was not a filed a complaint from patient #2's family member regarding the development of a pressure ulcer.

3. Interview at 7:30 PM with the complainant revealed the she/he had complained to nursing staff of his/her mother having a pressure ulcer to his/her buttocks. The complainant further stated that she/he had visited patient #2 at this facility and found that their family member had not been receiving any baths while she was in this facility. Also patient #2 had a bloody gauze on his/her neck for about 3 days.

3. Interview on 03/16/2011 at 2:30 PM with the Director of Risk Management revealed that they were unable to locate a complaint/grievance form written regarding patient #2. Also there was not a grievance documented with a resolution or neither was it in the grievance log.

4. Further interview on 03/16/2011 at 3:00 PM the Risk Manager and the Director Critical and Clinical Information revealed that they have not investigated a grievance voiced by Patient #2's daughter.

5. Interview with the Director of the Intensive Care Unit (ICU) on 03/16/2011 at 3:30 PM revealed that she had received a phone call from the family member of patient #2, who had complained of her/his mother, and stated to this surveyor, "I did do a complaint form, responded to the complaint and left it in the mail room for Risk Management."