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Based on interview and record the facility failed to follow its policy and procedure related to prompt response for grievances for 1 (#18) of 2 patients reviewed for grievances, out of a total of 20 sampled patients, resulting in the potential for unresolved and prolonged patient grievances. Findings include:

On 11/17/16 at 1030 a review of the closed electronic medical record documented the patient #18 was an 88 year old female admitted to the facility on 9/6/16.

On 11/17/16 at 1040 a review of the grievance file and investigation for patient #18 was conducted with Chief Nursing Officer Staff B. Staff B explained the grievance was received via e-mail on 9/8/16, but was not forwarded to the appropriate department for further review and investigation until 9/27/16.

On 11/17/16 at 1115 further review of the grievance file and investigation for patient #18 revealed an e-mail dated 9/8/16 from patient #18's representative that explained multiple issues with care, treatment and services during the patient's length of stay. (9/6/16 through 9/9/16).

A response to the grievance by the facility dated 9/27/16 via e-mail at 0834 offered an apology for the untimely (19 days) delay in addressing the concerns of the grievance.

On 11/17/16 at 1130 a review of the facility's undated, "Patient Experience Guide Admission" folder revealed a documented titled "Questions or Concerns? You and your family should feel you can always voice your concerns. If you share a concern or complaint, your care will not be affected in anyway. We are committed to resolving your concerns while you are here....E-mails may be sent to (name of organization)".

A review of the facility's "(Name of organization) Feedback Reporting (Compliment, Complaint, Grievance) Policy No: I.C.3 (dated 3/2/14), documented:
1.3.3 A written complaint (e.g. e-mail, fax or letter) received from a patient or patient representative constitutes a grievance.
2.3.2.1 Grievances will immediately be brought to the attention of the involved manager(s)
and Patient Relations/Service Excellence staff by phone and/or e-mail in order to meet the CMS 7-day timeline for response back to the patient."

On 11/17/16 at approximately 1220 Staff B stated, "We will have to review our processes for reporting grievances to make sure this does not happen again."