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Based on document review and interview the facility failed to follow its policy and procedure related to prompt response for 6 of 8 (#7, #9, #10, #11, #12 and #13) grievances and documentation of acknowledgement and resolution of grievances in 7 of 8 (#6, #7, #8, #9, #11, #12, #13) patient letters of grievance reviewed, resulting in the potential for unresolved and prolonged patient grievances. Findings include:

On 01/14/2016 at 1130 during a review of the facility's received letters of complaint revealed a lack of documentation regarding when the letters were received and reviewed for 6 of 8 (#7, #9, #10, #11, #12, and #13) letters reviewed. Making a determination of prompt resolution cannot be facilitated when the receipt date of the letter was not documented. Each letter was dated by the patient when it was written, however the envelope was missing.

On 01/14/2016 at 1230 a review of the the policy titled, "Patient Complaints and Grievances" number RI.01.07.01 dated revised 05/2011 on page one of five stated under Procedure 1. "General Management........ b. ........All comments will be responded to within 48 hours or the first business day after receipt. Resolution should not exceed 30 days for both written and verbal complaints or grievances........."

On 01/14/2016 at 1130 a review of the responses to written complaints revealed the following; Patient #6's grievance letter, dated 1/4/2016 lacked documentation of a response to the written grievance letter as of this date; Patient #7's grievance letter dated 8/29/2015 had an associated response letter dated 11/17/2015; Patient #8's grievance letter dated 10/22/2015 has an acknowledgement letter dated 11/4/2015 which stated "unable to reach by phone", however no resolution letter was found as of this date; Patient #9 grievance letter dated 11/5/2015 has a resolution letter dated after the required 30 days on 12/14/2015.

On 1/14/16 at 1130 a continued review of patient complaint letters and their response revealed that 3 of 8 (#11, #12, #13 )written complaints reviewed, lacked the provision of an acknowledgement letter within 48 hours per facility policy. Patient #11 had a grievance dated 11/12/2015 and a resolved letter dated 11/25/2015, however no acknowledgement of receipt of the complaint was sent within 48 hours per facility policy; Patient #12 had a grievance letter dated 11/03/2015 and a resolved letter dated 11/30/2015 however no acknowledgement of receipt of the complaint was sent within 48 hours per facility policy; Patient #13 had a grievance letter dated 12/7/2015 and a resolved letter 12/22/2015, however no acknowledgement of receipt of the complaint was sent within 48 hours per facility policy.

On 01/14/2016 at 1330 during interview of staff F, recipient rights officer stated, "I did not realize that I had to document that I had received a grievance in 48 hours and send a letter within 30 days related to the resolution of a grievance."