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Based on record review and staff interview, the facility failed to resolve 1 (Patient #7) of 3 grievances and to provide a response to the complainant. Failing to investigate and to follow up with grievances may result in missed opportunities to detect systemic problems that may impact care and services.

The findings include:

Patient #7 was admitted to the facility with a length of stay of 3 days after a motor vehicle crash and presented to the facility confused and combative. The patient complained that she did not received a bath, gown change or linen change. On the last day of hospitalization, the patient reported that staff threw a bedpan onto their lap telling them to urinate in it or a catheter would be inserted.

Review of the complaint revealed that Patient #7 stated that they received a letter stating the complaint was received; the issues would be investigated and it would take up to 14 days to complete. The letter stated Patient #7 would receive follow up in that time frame but the patient never received a return call.

Record review of the copy of the letter to Patient #7 from the facility confirmed Patient #7 would receive a letter of response following completion of the hospital's review.

Review of the facility's record regarding the grievance revealed documentation of the complaint from Patient #7 on 7/31/12 at 10:33AM documented by the Administrative Secretary in Risk Management as a telephone complaint. The complaint was sent to the Director of Quality to investigate and to document findings.

On 8/4/12 at 12:14 AM, the Director of Quality documented: Response: no investigation associated with this task.

On 8/8/12, at 3:55PM, it was documented that one of the hostesses made an unnecessary comment to the patient's sitter that upset Patient #7. It was documented by staff that a grievance was reported for your area. " Please review." On 8/15/12, the Director of Quality & Outcomes accepted the complaint and the complaint was routed by Risk Management to the Nurse Manager to investigate.

Review of the Nurse Manager's investigation dated 8/20/12 revealed a timeline of the patient's hospitalization. It was documented that no action was required. There was no documentation of the investigation noted. On 8/21/12, at 5:31 AM, the Director of Quality & Outcomes documented, "response: ready for closure." There was no documentation found of how the grievance was resolved or that Patient #7 received a follow up response about the grievance.

Interview with the Nurse Manager on 10/23/12 at 12:31 PM revealed that there was a patient who came into her office after discharged and yelled at her for how poorly they were treated. The Nurse Manager was questioned about her investigation and she stated that she was sent questions from Risk Management/ Quality to answer and she answered the questions.

Interview with the Director of Quality on 10/23/12 at 2:00 PM revealed the complaint was not a grievance. The Director of Quality stated that the patient did not complain when they were in the hospital and it was not a grievance. A copy of the policy and procedure for grievances was requested for review. There was no response as to why there was no follow up to the patient. The Director of Quality stated that she would go and do it now.

Review of the policy and procedure for Complaints/Grievance Patient revealed that a grievance is a written or verbal complaint by a patient or the patient's representative regarding patient care, abuse, or neglect, issues relating to the hospital's compliance with Centers for Medicare Medicaid Services (CMS) Hospital Condition of Participation, or a Medicare beneficiary billing complaint related to the rights and limitations provided by 42 CFR 489. " Halifax will review, investigate and resolve each patient's grievance within a reasonable time frame." "The goal for responding to non-urgent patient complaint/grievances is seven days."