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Based on document review and interviews it was determined the facility failed to provide the patient or patient's guardian with a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the complaint/grievance, the results of the complaint/grievance process and the date of completion. This failure was identified in one (1) out of ten (10) patient (patient #2) record reviews. This failure has the potential for all patient's complaints/grievances to be unresolved and decrease quality of patient care.

Findings include:

1. A review of the facility complaint investigation documentation dated 04/14/21 through 04/16/21 for patient #2 revealed the facility failed to provide written notification of the resolution to the patient or the patient's guardian.

2. A review of facility policy, "Grievance and Complaint Process," revised 07/24/19, states in part: "Documentation of review and follow-up on grievances shall be presented to complainant in writing either in person, by email or postal mail. The Quality Department staff shall facilitate this notification process."

3. An interview was conducted on 05/18/21 at approximately 4:25 p.m. with the Regional Director of Quality and Compliance. When asked if he sent a letter with the resolution to the guardian, he stated in part, "I didn't send one."