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Based on review of grievance forms, facility policy, and patient and staff interviews, the facility failed to provide the patient with written notice of its decision relating to patient grievances, including the steps taken on behalf of the patient, and results of the grievance process for 7 of 8 patient grievances reviewed (#3, #13, #15, #31, #32, #34, and #35).

Findings included:

On 9/17/2018 at approximately 12:30 PM, patient #18 approached the nursing station and stated he had a complaint about a staff member and that patient grievances were not being addressed. When asked if he had submitted a grievance, patient #18 stated that he had submitted the last grievance around one year ago, but nothing got done. Patient #15, who was in the vicinity, stated that he had submitted a grievance several months ago and nothing had been done. During the conversation, patient #16 approached and added that he had submitted 3 grievances in the past 2 days, but had heard nothing.

On 9/18/2018 at approximately 1:45PM, an interview was conducted with staff B, who stated she was in charge of collecting and problem solving patient grievances. She stated the facility had a Patient Problem Solving Form that patients completed and submitted when they had an issue. She further explained that patients would complete the form and place it into a slot in a door right next to her office where she would collect them from.

A review of the facility policy titled Grievances/Complaints, last revised on 04/16, under the heading "Formal Complaint Process" described the Patient Problem Solving Form as the formal complaint process form and stated that "upon receipt of the complaint, the Peer Specialist/Patient Advocate would log all complaints, and track and monitor for compliance of the following:
The date and time the formal complaint was originally received by staff (the date the complaint was written by the complainant); The date and time the formal complaint was received by the staff assigned to track the formal complaints (Peer Specialist/Patient Advocate); The name of the person making the complaint; The name of the person receiving services; The name of the individual assigned to investigate the complaint; The date the individual making the complaint was notified of the individual assigned to investigate the complaint; The due date for the written response; The nature of the complaint; The written disposition of the formal complaint; Whether the complainant wished to appeal the complaint; Date the appeal was forwarded to the facility Administrator, if applicable; The appeal suspense date, if applicable; and the date the complaint was resolved.
The policy further stated the Peer Specialist/Patient Advocate would provide the complainant with a written response within 24 hours of disposition, and it was the facility's expectation that the resolution of complaints would require no more than seven (7) days from the date that the complaint was received.

Review of the Patient Problem Solving form showed it had two sections. The top of the form was an area for patients to put their name, the date and time and then a description of their complaint along with their ideal resolution. The bottom half of the page was marked for staff use only and provided areas for documentation of the staff member's name, the date the complaint was received and a disposition of actions taken in response to the complaint. It also contained an area where findings were to be reported to patients and then documented if the patient was satisfied with the result or wanted to file an appeal.

Review of forms submitted to the Peer Specialist/Patient Advocate showed that most of the forms had either not been completed with an adequate disposition or the facility had failed to follow-up with the patient regarding the disposition.
Patient #3 submitted a complaint on 8/14/18, but the form did not show that the patient had been presented with the disposition of the complaint.
Patient #13 submitted a complaint on 7/24/18, but the form did not show that the patient had been presented with the disposition of the complaint.
Patient #15 submitted a complaint on 4/21/18, but there was no documentation showing that the complaint had been investigated, resolved, or that any findings had been presented to the patient.
Patient #31 submitted complaints on 8/24/18 and 8/26/18, but there was no documentation showing that the complaints had been investigated, resolved, or that any findings had been presented to the patient.
Patient #32 submitted a complaint on 8/25/18, but there was no documentation showing that the complaint had been investigated, resolved, or that any findings had been presented to the patient.
Patient #34 submitted a complaint on 9/2/18, but the entire bottom portion of the form was blank.
Patient #35 submitted complaint on 8/14/18, but the form did not show that the patient had been presented with the disposition of the complaint.