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Based on interview, closed record review, and review of the facility's policy/procedure, it was determined the facility failed to enter a complaint/grievance into the incident reporting system in accordance with the facility's policy titled "Complaint-Grievance Resolution," for one patient (#1), in the selected sample of ten patients. After Patient #1's discharge from the facility on 07/22/12, a family member attempted to file a grievance regarding the patient's care; however, there was no evidence an investigation was completed regarding the grievance.

Findings include:

A review of the facility's policy/procedure, "Complaint-Grievance Resolution," latest revision date 05/01/11, revealed, when a complaint/grievance is made, it is to be entered into the facility's incident reporting system. Additionally, the policy defined a grievance by stating, "If a concern or complaint is received after a patient is no longer at the facility, it becomes a grievance. Documentation of a grievance, including the date of the incident, the patient's/visitor's name, address and phone number, and all other pertinent information must be entered into the Incident Reporting system. The details will be entered by whomever receives the complaint."

A closed record review revealed the facility admitted Patient #1 on 07/19/12 with diagnoses to include Congestive Heart Failure (CHF). Patient #1 was discharged home on 07/22/12.

An interview with Patient #1's family member, on 09/10/12 at approximately 3:28 PM, revealed she tried to call the Patient Advocate to schedule an appointment to file a grievance regarding the occurrence of a wound during the patient's stay at the facility; however, the Patient Advocate did not return the phone call. After no response, she then called to speak to an Administrator and scheduled a time to go to the administration office.

An interview with the Patient Advocate, on 09/10/12 at approximately 1:50 PM and 3:40 PM, revealed no investigation was completed after the patient's visit to the administration office. Additionally, she stated there was no grievance paperwork completed as they did not believe there was a grievance. Additionally, the Patient Advocate stated she only initiated grievance paperwork if it was a formal grievance.

An interview with the Chief Compliance Officer, on 09/10/12 at approximately 4:20 PM , revealed there was no evidence an investigation or paperwork was filed regarding a complaint/grievance from this patient and/or family member. Additionally, she stated "I felt the patient's concerns should have been handled as a grievance, and I do not know why it was not."

An interview with the Area Vice President (VP) of Nursing, on 09/11/12 at approximately 10:15 AM, revealed she recalled a meeting with the patient and his/her family member, and informed the Patient Advocate to make a note of that meeting.

An interview with the Chief Compliance Officer, along with the Area VP of Nursing, as well as the VP of Nursing present, on 09/12/12 at approximately 1:53 PM, revealed her understanding was, if the patient filed a grievance after being discharged, then the policy was not followed. She further stated it was her understanding that the patient did call back to file a grievance after being discharged. Both the Area VP of Nursing and the VP of Nursing revealed they were in agreement with this statement.