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Based on record review and interview the facility failed to send a written response for a grievance reported by a patient's (P#1) family member (FM#2).

The findings were:

Review of P#1's medical records revealed the patient was a 30 year old male with Down Syndrome. The patient had limited speech and used hand gestures as a way to communicate. The patient was admitted to the facility on 06/22/14 with a chief complaint of chest pain. The patient was treated and discharged on 06/25/14.

Interview with FM#2 on 11/06/14 at 11:15 a.m. revealed FM#2 reported a grievance to the facility on 06/25/14. The grievance was an allegation of Sexual Abuse of P#1 by an unknown male while P#1 was being treated at the hospital. FM#2 indicated she did not receive any written response of the status of her grievance. FM#2 stated her grievance was not resolved.

Review of facility documents confirmed the facility was notified of FM#2's grievance on 06/25/14. Documents indicated the facility's Quality/Risk Manager, Director of Human Resources and other staff investigated the grievance and did not substantiate the allegations. Further review indicated a law enforcement agency also investigated the facility of FM#2's allegations. No written response was sent to FM#2 during or after the facility's investigation or prior to this Surveyor's complaint survey.

Interviews with the facility's Quality/Risk Manager on 11/06/14 at approximately 1:40 p.m. and Director of Human Resources on 11/06/14 at 1:50 p.m. confirmed FM#2 reported a grievance to the facility on 06/25/14 and the facility did not send a written response to FM#2's grievance during or after the facility's investigation.

Review of the facility's Patient Complaint/Grievance policy dated 10/31/13 required the facility to send a written response to the patient or patient's representative within seven (7) days of the complaint/grievance containing the following :

- Name of hospital contact person
- The steps taken on behalf of the patient to investigate the grievance
- The results of the grievance process
- The date of the completion
- If the grievance was not resolved, or if the investigation would not be completed within 7 days, the hospital would inform the patient or the patient's representative in writing that the hospital was still working to resolve the grievance with a follow up written response within 30 days. However, all complaints would strive to be completed within the 7 day timeframe.

During the exit conference on 11/07/14 at approximately 2 p.m. the facility was given an opportunity to ask questions, provide additional information and documents related to the deficient practice identified during the complaint survey. No additional information was given related to FM#2's grievance.