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Based on interview and record review, the facility did not follow their grievance process, in that, they did not meet their policy's specified time frames for a grievance, that "requires a written response or acknowledgement of receipt within seven days," for 1 of 1 patients (Patient #1).

Findings included:

It was reported that complaints were made regarding three hospitalizations for Patient #1 during 2010 (07/29/10, 07/30/10 and 11/24/10), and there had been no response from anyone.

Risk Management data revealed a verbal complaint to the facility was made on 09/28/10, through a telephone call to the facility's business office. The complaint was routed to the Risk Manager (Personnel #2) that day, and was listed on the facility's grievance log for that date.
Copies of correspondence between the facility Risk Manager and Patient #1, recorded the first response to the 09/28/10 grievance, was a letter sent 14 days later, on 10/12/10 from the Risk Manager (Personnel #2).

In an interview at 2:45 PM on 08/02/11 with the Risk Manager (Personnel #2), when asked if the first response to the 09/28/10 grievance regarding Patient #1 was within the 7 day timeframe required by the facility, she said "no," and verified this letter had been sent 14 days later, on 10/12/10.

Policy & Procedure:
The facility's "Patient Grievance Management" policy, last revised 03/09, noted the following:
5.1 "...the following complaints are considered a grievance, and require a written response or acknowledgement of receipt within seven (7) days:"
5.1.1 "Verbal or written complaints regarding patient abuse, neglect or harm to the patient when in the hospital."