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Based on record review and interview, the facility failed to they followed their own policies and procedures regarding providing prompt resolution of 1 out of 4 (#1 ) patients' grievances.

Findings:

1. Review of the Patient Complaint Resolution/Management/Grievance policy and procedure revealed it became effective September,2003, and last review date of February, 2012. Further review of this policy and procedure revealed the following:

* POLICY: A patient grievance is a formal or written or verbal complaint by a patient, or patient's representative , regarding the patient's care, abuse, or neglect, or Medicare billing complaint related to the rights and limitations provided by 42 CFR 489. A written complaint is always considered a grievance. All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with Center for Medicare Services (CMS) requirements are considered a grievance.

* PURPOSE: To Identify trends that impact patient care and customer satisfaction so that processes and outcomes will be improved. To provide a mechanism to resolve patient complaints and grievances that is in compliance with the Center for Medicare and Medicaid Services.

* PROCEDURE: Risk Management will determine type of complaint and refer to appropriate department as necessary and a letter of acknowledgement will be sent to the patient/representative within 7 days, unless issue can be resolved immediately. A grievance log will be maintained to track status of grievances.

Turnaround time for review of complaint and feedback to Risk management by departments is 5 business days.

Risk Management will collaborate with department manager and send letter to author of complaint/grievance within 45 days of original complaint. Resolution will be documented in RiskMaster.

2. Review of the Verbal and Written Complaint (Grievance) log revealed that there was a complaint filed by patient #1's family member on 03/01/2012, regarding patient care.

3. During an interview on 05/01/2012 at 3:30 PM the Risk Manager revealed that they do not have documentation of an investigation and a resolution of a grievance voiced by the family member of Patient #1 .