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Based on policy and record review and interview, the facility failed to establish a process for prompt resolution of patient grievances resulting in 1 of 1 discharged patients (patient #7) reporting a grievance that was not investigated and increasing the risk of grievances being ignored for all patients. Findings include:

Policy Review:

1. "Grievance and Complaint Management," states:
--"If the supervisor, manager or designee cannot resolve the complaint promptly, the complaint is then referred to as a grievance."
--A grievance may be a verbal complaint "regarding the patient's care" or "issues related to the hospital's compliance with CMS Hospital Conditions of Participation."
--"Grievances are handled according to the Sparrow Health System Complaint and Grievance Resolution Process." The first step is: "Investigate with appropriate individuals."
2. "Handling Apparent Violations of Rights," states:
--"The Recipient Rights Advisor shall receive reports and investigate any apparent violations of recipients' rights as guaranteed by Chapter 7 of the Michigan Mental Health Code.
--"When it is determined that a report does not contain an apparent violation of rights, this shall be noted on the Rights Complaint Log Register."
--There is no procedure for referring a patient's grievance to another department for investigation if a CMS Condition of Participation may have been violated but the Rights Advisor decides not to investigate because of a determination that the Michigan Mental Health Code Standards have not been violated.

Record Review:

1. On 4/24/13 review of patient #7's clinical record revealed a Progress Noted by Nurse #1, dated 4/24/13 stating: "Pt (patient #7)...expressed frustration about his stay here and what he perceives as a lack of communication. Pt was offered reassurance."
2. There was no documentation of patient #7's 4/24/13 complaint being logged on the facility complaint or grievance log.

Interviews:

1. On 4/24/13 at approximately 2:30 pm the Recipient Rights Advisor (RRA) stated that she was asked to meet with patient #7 regarding this complaint. The RRA stated: "I talked with (patient #7) about his (4/24/13) complaint of staff not communicating with him...I didn't think his complaint involved a Code (Michigan Mental Health Code) protected right." The RRA stated that she did not log patient #7's complaint on the Recipient Rights complaint log, investigate, or refer it to another department for investigation.

2. On 4/24/13 at approximately 1:30 pm the Director or Patient Experience, who oversees the Grievance process, verified that the (above) grievance was not listed on the complaint or grievance logs and had not been investigated.

Based on policy and record review and interview, the facility failed to provide 2 of 2 discharged patients (#7 and #9) with the opportunity to participate in the development of their treatment plans resulting in loss of patient rights. Findings include:

Policy Review:

1. Recipient's Involvement in Treatment Planning," states: "When the recipient identifies family, friends, or professionals to be involved in the development of their treatment plan, the treatment team will assist the recipient in obtaining the involvement of the identified individuals."
2. "Master Treatment Plan, Adult/Geriatric Psychiatry Programs," states: "The Master Treatment Plan shall be discussed and finalized at a team meeting within five (5) working days of the recipient's admission."
3. "Review of Treatment Plans," states: "A review of the recipient's treatment plan shall be completed every seven (7) days."
4. "Recipient's Involvement in Treatment Planning," states: "Treatment Plan Part I shall include: recipient and staff signatures...Treatment Plan Reviews shall include: recipient responses to review, date reviewed and recipient and staff signature."

Record Review:

1. On 4/24/13, review of patient #7's closed clinical record revealed only one Treatment Plan, dated 1/16/13, for the patient's hospitalization from 1/10/13-1/31/13. The Plan's line for "Patient/Patient Representative Signature" was blank. Under "Patient Involvement" the Plan states: "Patient is unable or unwilling to sign at this time." There was no explanation clarifying whether the patient was unable (and why) or had refused to sign and no documentation of attempts to involve the patient in other treatment team meetings. There was no documentation indicating that patient #7 had been asked if he would like to have friends or family involved in development of the Treatment Plan. These findings were verified during review by the Risk Manager on 4/24/13 at approximately 10:25 am.
2. On 4/24/13, review of patient #9's closed clinical record revealed that a Treatment Plan for the patient, hospitalized 1/23/13-2/4/13, could not be located. This finding was verified by the Clinical Director on 4/24/13 at approximately 2 pm.

Interviews:

1. On 4/24/13 at approximately 2 pm the Clinical Director stated that she was unable to locate documentation that patient #7 had more than one Treatment Team meetings than the one dated documented on 1/16/13 or that patient #7 had been offered the opportunity to have family members participate in development of the Treatment Plan or attend Treatment Plan meetings.
2. On 4/24/13 at approximately 2 pm the Clinical Director stated that she was unable to locate documentation of a Treatment plan in patient #9's closed clinical record.