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Based on review of hospital policy and five grievance records, it was determined the hospital failed to complete a timely resolution for 4 of the 5 grievances reviewed, and failed to inform the patient or the patient's representative of an anticipated time frame for a written response.

Per hospital policy titled, "Complaints/Grievance Resolution" (revised 9/15), "If the grievance will not be resolved within seven (7) days or if the investigation will not be completed within seven (7) days, the hospital informs the patient or the patients representative that the hospital is still working to resolve the grievance and the anticipated timeframe in which the patient/patient representative can expect a written response." The policy goes on to mention that all grievances, with a few exceptions, are attempted to be resolved within 30 days.

Grievance #2 was received on May 16, 2018. A resolution letter was sent May 31, 2018, 11 business days from the day received.

Grievance #3 was received on April 20, 2018. A resolution letter was sent May 24. 2018, 25 business days from the day received.

Grievance #4 was received on March 26, 2018. A resolution letter was sent May 7, 2018, 30 business days from the day received.

Grievance #5 was received on February 25, 2018. A resolution letter was sent March 29, 2018, 24 business days from the day received.

An acknowledgment letter was sent for all 4 grievances within 1-2 days, but did not give a stated time frame of when to anticipate a written response. Additionally, a review of the 4 grievance files found no other contacts which informed complainants of an anticipated time frame for a written response for investigations continuing longer than 7 days.

Based on review of 6 open and 4 closed medical records, including two restraint records it was determined that the hospital failed to document all components of a face-to-face for patient #8 and complete a face-to-face evaluation within 1 hour for patient #7.

Patient #8 was admitted to the behavioral health unit in June 2018. A day after their admission to the unit, patient# 8 was placed in seclusion at 01:47 due to threatening behavior to self and others and released at 03:47. A face-to-face assessment was found in a progress note at 02:24. The face-to-face assessment lacked the patient's reaction to the intervention and the patient's medical and behavioral condition.

Patient #7 was admitted to the behavioral health unit in May 2018. A day after admission to the unit, patient #7 was placed in seclusion at 18:30 due to violent behavior and released at 19:43. An incomplete face-to-face was documented at 21:19, over 2 hours from the initiation of the restraint.