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Based on record review and interview, the facility failed to respond to a grievance in a timely manner for 1 of 3 patients (patient #3) reviewed for the grievance process resulting in delayed resolution and denial of patient rights. Findings include:

On 11/05/19 at 0910, Patient (Pt) #3's record was reviewed and revealed the following information:

On 11/05/19 at 0930, review of the medical record revealed Patient #3 (Pt #3) was a 21-year-old female who was admitted to the facility on 06/29/19, with unspecified psychosis. The patient was involved in an altercation on 07/05/19, during her hospitalization, and per family request was transferred to another facility on 07/06/19.

On 11/05/19 at 0940, during record review for Patient #3 (Pt #3) it was determined that the Office of Recipient Rights (ORR) received the complaint on 07/05/19. The following correspondence with the complainant and Staff C took place:

07/12/19 (1st letter sent out to the to the complainant): " ...Your complaint allegation has been assigned for investigation. The Office of Recipient Rights (ORR) will be contacting you soon. Under most circumstances, the investigation will be completed in 90 days. While the investigation is completed, a Report of Investigative Findings (RIF) will be sent to the CEO (Chief Executive Officer/Staff A) The CEO will send you a Summary Report within 10 days after she receives the RIF) ..."

08/08/19 (2nd letter sent out to the complainant): " ...We are still in the information gathering stage. The ORR has secured video from the event and staffing documentation. As we discussed, part of ensuring a safe environment includes reviewing staffing and placement, staff's reaction to the escalation, as well as reviewing both the recipients medical record to see if the physician-ordered precautions were appropriate (compared to the admission information), and if they were followed. As discussed, the complaint allegation has been assigned for investigation. The Office of Recipient Rights (ORR) will be contacting you soon. Under most circumstances, the investigation will be completed in 90 days. While the investigation is completed, a Report of Investigative Findings (RIF) will be sent to the CEO (Chief Executive Officer/Staff A) The CEO will send you a Summary Report within 10 days after she receives the RIF) ..."

09/12/19 (3rd letter sent out to the complainant): " ...I have completed the information gathering stage and am writing the report. As we discussed, part of ensuring a safe environment includes reviewing staffing and placement, staff's reaction to the escalation, as well as reviewing both the recipients medical record to see if the physician-ordered precautions were appropriate (compared to the admission information), and if they were followed.
As discussed, the complaint allegation has been assigned for investigation. The Office of Recipient Rights (ORR) will be contacting you soon. Under most circumstances, the investigation will be completed in 90 days. While the investigation is being conducted, you will receive a status report on its progress every 30 days. When the investigation is completed, a Report of Investigative Findings (RIF) will be sent to the CEO (Chief Executive Officer/Staff A) The CEO will send you a Summary Report within 10 days after she receives the RIF) ..."

On 11/05/19 at 1030, during an interview with Staff C (ORR), it was determined that he had found some "new information and that is why it was late." Staff C confirmed that the last correspondence with the complainant was the letter that was dated 09/12/19 and that he "should have sent out another letter in the 30 days according to what is stated in our letter."

On 11/05/18 at 1400, a review of facility policy titled, "Complaint & Grievance Procedures Recipient Rights" last revised 11/ 17 was completed. This policy indicated, under section B, "2. It is expected that complaints be handled effectively by staff present.", and "7. If the grievance will not be resolved, or if the investigation will not be completed within 7 business days, (the facility) will inform the grievant and follow up with a response within a mutually agreeable timeframe".