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Based on staff interview and documentation review, the hospital failed to provide a written response of determination to the grievance filed by one of three patients.

Findings:

On morning of 04/19/2016, the hospital policy, titled, "Patient Complaints / Grievance Process". The policy documents, "Director/Risk Management/Clinical Manager- send a resolution letter within 7 days of receipt of grievance." This policy defined the required content of the resolution letter.

On the afternoon of 04/18/2016, the surveyor reviewed the hospital's adult behavioral unit's grievance log from 09/1/2015 through 11/30/2015. A total of three patient grievances were listed on the log. The word, "verbal" was written under the column titled, "seven day acknowledgement" for one of three patients entered.

On the afternoon of 04/19/2016, the Director of the Adult Behavioral Unit stated the managers of the unit are responsible to investigate grievances and provide the written response to the patient. She and the surveyor reviewed the grievance documents (including the investigation) associated with the "verbal" response entry. The Director stated she had conducted the investigation and contacted the patient in person, and husband by phone on the day following the event. She stated she felt the patient and husband were satisfied, but failed to send a written response.

Based on staff interview and documentation review, the hospital failed to communicate to the patient in writing that a physician was not present on the hospital premises 24 hours per day and 7 days per week.

Findings:

On 04/18/2016 at 10:45 a.m., the Director of the Adult Behavioral Unit and the Director of Nurses stated a hospital physician remained on the hospital premises until 5:00 p.m., and such information should be present in the patient admission packet.

On the afternoon of 04/18/2016, the surveyor requested and received the patient admission packet and the hospital document, titled "Patient/Family Handbook Adult Behavioral Health". Upon review of these documents, no information was found explaining to the patient that a physician was not present on the hospital premises 24 hours a day and 7 days a week.

On the afternoon of 04/19/2016, the Director of Nursing stated she had discovered the Clinical Admissions Department staff explained during the admission process, the extent of the physicians' presence at the hospital to the patients; however, this information was not provided in writing.