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Based on record review and interview, the facility failed to they followed their own policies and procedures to review, investigate, and resolve patient grievances within a specified time frame for 1 of 5 (#2) patients' grievances.

Findings:1. Review of the Patient Rights and Responsibilities policy and procedure revealed it became effective 12/2008 and was last reviewed on 01/2011. Further review of this policy and procedure revealed the following:
B. Communication of a complaint or grievance by the Patient, Family or Patient Representative
Hospital staff are expected to make reporting a complaint or grievance simple. Examples of reports include:
* Contact with any staff member (whether assigned to the patient or not) including Clinical Staff, case Manager/Social Worker, Supervisor or Manager.
* Requesting to speak to Administration
* Reporting concerns to the Kindred ASAP program verbally or in writing.
a. Option 1: ASAP forms are located in designated areas of the hospital
b. Option 2: Verbal complaints though the ASAP hotline can be logged by calling: 1-800- 359-7412
c. Concerns reported through the ASAP program, unless anonymous, are always treated as a grievance. They will be entered into the Complaint/ Grievance Log and a response letter will be sent within 7 days of receipt.
* Contact the Quality Improvement Organization (QIO) if a Medicare Patient

C. Managing Grievances
1. Document the Grievance on the Patient & Family Grievance Report Form and forward as directed on the form to the appropriate departments. Promptly investigate and forward to the next person identified on the form.

2. Random interview on 04/08/2011 at 11:00 AM with a person who filed a grievance at the facility revealed the she/he had complained to nursing staff and written a grievance in February 27,2011 of his/her mother needing an air mattress and that the Kendall sequential compression stockings the facility had applied to patient #2's legs were to large, and that she needed a size small. The family member further stated that she/he had submitted a second complaint on March 7, 2011 for patient #2, because their family member had not received a smaller size Kendall sequential compression stockings, and that she/he requested that patient #2 be changed from receiving Heparin, back to Fragmin, which the complaint feels is safer for patient #2 while she was in this facility. She/he further stated that she/he had not received a response from the facility to either one of these grievances.

3. Review of the Verbal and Written Complaint (Grievance) log revealed that there was not a filed a complaint from patient # 2's family member regarding the air mattress, Kendall sequential compression stockings, or about the request of the change of medications.

4. Interview on 04/08/2011 at 12:00 PM with the Administrative Assistant revealed that these complaint forms (ASAP) were supposed to be picked up from the box designated in the patient waiting room every day, although she had not emptied the box in the last 2 weeks. She remembered retrieving from the box a complaint from patient #2's family member from 02/27/2011 and placed it on the Director of Nursing's desk, but it could not be located from the facility. The second ASAP complaint form dated 03/07/2011 was retried from the complaint box on the day of the compliance survey on 04/08/2011.

5. Interview on 04/08/2011 at 12:30 with the Director of Risk Management revealed that they were able to locate only one complaint/grievance form dated 03/07/2011 written by patient #2's family member, and the facility had not respond to this grievance or acknowledged it. Also there was not a grievance documented with a resolution nor was it in the grievance log.