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Tag No.: A0123
Based on a review of facility documents and interview with staff (EMP), it was determined that the facility failed to follow their established policy and ensure that a written resolution letter was sent to the complainant for one of one grievance reviewed. (MR1)
Findings include:
Review of facility document titled "Resolution of Patient Complaints and Grievances," last revised September 2008, revealed "Upon Resolution of a grievance, the Patient Representative, or appropriate organizational manager, will provide a resolution letter to the complainant."
1. A review on April 29, 2010, of a facility complaint letter dated February 19, 2010, revealed the facility had investigated the complaint. There was no documented evidence that a letter was sent to MR1 and the facility could not provide a resolution letter.
2. An interview with EMP1 and EMP2 on April 29, 2010, at approximately 9:15 AM confirmed that the facility did not send a resolution letter to MR1.