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Based on record review, staff interview and policy review, the facility failed to provide written communication to the patient or patient's representative regarding resolution of the grievance containing the contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 2 of 17 patient charts reviewed (#16 and #17).

Findings include:

Record review done in the morning of 7/10/12 revealed that the mother of Patient #16 had complained that she had difficulty getting a procedure scheduled for P#16. According to the mother, P#16 was seen by a physician on 5/6/12 and as a result was to have a colonoscopy scheduled. When the clinic called the Operating Room (OR) scheduler, they were told to call back tomorrow because "my computer is off and I am going home." On 5/7/12 the mother received three (3) separate phone calls changing the time of the colonoscopy from a Tuesday at noon to a Tuesday at 7:30 A.M., then the last call was for Monday at 7:30 A.M. The mother expressed concern for P#16 as she found the scheduling process and changes "very disturbing and confusing."

Further review of the record found handwritten documentation that the "procedure was done 5/14 @ 0730" but also stated "I did not talk to mother." There was no signature or date on the document.

Interview was conducted with Director of Quality and Risk Management (DQRM) on 7/12/12 at 3:15 P.M. Director stated that the OR scheduler was re-educated on appropriate management of schedules and telephone etiquette and he/she thought P#16's mother had been called. However, no documentation could be produced on a follow up letter to the mother informing her of the steps taken to resolve her concerns and the date of completion of the resolution.

Record review done on Patient #17 also revealed a lack of written communication to the patient or patient's representative regarding the complaint. P#17's attorney wrote the complaint on behalf of the patient. In the letter dated 6/19/12, the attorney stated that the patient was "forcefully given" Morphine Sulfate against his/her wishes and as a result P#17 suffered from an elevated pulse for approximately one month after discharge from the hospital.

Interview was conducted with DQRM on 7/12/12 at 3:30 P.M. who stated that since the patient's attorney submitted the complaint, the facility's practice was to notify their legal counsel and thereby communication would then be only attorney to attorney. Review of the grievance file on P#17 revealed that there was no evidence of follow up to the patient's complaint nor any notification to the facility's legal counsel. The DQRM searched email and written files, however, no documentation could be produced on the facility sending a letter notifying their attorney about this complaint.

Review of facility's Policy and Procedure on "Patient Grievances," with revised date of July 2012 revealed that every effort will be made to resolve patient grievances within seven (7) days or less. Some resolutions may take longer than 7 days but in both instances, the policy states that communication will be made to the patient or representative. The policy further states that once the Grievance Committee members are in agreement with the findings of the investigation and resolution, a letter will be sent to the patient or patient representative "detailing the name of the contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion."