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Based on interview, record review, and review of facility's Policy, it was determined the facility failed to ensure patients with a grievance received written notice of the hospital contact person, the steps taken to investigate the grievance, the date of completion, and the resolution of the grievance.

The findings include:

Review of the facility's Policy "Complaint and Grievance Procedures," last revised 01/2020, defined a patient grievance as a written complaint, or verbal complaint not resolved at the time of the complaint by staff present. It further defined a grievance as initiated by a patient or a patient's representative, regarding patient care related to the hospitals compliance with CMS Hospital Conditions of Participation (CoP). Continued review of the policy revealed written notice will be provided to the patient within seven (7) days of the name of the Patient Advocate, the steps taken to resolve the grievance, the results of the complaint and grievance process, and the date of completion of the grievance process.

Review of fourteen (14) grievances over the past fourteen (14) months revealed no documented evidence the patient or patient representative was contacted following the resolution of the grievances.

Interview with the Patient Advocate, on 02/21/2020 at 12:09 PM, revealed she was uncertain of the details regarding the resolution of the grievances which were reviewed. Continued interview revealed she had been in the role of Patient Advocate since April 2019, and had been responsible for fourteen (14) of the fourteen (14) grievances reviewed. She revealed upon assuming the position of Patient Advocate, she was provided a binder to use as a template for her role; however, she was provided limited education. Per interview, she only spend a short time shadowing her predecessor. Continuing interview with the Patient Advocate revealed in some instances, she did make phone contact with patients or patient representatives, but had never provided written notification of grievance results to patients or patient advocates, as she did not know to do so. She further revealed she had limited knowledge in a grievance that involved staff. She stated if a grievance involved staff, she would alert the involved staff's supervisor of the grievance, but she was not kept informed of what was done to address the grievance. Per interview, the resolution to the grievances was not provided to her.

Interview with Assistant Director of Nursing (ADON) #1, on 02/21/2020 at 2:07 PM, revealed
the Patient Advocate's immediate supervisor would have been the Quality Risk Manager (QRM), who resigned two weeks ago. Continued interview revealed the Chief Nursing Officer (CNO) was responsible for the QRM's duties until that position was filled; however he was currently out of the facility sick. Further interview revealed, staff should follow the facility's policies regarding grievances to ensure regulatory compliance and patient satisfaction.

Interview with the Chief Executive Officer (CEO), on 02/21/2020 at 2:59 PM, revealed that in protecting confidentiality of other employees, the information regarding the efforts taken in resolving grievances involving employees was limited. He went on to reveal there could have been some situations when the facility had been erroneously classifying as "grievances" which could be better described as patient concerns that were resolved at the time they were brought to staff attention. The CEO voiced his expectation that any actual grievance would be followed up with patients in writing and per the facility's policy and regulations.