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Based on document review, record review and staff interview it was determined the facility failed to ensure patients received a timely written complaint resolution. This deficient practice was identified in one (1) of ten (10) records reviewed (patient #1). This failure has the potential to impact all patients negatively if written complaint resolutions are not sent to the complainant in a timely manner.

Findings include:

1. Review of the policy entitled "Customer (Patient/Family/Visitor) Concern/Complaints/Grievance Process", last reviewed 8/16, revealed the policy states, in part: "...to resolve the issue within 7 business days; however a letter will be sent for those concerns that require further investigation. Resolution should be made as soon as possible and communicated to the patient or his/her representative...The written notice of resolution will include: name of the contact person, steps taken to investigate, the results, the date of completion and a number to contact if they are dissatisfied with the resolution."

2. Review of Patient #1's medical record revealed the patient was admitted to the facility on 2/13/17 with a diagnosis of congestive heart failure. The patient received treatment and was discharged on 2/20/17 against medical advice (AMA). The patient's legal guardian made a complaint about the discharge on 3/1/17.

3. A review of the complaint (facility term is grievance) made by Patient #1's legal representative revealed the facility had investigated the grievance but had not sent a written notice to the patient or his representative.

4. In an interview with the Director of Care Management on 4/4/17 at about 3:30 p.m. (who investigated the grievance), she stated she had not sent any letters of notification to Patient #1 or his legal representative with the findings of her resolution.

5. A review of the grievances received by the facility from 2/1/17 to 4/1/17 revealed thirty-two (32) of the grievances did not have a written notification of resolution sent to the complainant by the facility.

6. In an interview with the Patient Advocate, whose duties include investigation and response to grievances, on 4/5/17 at about 11:00 a.m., she was asked about the above noted grievances. She stated she had not responded to the thirty-two (32) grievances and that all were outside the seven (7) day parameter set by regulation and the facility's own policy.

Based on document review, record review and staff interview it was determined the facility failed to ensure nurses followed their own policy for discharging patients against medical advice (AMA). This deficient practice was identified in one (1) of one (1) records reviewed of patients who had been discharged AMA (patient #1). This failure has the potential to negatively impact all patients who receive care at the facility.

Findings include:

1. A review of the facility policy entitled "Discharge Against Medical Advice", last reviewed 5/12, revealed it states, in part: "A patient may request to be released from the hospital. The nurse should meet with the patient to determine the reason for the request, to present the risks and consequences involved, to give the patient any pertinent information, and to ask the patient to reconsider his decision...If the patient is legally incompetent to make a judgement or lacks decision making capacity, the hospital may exercise reasonable efforts to keep the patient hospitalized if a surrogate has been appointed...The hospital may exercise its discretion to deny AMA discharge if the patient's release poses a threat to public health and safety (legal action will be taken to involuntarily hold the patient...Information involving the request...must be carefully documented in the patient's medical record. This will include the reasons for requesting the release, the risk and consequences leaving AMA..."

2. A review of Patient #1's medical record revealed he was admitted to the facility on 2/13/17 for a diagnosis of congestive heart failure. He received treatment and was discharged on 2/20/17 AMA.

3. In an interview on 4/4/17 at about 1:07 p.m. with the Discharging Nurse of Patient #1, the above situation was discussed and she stated she did not document the risks and consequences in Patient #1's medical record. She stated she notified the doctor, and the facility documented multiple attempts to contact the legal representative, which were unsuccessful. The patient was alert and oriented and could verbalize his condition and treatment, but he wanted to go home. The doctors documented it was alright from their view point and the patient could be discharged, but would wait for the outcome of the attempts to tell the legal representative the patient was insisting on going back to his own home. She agreed she did not ensure the documentation was complete according to the facility's AMA policy.