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Based on observation, interview and review of the facility policy regarding "Patient Grievance and Complaint Process," it was determined the facility failed to complete appropriate notification for five (5) of thirteen (13) grievances reviewed. There was no evidence that written or oral acknowledgement had been made within 7 days, nor evidence of a follow up written response within the hospital policy of 30 days.

The findings include:

Review of the facility policy, dated 05/21/10, revealed "When a Patient communicated a Patient Grievance orally or in writing to the patient representative, or to an other representatives of the hospital or to a physician, the patient grievance process begins ....The Patient Representative will, as soon as reasonably possible, but ideally within seven (7) business days of the communication of a Patient Grievance, begins an investigation by: 1. Contacting the patient in writing or orally acknowledging receipt of the Patient Grievance; 2. Describing the Patient Grievance steps and estimating time to Hospital's conclusion of the Patient Grievance (30 days); 3. If resolution has been reached within that time, then final written notice is sent to the patient.

1. Review of the "Patient Representative Program Record of Contact" #1, on 11/16/11, revealed the grievance had been received by the hospital on 05/03/11, with no date on the grievance regarding the date of the incident. Review also revealed the un-sampled patient was called on 08/11/11, (over three (3) months later); however, the telephone had been disconnected. Although there was an address listed, the facility did not attempt to notify the patient in writing, after being unable to reach by telephone.

2. Review of the "Patient Representative Program Record of Contact" #2 revealed the grievance had been received on 05/03/11, with an incident date of 04/18/11. The grievance revealed the un-sampled patient had been called, on 05/10/11, to acknowledge the grievance, however a final follow up letter was not sent until 07/27/11, over two months later.

3. Review of "Patient Representative Program Record of Contact" #3 revealed the grievance was received, on 06/20/11, with no date of the incident indicated on the grievance. Review revealed a telephone call was made to the un-sampled patient, on 06/22/11, however there was no response. A follow up letter to acknowledge the grievance was not sent until 07/18/11 (or one month later), at which time the complainant called back on 07/20/11 to discuss the grievance. A final letter response was not sent until 08/02/11.

4. Review of "Patient Representative Program Record of Contact" #4 revealed a receipt of 07/26/11 with a date of incident on 02/13/11. However, a voicemail for acknowledgement was not sent to the un-sampled patient until 10/20/11 (or almost 3 months later), at which time the final response letter was sent.

5. Review of "Patient Representative Program Record of Contact" #5 revealed a receipt of 07/27/11, with no incident date documented. Review revealed the un-sampled patient was not telephoned until 08/22/11, and a voicemail that concerns were being addressed. However, a second telephone call was made on 08/30/11, to respond to the grievance with no written response sent, as per facility policy. Review of the grievance log revealed the complaint was not closed until 09/30/11, or over 2 months after the grievance was initiated.

Interview with the Patient Representative, on 11/16/11 at 11:00 AM, revealed she was responsible for investigating patient grievances and initially completed the Patient Representative Program Record of Contact. The Patient Representative initially contacts the patient within 7 days or sends a letter stating the hospital was investigating. She stated she involved appropriate parties along with the Medical Director, who reviewed the patient chart with her at which time a plan of action would be put into place. She stated the patient was called, and notified of the response with a 30 day follow up letter. The Patient Representative stated in the final response letter, there would be information regarding the right to appeal to the Grievance Committee. She stated the dates of the incident should be on the form, with appropriate dates of notification.

Interview with the Chief Nursing Officer (CNO), on 11/16/11 at 1:45 PM, revealed all grievance logs and grievances reported are sent to her for review. The CNO stated that although the policy for 7 day written or oral acknowledgement of receipt of the grievance, and written 30 day response had not been followed as required, she had not picked up on the non-adherence to the facility policy.