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Based on interview and document review, the facility failed to investigate 1 of 2 grievances sent to the administrative officer for further review. Additionally, the facility failed to notify the complainant with ten working days of receiving the forwarded grievance in writing with the investigative findings.

This failure allowed grievances to be closed although the facility assured the complainant further investigation would be complete via an administrative review.

Policy

According to Grievance Mechanism, Patient/Family/Legally Authorized Representative, if the complainant is dissatisfied with the report, the Patient Representative will, upon request, either: provide contact information for the CDPHE, the Joint Commission, DORA, ESRD Network #15 or Director of the Division of Mental Health, Department of Human Services; or forward the report to the appropriate internal designee for administrative review. An administrative review will then begin with an additional investigation and the designee will provide the results in writing to the complainant within ten (10) working days.

1. The facility did not investigate grievances at an administrative level after client request and informing the client a review would be conducted.

a) During a review of Patient #1's grievance documentation, the guardian of the Patient #1 requested an administrative review of the grievance to be conducted by the risk management department. The facility notified the guardian in writing that an Administrative Review would be conducted by the Risk Management Department. No additional investigation documentation was presented and no letter was noted to have been sent to the patient with the Administrative Review findings.

b) An interview with Employee # 1 was conducted on 4/20/16, at 1:33 p.m. S/he stated s/he was not aware of an additional investigation completed by risk management regarding Patient #1's grievance. S/he stated the facility did not send a letter to the guardian of Patient #1 to confirm an administrative review had been completed and informing him/her of the findings.

c) An interview with Employee #2 and Employee #3 was conducted on 04/20/16 at 2:27 p.m. Employee #2 stated the procedure of an administrative review began with a call to the complainant to see what they felt had not been resolved in the initial investigation. If the risk management team was unable to contact the complainant via telephone, no further investigation was completed.

Employee #3 stated the risk management department did not look into grievances beyond the information they had already received from the patient representatives as they would not know what additional information the complainant wanted reviewed unless they spoke with the complainant. Employee #2 confirmed no letter was sent out explaining the administrative review process or additional options available to the Patient #1's guardian.