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Based on administrative record review and staff interview, the facility failed to provide evidence of prompt resolution of patient grievances. The facility also failed ensure staff adhere to the established process for processing grievances and resolutions.

The findings include:

On 4/3/2014, the surveyor requested the facility's grievances for the past 6 months for review. Upon receipt and review of what was presented, the surveyor inquired of the Quality Manager if the information presented is complete. The Quality Manager later returned and stated the facility is in receipt of several complaints which had not been logged into the systems as to date. Upon further review and selection of identified patient complaints, it was found that 3 of the 6 patients' complaints selected, which were received on 3/2/2014, 3/6/2014 and 3/25/2014, had not been entered in the facility's data entry system until 4/3/2014.

An interview was conducted on 4/4/2014 in the morning with the Quality Manager who stated she had reviewed the complaints the surveyor had chosen and realizes the facility has an issue. In addition to the delay of the complaints being logged into the data system, there had been no follow-up nor resolution for the complaints. It was learned once the Administrative Assistant logs the complaint and the complaint is filtered to the appropriate Director, follow-up was not done to ensure the resolution.

Review of the facility's policy regarding Patient Complaints reveal "Patient related complaints are investigated by the Department Director and/or Manager. Interviews of parties directly involved, research of incident, as well as identification of the issue is handled as quickly as possible. Recommendations for an appropriate resolution to the problem are made. A Plan of action is developed when appropriate. Follow-up with the patient/family is completed. Directors, Managers and staff receiving a Patient Relations Report need to respond as appropriate and return a written response within 10 working days to Administration and appropriate Vice President. The Administrative office will maintain a repository of all patient complaints and the disposition of each case. Patient Complaints received in Administration Written or Telephone Call. The complaint when received is forwarded to the Administrative Specialist who enters the complaint information in the MIDAS System. The complaint is forwarded to the Department Director and/or Manager for review and action and a copy of the complaint is sent to the appropriate Vice President. The Director or Manager will investigate the complaint and follow-up with the person who initiated the complaint. It is the responsibility of the director/manager to timely resolve the complaint/issue/concern. (a telephone call to the person initiating the complaint should be within three days and a written follow-up describing the resolution to the complaint to the person should be within 10 days.) The Manager/Director will email the Administrative Specialist or designee, with a summary of the resolution of the complaint. A copy of the complaint and resolution will also be forwarded to the appropriate Vice President."

The facility failed to substantiate the policy was followed for the following complaints reviewed, furthermore there is no evidence of administrative review per the policy standards.

1) A complaint was filed on behalf of Patient # 10 by the spouse contacting the facility on 01/29/2014 voicing complaints regarding the care provided to the patient by the Emergency Department Physician. The complainant also included concerns she also had regarding the behavior of the nurse providing the patient's care. The complaint was referred to Medical Services for follow- up regarding the physician. The Risk Manager (RM) documented that the patient's spouse was contacted on 2/11/2014. The RM noted that the complaint was forwarded to the Nurse Manager for follow-up regarding the alleged behavior of the nurse. As of the dates of survey, 4/03/2014 and 4/04/2014, there is no further follow-up or administrative review documented or provided (An excess of 2 months after the complaint was filed, actions were not taken per policy.)

2) Patient # 4 filed a complaint with administration on 1/13/2014 regarding the care and services she received in the Emergency Room and staff behavior . The complaint was forwarded to Medical Services for follow-up and the Nurse Manager for the nursing issues. Review of the facility's records regarding the complaint failed to yield evidence that the complainant was addressed nor is there evidence of a resolution.
During an interview with the Medical Director for the Emergency Department on 4/3/2014 at 1:07 PM, the Medical Director stated, she did a medical review on the patient's records and followed up with the Emergency Room physician involved. The Medical Director denied follow-up with the patient, regarding findings and resolution.

An interview was conducted with the Nurse Manager on 4/4/2014 in the afternoon, who stated she thought she had followed up with the nurse allegedly involved, but after reviewing her notes, she had not. She also confirmed that she had not followed up with the patient regarding resolution of the complaint that was filed on 1/13/2014, almost 3 months later.
There is no evidence of administrative review for the patient's complaint as of 4/4/2014.

3) A complaint was filed on 3/02/14 on behalf of Patient # 9 by the patient's who contacted administration regarding the patient's spouse's care. As of 4/03/2014, the complaint had not been logged into the facility's MIDAS System. Furthermore, there is no evidenced of contact with the complainant regarding the issue until 4/3/2014 at 11:34 AM, over a month after the complaint had been filed. A referral forwarded to Medical Services for further follow-up was not available/provided upon request. No further information was available regarding the status of the follow-up, resolution or administrative review.

4) A complaint was filed on behalf of Patient # 1 on 3/25/2014. This complaint was not entered into the facility's MIDAS system as of 4/3/2014, 9 days after the complaint was received. No evidence was provided, indicating the initiation of processing as per policy.

Based on administrative record review and staff interview, the facility failed to ensure they provide patients with written notice of findings for filed grievances and/or resolutions. This affected 3 of 5 patients whose records were reviewed for complaints. ( Patient # 4, # 9 and # 10) as evidenced by the facility failure to provide written follow-up of the complaint's resolution.

The findings include:

Review of the facility's policy regarding Patient Complaints documents "Patient Complaints received in Administration Written or Telephone Call. The complaint is forwarded to the Department Director and/or manager for review and action. The Director or Manager will investigate the complaint and follow-up with the person who initiated the complaint. It is the responsibility of the director/manager to timely resolve the complaint/issue/concern. (a telephone call to the person initiating the complaint should be within three days and a written follow-up describing the resolution to the complaint to the person should be within 10 days.)"

1) A complaint was filed on behalf of Patient # 10 by the spouse on 1/29/2014 who voiced complaints regarding the care provided to the patient by the Emergency Department Physician, and concerns regarding the behavior of the nurse providing the patient's care. The complaint was referred to medical services for follow- up regarding the physician. The Risk Manager forwarded the complaint to the Nurse Manager for follow-up regarding the alleged behavior of the nurse. At the time of survey, 4/3/14 and 4/4/14 there is no evidence found or provided that written follow-up describing the complaint resolution was forwarded to the complainant

An interview was conducted on 4/4/2014 in the afternoon with the Quality Manager and Clinical Documentation who confirmed that the results and the resolution was not forwarded to the complainant as of the 4/4/2014 review (over 2 months after the receipt of the complaint).

2) Patient # 4 filed a complaint on 1/13/2014 regarding the care and services she received in the Emergency Room and staff behavior . The complaint was forwarded to Medical Services for follow-up and the Nurse Manager for the nursing issues. Review of the facility's records regarding the complaint, on 4/3/14 failed to yield evidence that the complainant was provided written follow-up of the resolution, over 2 months after receipt of the complaint.

An interview was conducted with the Medical Director for the Emergency Department on 4/3/2014 at 1:07 PM, who stated she did a medical review on the patient's records and followed up the Emergency Room physician involved. The Medical Director denied forwarding written resolution to the complainant.

An interview was conducted with the Nurse Manager on 4/4/2014 in the afternoon, who stated she thought she had followed up with the nurse allegedly involved but after reviewing her notes, she had not. She also confirmed that she had not sent written notice of the resolution to the patient.

3) A complaint was filed on 3/02/14 on behalf of Patient # 9 regarding the patient's care. There is no evidence that written follow-up was sent to the complainant as of 4/4/2014.