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Based on staff interviews, review of the facility's written response to grievances, review of policy and procedures, and during the course of a complaint investigation it was determined the facility failed to provide the complainant with complete results of the grievance process, or a date the investigation will be completed. The grievance was filed on behalf of Patient #3.

The findings were:

The facility's Associate Chief Nursing Officer (ACNO), Continual Readiness Coordinator, Vice President of Quality and Compliance, and Associate Administrator for Complaints and Grievances were interviewed on 9/26/12 in the a.m. The administration staff explained the facility's grievance process and specifically discussed how the facility responded to the grievance placed on behalf of Patient #3. The facility sent the complainant two separate written responses approximately two months apart.

The surveyors reviewed the facility's initial response, a letter, which was sent by the facility's ACNO dated July 17, 2012. The letter was in response to a telephone call placed by the complainant. Within the facility's response letter, the ACNO lists the complainants concerns, "During your conversation, you indicated you were displeased with this visit because you were concerned about our care and treatment of your father-in-law whom has advanced dementia. You voiced that you felt he was placed on medications he should not have been given and that the physicians ignored your requests regarding limitations of care and treatment." The response letter summarized Patient #3's hospital course and medications the patient received following the facility's review of the patient's medical record. No evidence of how the facility investigated the concern related to limitations of care and treatment was noted. There was no indication the investigation was to continue in order to answer those concerns. In an interview with the facility's Continual Readiness Coordinator on 9/27/12, she acknowledged the letter did not contain these elements. The facility's Associate Administrator for Complaints and Grievances was interviewed on 9/28/12 and she acknowledged the facility expected the letter from the ACNO to the complainant to be the end of communication related to this complaint until the facility received written communication from the complainant on 8/27/12. The facility considered that information from the complainant as an appeal to the facility's grievance response. The facility's Chief Executive Officer (CEO) then replied to the complainant's appeal via a letter dated September 11, 2012.

The facility's second response letter was reviewed on 9/27/12. Within this letter, written by the facility's CEO, the complainant's concerns were acknowledged and the letter indicated there had been an investigation launched. There was no mention of a date of completion for that investigation.

The facility's policy and procedure titled, "Patient Complaint and Grievance" was reviewed on 9/26/12. The policy's latest approved and revised date was 11/2010. The seven-page policy included a Grievance Resolution Process that read in part, "3. Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days." And, "8. A grievance is considered resolved when the patient and/or patient representative are satisfied with the actions taken on their behalf. There may be situations where the organization has taken appropriate and reasonable actions on the patient's behalf in order to resolve the patient's grievance and the patient or the patient's representative remains unsatisfied with the actions taken by the organization. The patient may appeal this decision in writing to the hospital CEO."