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Based on review of documents and interview of staff, it was determined the facility failed to ensure a complainant received a response to a grievance in the time frame specified in facility policy for one (1) of one (1) complaint files reviewed (Patient #1). Failure to provide a response to grievances infringes the rights of all patients and their representatives to have their concerns addressed and responded to in a timely fashion.

Findings include:

1. Facility policy entitled "Customer (Patient/Family/Visitor) Concern/Complaints/Grievance Process", last revised 8/15, states, in part, "Management will, in coordination with the Patient Advocate, write a formal letter within 7 days of receipt of the grievance to inform the appropriate individual of follow-up action and closure. If investigation is not complete within 7 days, the response should inform the complainant the medical center is still working to resolve the complaint and that a written resolution is forthcoming".

2. The complaint file initiated on behalf of Patient #1 by a family member was reviewed on 6/29/16 at 9:03 a.m., at which time an interview of the Advocate was also conducted. The file revealed a total of four (4) telephone calls had been made by the complainant with concerns about quality of care and physician communication issues. The Advocate stated the first call, made on 5/24/16, had been perceived as a complaint that was resolved at the time of the phone call and no letter had been sent. She then agreed the three (3) follow-up phone calls made by the complainant, on 5/26/16, 6/8/16, and 6/10/16 could not be resolved at the time of the calls, and an investigation had been conducted. She stated she was aware the complaint would now be considered a grievance per facility policy. When asked if the complainant had ever received written notification of the investigation and/or any resolution reached, she stated: "No, he's still a patient here, and I was checking on him".