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Based on policy review, staff interview and document review, the facility did not provide Patient #1's family with a written notice of the grievance decision.

Findings include:

Review of policy "Patient Complaint Process: CJS-QPS-029" last facility review on 09/2016 revealed the facility must provide a written response to each grievance that includes steps taken to investigate the grievance, the results of the grievance process and date of completion.

Review on 06/14/18 of Facility's Confidential Complaint/Grievance log revealed two separate complaints/grievances related to Patient #1. The first grievance/complaint dated 11/03/17 was submitted by Patient #1's parents and a meeting was held on 11/03/17 to discuss care issues. There is no documentation regarding the discussion that occurred at the meeting, nor is there any evidence to indicate a closure letter was provided to the parents. A second grievance/complaint dated 11/13/17 was submitted by a family member. A closure letter dated 12/04/17 was sent, but returned to the facility for the wrong address. There is no evidence to indicate a second letter was re-sent to the correct address.

Interview on 06/14/18 at 01:00 PM with Staff (P), Patient Advocate verified the findings above indicating she was present at the 11/03/17 meeting between Patient #1's family and facility staff. The meeting was not documented and a closure letter was not sent to the family. The closure letter for the second complaint/grievance submission dated 11/13/17 had an address that differed from the one listed on the complaint/grievance form. The letter was returned and the facility did not attempt to re-send the closure letter to the correct address.

Interview on 06/14/18 at 01:45 PM with Staff (A) Vice President of Patient Care Services, and Staff (B), Director of Quality & Patient Safety confirmed the above findings.