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Based on review of facility policy/procedure and staff interviews, it was determined the facility grievance process failed to specify timeframes for review of the grievance and the provision of a response.

The findings include:

On July 20, 2010, a review of the facility's grievance policies/procedures was conducted. The grievance policy revealed the facility was required to provide a written response to the patient filing a grievance, but did not specify timeframes for the written response to the patient/patient representative as required by Federal Regulation.

Staff interviews conducted on July 23, 2010, at 11:05 AM, with the Risk Manager and Chief Nursing Officer revealed the staff did not know why the grievance policy did not have a specified timeframe for a written response to a patient/patient representative who filed a grievance.