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Based on interviews and document review, the facility failed to ensure grievances were responded to within the specified time frame in 11 out of 20 grievances reviewed (Patients #1, #2, A, B, C, D, E, F, G, H, and I).

This failure resulted in patients not knowing their grievance had been received and was being investigated.

FINDINGS

POLICY

According to the facility policy, Patient/Family Resolution of Complaints, the Patient Advocate will acknowledge receipt of the grievance by documenting the time and date of the grievance on the grievance form and communicate with the person filing the grievance within 3 working days.

The Patient Advocate will establish a date by which time a response is expected. A
7 day time frame is considered appropriate. If the grievance will not be resolved within 7 days the patient will be informed that the grievance is still being investigated and a number of stated days of when the grievance is expected to be resolved will be included, not to exceed 15 working days from the date the grievance was submitted.

1. The facility failed to ensure that acknowledgement of grievances submitted by patients was completed within its specified time frames.

a) In an interview with Employee #3 on 07/22/15 at 1:33 p.m., s/he stated that after receipt of the patient's grievance, the date of receipt of the grievance should be documented on the Patient Grievance form in the 1st Level Resolution section followed by a letter to the patient within 3 days.

The Director of Nursing (DON #1) also present during the interview stated the intent of the 1st Level Resolution section of the Patient Grievance form was to begin documentation of the investigation process.

b) Review of the Patient Grievance forms showed there was no documentation in the section 1st Level Resolution to indicate the date the grievance was received and that acknowledgement of receipt to the patient within 3 days had occurred. As example:

Patient #1 submitted 2 grievances on the Patient Grievance form dated 04/25/15 and 04/29/15. There was no documentation on the Patient Grievance form to show the patient received an acknowledgment of receipt of the grievances within the 3 day time frame specified by the facility.

Patient A submitted a Patient Grievance form on 06/25/15. There was no documentation on the form to show when acknowledgement of the grievance was communicated with the patient.

Patient C submitted a Patient Grievance form on 05/15/15 regarding harassment by fellow patients on the unit and requested an immediate response. The 1st Level Resolution section of the Patient Grievance form lacked documentation which showed the date of receipt of the grievance or that communication to acknowledge receipt of the grievance was made with the patient.

Six Patient Grievance forms were submitted by Patient H between the dates of 01/23/15 and 02/11/15. There was no documentation on 6 of the 6 forms to show acknowledgement of the grievance was communicated to the patient within the specified 3 day time period.

Review of the Patient Grievance form submitted by Patient F on 01/22/15 revealed no documentation of the date the form was received or a date to show the grievance was acknowledged within the facility's specified 3 day time frame.

Review of patient grievances submitted by Patients #2, B, D, E, G, and I showed similar deficient practice in which there was no documentation to show the grievance had been received and the patient had been informed the grievance was being investigated.