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Based on review of the facility's policies and procedures, facility records, and staff interview, the facility failed to follow their policies and procedures to ensure 1 of 3 patients (Patient #2) or their representatives received timely attempts to resolve and respond to a grievance.

The findings included:

The facility Policy and Procedure titled Patient Grievance, policy date 04/19/18, documents under Policy: "For the purpose of this policy, a grievance is defined as a "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489."

The facility Policy and Procedure titled Patient Grievance, original policy date 04/19/18, documents under Procedure:

"4. The staff member receiving a verbal or written grievance shall insure that a Patient/resident Concern Notification is completed and notify the Patient Advocate or Shift Supervisor.

"5. The Patient Advocate or in his/her absence, the Shift Supervisor shall investigate and address the grievance within 24 hours of the time the grievance is received if possible.

"6. If the concern cannot be resolved a this level, the Patient/resident Advocate will facilitate the investigation and resolution of the grievance through complete investigation by the appropriate department head.

"7. The Patient/Resident Advocate responding to the grievance shall inform the patient/resident or family the timeframe within which he/she shall expect follow-up. This time frame shall not exceed 7 days unless there are extenuating circumstances, at which point the patient/representative shall be notified of the need for an extended time frame and an agreement made as to when follow up will occur."

Review of Patient #2's record on 07/05/18 revealed a copy of a written grievance dated 06/26/18 listing items of concern regarding Patient #2's care, but no documentation that the grievance had been addressed.

During an interview with the Performance Improvement Director, on 07/05/18 at 11:29 AM, she acknowledged that she processes all grievances but had not seen this grievance before; that staff should have given it to her instead of merely placing it in Patient #2's chart. The Performance Improvement Director conferred staff did not follow policy to forward the grievance to her so it could be addressed.