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Based on interview and record review the facility failed to establish a process for identification and prompt resolution of patient grievances, resulting in 4 of 6 patients (#14, #15, #16 and #17) not having their grievances resolved in a timely manner, placing all patients at risk of not receiving timely grievance resolution. Findings include:

Policy Review:
On 5/14/14 at approximately 1400 policy #195, Treatment of Patients: Patient Grievance, dated 8/15/11, was reviewed. The policy states:
"Patient Relations along with at least one ad hoc member of the Grievance Committee will promptly investigate all grievances."
A grievance is defined as: "A complaint that is not resolvable by staff present at the time the complaint is made because it requires additional investigation, is referred to other staff for later resolution and/or requires further actions for resolution."

Record Review:
On 5/14/14 from approximately 1230-1400, patient complaints were reviewed with staff F, revealing:
---On 4/15/14 Patient Relations staff F received a phone call from staff G, the patient's physician. Staff F's note states: "She (patient #14's wife) said that they had not received any information about this discharge....and were upset about this." The next day, on 4/16/14, staff H documented that patient #14's discharge plan was unresolved, "leaving the family with no good choice right now." There was no further documentation regarding patient #14's discharge or whether the patient, 66 years old, was provided with "An Important Message from Medicare" at the time of discharge. This verbal complaint regarding discharge planning was not classified as a grievance.
---Patient #15 submitted a written complaint on 3/19/14. Patient Relations staff F had documentation of 4 requests for information (addressed to staff) necessary to resolve the grievance. This grievance remained unresolved on 5/13/14.
---Patient #16's family member sent in a written grievance regarding the patient's care. The grievance letter was dated 2/11/14. The complaint was received by the Patient Relations Department on 3/17/14. There was nothing in the file to explain who received the letter, on what date, and why there was a delay in forwarding it to Patient Relations.
---Patient #17's written grievance regarding care was dated 1/8/13. Staff, the Patient Relations Coordinator documented receipt of the complaint on 3/31/14, noting that the grievance letter was forwarded to Patient Relations on that date. Documentation indicating who initially received the letter and the date of receipt by hospital staff was not found.

Interview:
The above findings were confirmed by staff F during record review on 5/14/13 from 1230-1400. In regard to the verbal grievance made by patient #14''s wife, staff F stated that Patient Relations staff viewed this as a complaint that was immediately resolved, not a grievance, despite the fact that follow-up discussion with staff was documented on the day after the complaint was received. Staff F stated that she did not know the outcome of patient #14's discharge plan or whether the patient or his wife were satisfied with the discharge plan. Staff F stated that she did not know if the patient (66 years of age) was provided with "An Important Message from Medicare," at discharge, which contained discharge appeal rights.

Based on interview and record review, 1 of 1 current patients (patient #6) who provided the hospital with an advance directive was not provided with delegation of decision-making authority in keeping with his wishes, placing all patients at risk of not having advance directives honored. Findings include:

Policy Review:
On 5/14/14 from 1300-1430 policy #208, Do Not Attempt Resuscitation (DNAR) Orders, dated 5/6/13 was reviewed. The policy states:
"When the decision to limit resuscitative attempts for a given patient is being considered, it is the responsibility of the attending physician to:
-Discuss with a patient with decision-making capacity the options for resuscitative efforts and their implications and rationale. The patient with decision-making capacity is ultimately responsible for determining whether a DNAR order shall be entered. For patients without decision-making capacity, options for resuscitative efforts and their implications and rationale need to be discussed with the designated Patient Advocate..."

Record Review:
1. On 5/13/14 at 1140 review of patient #6's clinical record revealed a "Durable Power of Attorney for Health Care, Custody, and Medical Treatment Decisions." Patient #6 designated a patient advocate "to make decisions regarding care, custody or medical treatment if I become unable to participate in care, custody and medical treatment decisions. The determination of when I (patient #6) am unable to participate in care, custody and medical treatment decisions shall be made by my attending physician and another physician or licensed psychologist." The authority to execute a "Do Not Resuscitate Order" was listed as a delegated right after activation of the document. A second person was named as alternate, in the event that the primary named advocate was "unable, unwilling or unavailable."
2. On 5/14/14 from 0900-1330 review of patient #6's clinical record revealed documentation that Nurse Practitioner E wrote an order for, "No resuscitation or CPR efforts if cardiac or respiratory arrest occurs." Statements documenting that patient #6 was unable to participate in medical treatment decisions, by his attending physician and one other physician or licensed psychologist, were not found in the patient's record.
3. On 5/14/14 from 0900-1330 review of patient #6's record revealed no specific documentation of a conversation with the patient or an activated patient advocate acting on behalf of patient #6 in regard to the "Do Not Resuscitate Order."

Interview:
The above findings were confirmed by staff C during record review on 5/14/14 from 0900-1330.