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Based on interview and record review the facility failed to ensure compliance to its grievance policy in one of one sampled patients with documented grievances (patient #1).

The patient did not receive timely post-investigation communication (phone, meeting, formal written acknowledgement) as indicated in the hospital policy.

Findings:

Interview on 12/5/2017 with the customer relations staff revealed, patient #1 received a notification letter on 10/31/2017 and received a phone call from customer relations on 11/27/2017 (19 working days).

Record review on 12/5/2017 of the notification letter dated 10/31/2017 stated "Your concerns will be carefully reviewed by the staff, and upon completion of the review, we will respond directly to you. You may expect a call within ten (10) working days".

Record review of the facility policy Complaint/Grievance, Hospital Response dated 2/18/2014 stated Patient relations will coordinate final written notices of resolution within thirty (30) calendar days.