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Based on staff interview and record review, the facility failed to review and resolve a patient grievance according to facility policy for 1 applicable patient (Patient #1). Findings include:

The facility failed to provide prompt resolution to a patient representative's grievance regarding the care and services provided to their family member. Per medical record review, Patient #1 had two inpatient hospitalizations in February 2018 which resulted in referrals for outpatient services from multiple healthcare providers following discharge. Upon record review, a grievance was submitted by the patient's representative, which was signed as received by the hospital on 4/3/2018 and scanned into Patient #1's medical record. The grievance addressed concerns related to communication among Patient #1's healthcare providers and the potential need for a mental health evaluation. At the time of the investigation, there was no evidence that the grievance had been investigated, or that the patient's representative had been provided with a response to his/her letter.

The hospital policy, Complaints and Grievances: Patient (last review date 4/17/2018) states, "if the patient or patient's representative....submits the complaint in writing, the complaint is considered a grievance." The policy states under Procedures 4.) The Director of Patient Experience will enter the grievance into the incident reporting system if it has not been previously entered, review the Grievance with the Grievance Committee, and assign it to the appropriate party for investigation and follow up."

Per interview on 4/24/2018 at 1:00 PM, the Executive Director of Quality, Utilization and Care Management confirmed that while s/he he had notified the staff identified in the letter about the content of the patient representative's concerns, s/he had, "not managed the letter as a grievance". S/he confirmed the letter had not been logged as a grievance and the patient's representative had not been provided with notification regarding the steps taken to review or resolve the grievance.

Based on staff interview and record review, the facility failed to ensure that a response was provided to a grievance within the timeframe identified in the facility's policy for 1 applicable patient/patient's representative (Patient #1). Findings include:

Per record review, a grievance submitted to the facility was written by Patient's #1's representative and signed as received by the facility on 4/3/2018. Per record review, the facility's policy, Complaints and Grievances: Patient (last review date 4/17/2018) states that , "the patient will be provided with a response within two weeks when possible...if the written response to the grievance is determined to take longer than two weeks, the patient will be notified by the Director of Patient Experience or his/her representative" and an approximate date of resolution will be communicated to the grievant. Per interview on 4/24/2018 at 1:00 PM, the Executive Director of Quality, Utilization and Care Management confirmed that s/he made no contact with Patient #1's representative and subsequently had not provided the grievant with written notification following receipt or resolution of the grievance.