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Based on interviews and document review, it was determined the facility's grievance process failed to specify time frames for the provision of a response, as per the standard of the regulation.

The findings include:

On 10/24/23 at 10:35 a.m., Staff Member #19 (S19) explained that when the facility receives a grievance, the Patient Experience office sends an acknowledgement or response letter to the complainant within seven (7) days.

On 10/24/23 at 11:15 a.m., a request was made to Staff Member #3 (S3) for any evidence of the time frame in which the facility had to review a grievance and provide a resolution response to a complainant. The surveyor was provided with the facility's "Complaint and Grievance Management", policy 9420432, last approved 4/2021 and a copy of the Patient Experience Department's Internal "Patient Complaint/Grievance Flow Chart".

A review of the facility's policy "Complaint and Grievance Management" policy 9420432, last approved 4/2021, stated in part:
"...GRIEVANCE PROCEDURES: "Patient Experience staff should be notified of all grievances and will resolve them in accordance with applicable laws and regulations, including conducting a review and facilitating a thorough and timely response to the patient...".
There was no evidence of specific time frames for the review of the grievance and provision of a response in the policy.

A review of the facility's Patient Experience Department's internal "Patient Complaint/Grievance Flow Chart", not dated stated in part:
"...Investigation complete within 7 days?...".
No evidence was provided that specified the timeframe's for the provision of a response to a grievance.

The findings were discussed with Staff members #1-7, #9, #13, #15-17, #19 and #37-44 at the exit conference on 10/24/23 at 1:40 p.m.

Based on interviews and document review, it was determined the facility staff failed to provide written notice of it's grievance decision on two (2) of five (5) complaints sampled from the facility's complaint and grievance log.

The findings include:

On 10/24/23 at 10:35 a.m., an interview was conducted with Staff Members #2 (S2), #18 (S18) and #19 (S19). S18 stated that S18 met with Patient #7's (P7) spouse in June, 2023 at the facility. S18 stated that P7's spouse had questions regarding P7's care while P7 was admitted in the hospital, but was not making a complaint or a grievance at that time. S18 answered P7's spouse's questions. S18 was not aware of a letter that was sent by P7's spouse at a later date. S2 stated that the spouse of P7 sent a complaint letter to the facility in July, 2023. Once the letter was received, P7's medical record was thoroughly reviewed by 7/24/23 but no follow up letter was ever sent to the spouse of P7. S2 stated "this probably fell through the cracks". Staff Member #19 (S19) explained that when a grievance is received, the Patient Experience office sends a follow-up letter to the complainant within seven (7) days of receiving the grievance.

A review of the facility's policy "Complaint and Grievance Management", policy 9420432, last approved 4/2021, stated in part:
"...GRIEVANCE PROCEDURES: "Patient Experience staff should be notified of all grievances and will resolve them in accordance with applicable laws and regulations, including conducting a review and facilitating a thorough and timely response to the patient...".

A review of the facility's Patient Experience Department's internal "Patient Complaint/Grievance Flow Chart", not dated stated in part:
"...Receive a complaint>>Did patient request file as formal complaint>>Yes>>Define incident as grievance>>Add to Patient Experience Tracking System>>Begin investigation>>Input from another dept needed>>No>>Investigation complete within 7 days?>>No>>Update status>>Investigation complete within 7 days?>>Yes>>Send letter to patient explaining actions taken to resolve...".

On 10/24/23 at 12:30 p.m., a review of the facility's Complaint/Grievance log from 7/1/23 through 10/23/23 was conducted. A total of five (5) grievances were sampled from the log. Two (2) of the grievances sampled did not provide evidence that a follow-up letter was ever sent to the complainants. One (1) of the two (2) included the complaint from P7's spouse. The entry revealed that S18 met with the spouse of P7 on 6/22/23. There was no evidence that a complaint letter was received from P7's spouse after 6/22/23, and no evidence that anyone in the Patient Experience Department ever spoke or followed-up with the spouse of P7. The second complaint log sampled revealed that a complaint was received at the Patient Experience Department on 7/5/23. There was no follow-up letter of resolution documented in the complainant's log.

On 10/24/23 at 12:55 p.m., an interview was conducted with S19. S19 stated staff followed up grievances with a mailed letter unless the complainant requested a response through email. S19 also stated a resolution letter documented in a complainant's log was evidence that the letter was mailed.

The findings were discussed with Staff members #1-7, #9, #13, #15-17, #19 and #37-44 at the exit conference on 10/24/23 at 1:40 p.m.