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Based on record review and interview the facility failed to follow it process for prompt resolutions of patient grievances in 2 out of 2 patient grievances reviewed. (Patient # 1 and # 2) as required by the regulation and facility policy. In addition there is no resolution date indicating the date the resolution letter was sent to the complainant for complaints received and logged on the logs for the month of February on 42 out of 42 entries (Patient 3-45).

Review of the complaint logs for the month of January 2011 revealed the patient # 1 complaint he verbalized to patient representative that he received his medication incorrectly was no logged on the facilities grievance logs. Interview with staff #2 on 03/29/2011 at 11:30 a.m., revealed the patient did complain to her that he received his medications incorrectly which resulted in him having a seizure and he had to be transferred to the emergency department at another local hospital. She stated she apologized to the patient and though he was satisfied. She stated she thought she logged the complaint on the complaint log but when requested to provide the log that listed this complaint she stated she was unable to locate it on the log.

Review of the patient satisfaction survey for patient # 1 on 03/29/2011, revealed the facility received the survey by the press grainy survey system on 03/02/2011 and they printed the copy on 03/03/2011.

Review of the complaint log for the month of March 2011 revealed the log did not contain follow up and resolution to a second complaint received via the press gainey system form patient # 1 by the time of the survey on March 29, 2011. Review of the facilities grievance policy on 03/29/2011, revealed the policy title " Patient and Customer Complaint/Grievance Policy effective 11/29/2010, stated in the section titled Issues verses Grievance, A patient issue is defined as concern that meets all of the following criteria. 1.0 Issues that can be immediately resolved by the staff (typically on the spot. 2. Issues is of minor nature ( i.e., change in bedding, housekeeping issues, room temperature, serving preferred food and beverages, noise level ). 3 Concern is not recurring and 4. States The patient / customer is satisfied with the actions taken "
The next section of the policy titled Customer Complaint / Grievance: states A complaint / Grievance are defined as an issue that meets any of the following criteria: 1. Complaint cannot be immediately resolved to the customer ' s satisfaction by the staff (includes unresolved or recurring minor concerns listed above in definition of customer issues, 2. Complaint / Grievance are of significant nature such as patient care and treatment issues. 3. Customer is not satisfied with previous actions taken. Page 3 states most complaints should be resolved within seven days, but for more complex issues, the maximum time frame for this communication must not exceed thirty days from the date of receipt of t he complaints. There was no evidence the facility followed its own policy on this potentially serious complaint at the time it received the original complaint or at the time it received the second complaint on its satisfaction survey. Page 4, 3. States the hospitals risk management will record the complaint / grievance on a patient complaint log.

Review of patient # 2 complaint follow up letter on 03/29/2011, revealed the facility receive the complaint on January 19, 2011 and the complaint resolution letter was dated February 18/, 2011. Review of the complaint log for February the complaint is not log to indicate why the complaint was not addressed in the first seven days as required by policy.

Review of all complaint logs for the facility for January -February 2011 there is no indication on the logs to indicate if the facility is meeting its 7 day goal in the resolution of the complaints as required. The resolution date is missing on all 42 entries made on the two logs provided to the surveyor for the month of February.

Interview with staff # 1 on 03/29/2011 at 2:30 p.m., confirmed she had not completed the investigation and had not sent the patient a letter concerning his grievance as required by regulation regarding the outcome of her investigation.