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Based on medical recod reviews and staff interview, the facility failed to establish a process for prompt resolution of patient grievances for one of four patients (Patient #1).

The findings include:

Patient #1 was admitted to the facility on 8/29/10. Per the facility triage form, the presenting problems for this patient was depression and not eating. Per the psychiatric evaluation, dated on 8/29/10, the patient recently moved to the area from out of state. The record reflected the patient had been on disability for 11 years secondary to mental health issues. The patient denied any history of mental illness, had recently lost 20 pounds, had a history of gastro-esophygeal reflux disease (GERD), denied suicidal and or homicidal ideations and had delusions of grandiosity. Past psychiatric history stated the patient had two past hospitalizations, one in September 2009 and another in 1994, for mental health issues, undefined. The record continued to state the patient appeared guarded when discussing the mental health history.

On evaluation, the mood was depressed, weight 140 pounds, 5' 10 inches. Grooming and hygiene were compromised, memory intact, thought process full of delusions and grandiosity. Provisional diagnoses include, 1. Psychosis, NOS, 2. Rule out schizophrenia, paranoid type, 3. Major depressive disorder with psychotic features, Barretts esophygus, diverticulitis and GERD. Initial nursing assessment stated the patient was alert and oriented, anxious and an interim care plan was developed, which was appropriate for patient need.

The day after admit on 8/30/10, the patient was visited by the registered dietician secondary to the patient claim of losing approximately 30 pounds in one month due to anxiety, reports obsessive compulsive disorders regarding food, he/ she also reported past medical history of borderline diabetes mellitus, diverticulitis. The dietician note reflected that the patient was 82% of body mass index, estimated nutritional needs were 2000-2400 kcal diet, soft diet, boost or ensure three times per day, weigh patient weekly and monitor blood sugar.

On this same date, the record reflected that the patient wrote the following statement on the Community Meeting Goal Sheet, "This program is fraud, advertised as an eating disorder clinic, where ....(ended) ...call government officials immediately now. "

The grievance log was reviewed at 12:00pm, and it was noted there was no entry in the log of this patient's complaint or grievance.

The Patient Advocate was interviewed at 2:00pm regarding this patient's verbal complaint and written grievance. Per the Patient Advocate, she/he was not aware of this patient's dissatisfaction with the facility. She agreed that staff should have contacted her about this patient's verbalization of dissatisfaction and written grievance.

The Patients Rights Form was reviewed for facility process of responding to patient grievances. Per the policy, the complaint process shall be verbally explained during the orientation process and provided in writing in a language and terminology that the person receiving can understand. Any staff person receiving an informal or formal complaint dealing with life-safety issues will take immediate action to resolve the matter .

Per the form, informal complaints are initial complaints that are usually made verbally by a person receiving services or by an individual acting on his or her behalf. If resolution cannot be mutually agreed upon, a formal written complaint may be initiated. The complaint shall include the date and time of the complaint and detail the issue and the remedy sought. All formal complaints shall be forwarded to the staff person or designee, who is assigned to track and monitor formal complaints. All formal complaints shall be tracked and monitored for compliance. A written response must be given or mailed to the person receiving services within 24 hours of disposition. The individual acting on the behalf fo the perosn receiving services shall be notified of the completion fo the investigation but will not be given specific details of the disposition unless they have the legal right to the information or a signed release for information in its place.

The facility Client/Patient Advocacy Program Policy was reviewed. Per the policy, the Patient Advocate ensures a copy of client/patient rights statement is posted on the unit; in a community area. The Patient Advocate also provides and maintains free access to the client/patient advocacy forms or the representative and reviews received advocate forms daily during the week, enters into log with date and makes a copy and forwards to all applicable department managers for review the same day as received.

The department manager then signs and reviews all forms daily, and within 2 days discusses the issue with the client, family or guardian. Upon resolution, the patient shall sign the form as resolved and return the form to the Patient Advocate within 2 days. If resolutionis not met within 2 days, the department manager forwards the grievance form to the Patient Advocate for an internal hearing to be scheduled within 2 days. The policy does not address the definition of a grievance and or complaint.

The Performance Improvement Coordinator, was interviewed at 3:05pm regarding the facility defintion of a complaint versus a grievance. She agreed the facility does not define a complaint or a grievance, and this does not meet the standard. She then was asked about Patient #1's written and verbally voiced complaints. She agreed that the Patient Advocate should have been notified of the grievance and responded to the patient.