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Based on review of facility policies and procedures, Patient' Rights information, and Patient Information Handbook, it was determined that the facility failed to notify patients and their representatives of how to file a grievance with the state agency.

Findings were:

Review of facility policy, entitled Customer Complaints and Grievance Process, Policy # 1019.00, revised 12-20-09, revealed on page 3 that all patient complaints/grievances brought to the facility's attention from any source, including patients, families, staff, and outside agencies, would be investigated. Statement #6 on page 4 of the policy indicated that for complaints/grievances that could not be resolved promptly, an initial response would be provided within seven (7) working days. Further review of the policy failed to reveal that the address of the state agency to contact to file a complaint/grievance would be provided to the patient/complainant.

Review of information given to the patient/patient's family, entitled Patient's Rights, failed to include the address or phone number to contact the state agency to file a complaint/grievance. Upon admission, patients also received a Patient Information Handbook. On page 13 of the handbook, the complaint procedure was written, but no information was provided as to how the patient could file a complaint/grievance with the state agency.

Based on review of facility policies and procedures, facility reports, staff interviews, and staff statement, it was determined that the facility failed to respond to a complaint regarding a patient's care.

Findings were:

Review of facility policy, entitled Customer Complaints and Grievance Process, Policy # 1019.00, revised 12-20-09, revealed on page 3 that all patient complaints/grievances brought to the facility's attention from any source, including patients, families, staff, and outside agencies, would be investigated. Statement #6 on page 4 of the policy indicated that for complaints/grievances that could not be resolved promptly, an initial response would be provided within seven (7) working days. Further review of the policy failed to reveal that the address of the state agency to contact to file a complaint/grievance would be provided to the patient/complainant.

Review of information given to the patient/patient's family, entitled Patient's Rights, failed to include the address or phone number to contact the state agency to file a complaint/grievance. Upon admission, patients also received a Patient Information Handbook. On page 13 of the handbook, the complaint procedure was written, but no information was provided as to how the patient could file a complaint/grievance with the state agency. The information did indicate that once a concern was received, the review process would begin immediately. The handbook further noted that for complaints/grievances not resolved promptly, an initial written response would be provided within 7 working days and for complaints that were complicated and required extensive investigation, a follow-up response would be provided.

Review of the facility's Risk Occurrence report indicated that the patient advocate had spoken with patient #4's adult child regarding complaints and concerns one day before the patient died. According to the documentation, the adult child voiced concerns regarding the care and management of the patient. No further documentation or follow-up letter was documented on the log.

During an interview at 1:42 p.m. on 10/13/2010 in the facility's conference room, the Patient Advocate (employee #5) stated that he/she had spoken with patient #4's adult child concerning the care of the patient. The Patient Advocate stated that Guest Relations made the determination of who would receive a copy of a complaint/grievance investigation, and that only the patient or patient representative would receive a copy of the investigation, regardless of who filed the complaint.

Review of a written statement submitted by the Quality Improvement Coordinator (employee #8) indicated that patient #4's adult child verbalized concern regarding the care of the patient and that this information was shared with the patient's spouse. According to the written statement, since the patient's spouse did not have any issues with the care that was being rendered and did not have a grievance, the facility did not provide a follow-up response to the patient's adult child.