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Based on review of facility documents and interview with staff (EMP), it was determined the facility faciled to provide timely resolution of grievances for one of two grievances reviewed.
Review of facility policy, Complaint and Grievance process, last revised October 1, 2017, revealed, " ... 9. The Director of Quality Management and/or Chief Nursing Officer will investigate the circumstances surrounding the concern or complaint and review the issues with the Hospital's CEO. The investigative procedure should be completed, corrective action taken and a written response sent within 7 days of receipt of complaint. If the grievance will not be resolved or the investigation completed within 7 days, the hospital shall inform the patient or the patient's representative that the hospital is still working to resolve the grievance and will follow-up with a written response in a stated number of days."
1. Review of facility documentation revealed the family of MR1 filed a grievance to the facility on June 24, 2018. Further review of facility documentation revealed a response was sent to the family on June 24, 2018 stating a complete written follow up letter will be sent by July 6, 2018. Further review revealed the complete written follow up letter was dated July 19, 2018.
2. Interview with EMP1 on September 11, at 10:30 AM confirmed the above findings.

Based on review of facility policy and interview with staff, it was determined the facility failed to specify training requirements for physicians and other licensed independent practitioners authorized to order restraints in the facility restraint policy.
Review of facility policy, Restraints and Seclusion, last reviewed, February 28, 2018, revealed no training requirement for physicians and other licensed independent practitioners.
Interview with EMP1 on September 12, 2018 at 0945 confirmed the policy does not address restraint training for physicians.