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Based on records review and interviews, the facility failed maintain the grievance log according to the facility's policy and procedure for 3 of 10 patients (Patient #1, 13, 16) reviewed from facility complaint/grievance log.

Findings included:
Review of the Mid Coast Health System policy and procedure titled, "Patient Complaint/Grievance Policy", effective 05/2022, revealed the following:
"POLICY: Grievance means an oral or written complaint that is not immediately resolved at the time of the complaint by the staff present.

"Processing a Grievance: ...
D. After the hospital receives a complaint/grievance, the CEO, Patient Advocate, and appropriate department manager will review the complaint to see if the issue can be quickly resolved;"
E. A letter will be sent to the patient/patient representative explaining the grievance process steps within seven working days.
F. The written notification will explain how the grievance will be resolved, describing each step in the process, the time frame for each step and the patient's rights or responsibilities at each step."

"Review Process - ....
C. If the complainant is satisfied at this level, the complaint/grievance and its resolution will be documented on the complaint log and the information will be available for internal performance opportunities for improvement."
D. ..... The hospital must maintain documentation of the efforts and demonstrate compliance with CMS requirements."

Patient ID#1
Record review of the facility's grievance and complaint log for the past year from December 2021 until November 9, 2022 revealed a white binder with tabbed sections organized by month provided by Staff ID #55. A printed copy of an email dated June 3, 2022, which was sent from Patient ID #1's family to Staff ID # 55 was located in June 2022 section. There was no date acknowledging receipt of the email, no documentation with printed email acknowledging who it had been sent to, no evidence of communication or dialogue/investigation or follow-up and no family communication.

Interview 11/9/22 2:50 p.m. with Staff ID #55 revealed she had forwarded that email to CEO, Staff ID #64.

Electronic communication 11/9/22 4:50 p.m. with Staff ID # 51 stated that CEO, Staff ID # 64 had called Patient ID #1 family to respond to the complaints/grievance he was forwarded. He stated that the family threatened an attorney. Staff ID #51 confirmed there was no documentation or log reflecting any follow-up in the case.

Patient ID #13
Record review of the facility's grievance and complaint log for the past year from December 2021 until November 9, 2022 revealed a white binder with tabbed sections organized by month provided by Staff ID #55. On 8/1/22 11:18 a.m., the log documents an email from Patient ID #13 family to Staff ID #55. 8/1/22 11:33 a.m., the email is forwarded to Nursing Director Staff ID #54. On 8/1/22 5:25 p.m., an email from Staff ID #54 to ED Medical Director Staff ID #65. There is no further information in the grievance or complaint log. There was no evidence of communication with family, no evidence of letter being sent to explain complaint/grievance process or timeline and no resolution documentation.

Interview 11/9/22 2:00 pm with CNO, Staff ID #51, she validated there was no documentation or evidence that a letter had been sent to the complainant detailing grievance process, no follow-up on the issue and no resolution for the complainant. She stated she would need to provide additional training to leadership on the requirements.

Patient ID #16
Record review of the facility's grievance and complaint log for the past year from December 2021 until November 9, 2022 revealed a white binder with tabbed sections organized by month provided by Staff ID #55. On 8/8/22, Patient ID #16 filed a grievance regarding care and treatment received by an ED provider. There was no facility documentation of the followup or resolution in the case.

Interview 11/9/22 2:15 pm with Nursing Director Staff ID #54, she stated she had called the patient. She stated she forwarded the physician complaint to the physician group. She verified there was no documentation of this process, no formal letters sent to the family per policy and there was no loop closure, documentation of follow-up in the case.

Based on interview and record review, the facility failed to follow its established grievance policy by failing to provide a patient/complainant with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion in 6 of 10 cases reviewed. [Patient IDs #1, 5, 8, 13, 14, 16].

Findings included:
Review of the Mid Coast Health System policy and procedure titled, "Patient Complaint/Grievance Policy", effective 05/2022, revealed the following:
"POLICY: Grievance means an oral or written complaint that is not immediately resolved at the time of the complaint by the staff present.

"Processing a Grievance: ...
D. After the hospital receives a complaint/grievance, the CEO, Patient Advocate, and appropriate department manager will review the complaint to see if the issue can be quickly resolved;"
E. A letter will be sent to the patient/patient representative explaining the grievance process steps within seven working days.
F. The written notification will explain how the grievance will be resolved, describing each step in the process, the time frame for each step and the patient's rights or responsibilities at each step."

"Review Process - ....
C. If the complainant is satisfied at this level, the complaint/grievance and its resolution will be documented on the complaint log and the information will be available for internal performance opportunities for improvement."
D. ..... The hospital must maintain documentation of the efforts and demonstrate compliance with CMS requirements."

Record review of the facility's grievance and complaint log for the past year from December 2021 until November 9, 2022 revealed a white binder with tabbed sections organized by month provided by Staff ID #55. There were no copies of letters or communications with complainants for Patient ID 1, 5, 8, 13, 14, and 16.

Interview 11/9/22 at 2:00 p.m. with CNO, Staff ID #51 confirmed there were no letters sent to Patient ID# 1, 5, 8, 13, 14 and 16. She reviewed the facility complaint/grievance policy and confirmed they should have been sent and recorded/documented.

Based on record review and interviews, the nursing staff failed to provide accurate nutritional risk assessments and implement nutrition consults for 3 of 6 patients who were admitted to the facility. (Patient ID #1, 11, 12)

Findings Included:
A. Patient ID #1: Nursing staff failed to provide intervention/initiate dietitian consultation for patient #1 who was admitted on 9/5/22 with a pressure ulcer, dysphagia with feeding tube dependent nutrition status and a low albumin of 2.8. The patients nutritional risk score was documented as a 10 and the electronic medical record stated "8-11 points: at risk of malnutrition - Dietary consult."

B. Patient ID # 11: Nursing staff failed to provide intervention/initiate dietitian consultation for patient #11 who was admitted 8/7/22 with nutrition risk score of 10. The electronic medical record stated "8-11 points: at risk of malnutrition - Dietary consult." The record stated consult was "deferred" with no explanation.

C. Patient ID #12: Nursing staff failed to provide intervention/initiate dietitian consultation for patient #12 who was admitted 9/26/22 with an active infection, was malnourished with a weight loss down to 122 pounds and a low albumin of 2.7.

Record review of Mid Coast Health System "Nutritionally at Risk Patients - Assessment and Dietary Referral", effective 02/2022, was performed. The policy stated "All patients will have nutritional screen done upon admission. 1. The nutritional at risk indicators are but not limited to: a: dysphagia, b. N/V/diarrhea > 5 days, d. 2nd surgery within 3 months, e. Poor appetite/intake for > 5 days, f. TPN/NG Tube, g. Presence of skin breakdown, h. Albumin below 3.0. The Procedure stated "3. If the assessment reveals the patient is at nutritional risk, notify the Dietitian of Nutrition screening. A. If it is during the might shift, this can be done just before leaving your shift in the morning. 4. Document in the EMR that the dietitian was notified of Nutrition Screen."

Record review of Dietitian consultation list for August and September 2022, provided by Dietitian, Staff ID # 56, failed to identify Patient ID #1, 11 and 12 on the consultation completed list.

Interview the Director of Quality Staff ID #52 confirmed that there should have been nutrition consults on Patient ID #1, 11 and 12 but there was no consult call to the dietitian made by staff nurses based on documentation.

Based on interview and record review, the facility's nursing staff failed to implement an accurate nursing care plan and follow patient's dietary orders for 1 of 6 patients reviewed (Patient ID # 1)

Findings:
Record review revealed that Patient ID #1 had orders placed by Physician Staff ID #62 which stated "1 can Ensure Plus TID (9-1-5). Record review revealed that CNA ID #58 documented 9/5/22 18:04 a "CNA Patient Care Flowchart" entry which stated "Nutrition: Dinner 75%" for Patient ID #1. Medical record entry on 9/5/22 19:29 by Staff RN #57 stated "per report by day shift, pt had received a tray of food and ate, however pt has peg tube and does not normally eat PO solid foods. On assessment pt is gurgling and belching, no distress noted, however daughter is in room and is concerned about risk of aspiration. HOB elevated and RT is in room assessing pt."

Interview with Director of Quality, Staff ID # 52 on 11/9/22 at 11:25 a.m., validated that it is expected that all patients have a nursing care plan which is based on physician orders for a therapeutic diet. She confirmed that it would be facility standard of care to obtain a physician order for an oral diet.

Based on record review and interviews, the facility failed to accurately assess and provide nutritional consultation to 4 of 6 sampled patients at risk for nutritional compromise (Patient ID #1, 3, 11, 12).

A. There was no dietitian consultation ordered or completed for patient ID #1 who was admitted on 9/5/22 with a pressure ulcer, dysphagia with feeding tube dependent nutrition status and a low albumin of 2.8. The patients nutritional risk score was documented as a 10 and the electronic medical record stated "8-11 points: at risk of malnutrition - Dietary consult."

B. There was no dietitian consultation ordered or completed for patient ID #3 for who was a current inpatient with multiple sclerosis, a tunneled wound and was on NPO (nothing by mouth) diet status due to pancreatitis.

C. There was no dietitian consultation ordered or completed for patient ID #11 who was admitted 8/7/22 with nutrition risk score of 10. The electronic medical record stated "8-11 points: at risk of malnutrition - Dietary consult." The record stated consult was "deferred" with no explanation.

D. There was no dietitian consultation ordered or completed for patient ID #12 who was admitted 9/26/22 with an active infection, was malnourished with a weight loss down to 122 pounds and a low albumin of 2.7.

Record review of Mid Coast Health System "Nutritionally at Risk Patients - Assessment and Dietary Referral", effective 02/2022, was performed. The policy stated "All patients will have nutritional screen done upon admission. 1. The nutritional at risk indicators are but not limited to: a: dysphagia, b. N/V/diarrhea > 5 days, d. 2nd surgery within 3 months, e. Poor appetite/intake for > 5 days, f. TPN/NG Tube, g. Presence of skin breakdown, h. Albumin below 3.0. The Procedure stated "3. If the assessment reveals the patient is at nutritional risk, notify the Dietitian of Nutrition screening. A. If it is during the night shift, this can be done just before leaving your shift in the morning. 4. Document in the EMR that the dietitian was notified of Nutrition Screen."

Record review of Dietitian consultation list for August and September 2022, provided by Dietitian, Staff ID # 56, failed to identify Patient ID #1, 11 and 12 on the list of completed dietary consults.

Interview 11/9/22 11:25 am with the Director of Quality Staff ID #52 confirmed that there should have been nutrition consults on Patient ID #1, 3, 11 and 12 but there was no consult call to the dietitian made by staff nurses based on documentation.

Interview 11/9/22 11:00 am with Staff Physician ID #62 regarding Patient ID #3, revealed the patient was NPO with acute pancreatitis, multiple sclerosis and a chronic tunneled wound. There was no dietitian consult ordered or in progress for Patient ID #3.