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Based on review of the grievance log, review of policy, review of grievance investigation and interview, it was determined there was no evidence each allegation of the complaint was investigated for two (#8 and #12) of three (#8, #11 and #12) patient grievances. The failed practice created the potential for missed opportunities to improve the quality of patient care. The failed practice had the potential to affect all submitted complaints or grievances. The findings were:

A. Review of the policy, ON008PC, Complaint and Grievance Process (Patient/Family) revealed "A record of the complaint/grievance, investigation and follow-up action to the patient/family/patient representative will be documented and retained in the Administrative office of the facility the complainant was located via the Complaint/Grievance Database."

B. Patient #8: 1) In an interview on 02/14/12 at 1614, the Chief of Guest Relations was questioned regarding the evidence of the exact grievance and investigation of the allegations concerning Patient #8. The Chief of Guest Relations stated the complaint dealt with a staff member being offensive, bruises, IV (intravenous) attempts, tourniquet and communication with the physician.
2) There was no evidence of the investigative action on how many attempts were made to start an IV or who the attempts were made by; the tourniquet being left on the patient's arm; the possible connection between the tourniquet, multiple IV sticks, and the left upper extremity causing the blood clots; whether the patient had bruises or not; and whether interviews were conducted with the nurse who was actually assigned and the nurse who came in to assist in starting the IV regarding the tourniquet and number of attempts to start the IV.

C. Patient #12: The complainant's allegation was the nurse was rude when patient needed assistance in getting to the bathroom. There was no evidence the allegations were investigated as to which nurse was involved in the allegation, what was going on in the Unit at the time of the allegation, and the conclusion of the investigation.

Based on clinical record review, policy review and interview, it was determined for three of three (#1, #2 and #6) patients selected for restraint use, the restraint was not included in the plan of care. The failed practice did not assure the use of the restraints was assessed on an ongoing basis and the plan of care modified when changes occurred. The failed practice affected Patient #1, #2 and #6 and all patients in which restraints were used. The findings were:

A. Review of the policy, "OC003PCS, Restraint Usage In Non-Behavioral Health Units" revealed the restraints were to be included in the patient's plan of care.

B. Patient #1: Review of the "Interdisciplinary Plan of Care" revealed the use of restraints was not addressed on the plan of care. In an interview on 02/14/12, the Nurse Manager of CCU (Critical Care Unit) confirmed the clinical record findings for Patient #1.

C. Patient #2: Review of the "Interdisciplinary Plan of Care" revealed the restraints were not addressed. In an interview on 02/14/12, the Nurse Manager of CCU confirmed the clinical record findings for Patient #2.

D. Patient #6: Review of the "Interdisciplinary Plan of Care" revealed
the use of restraints was not addressed. During an interview on 02/14/12 at 1300, the Nurse Manager of MICU (Medical Intensive Care Unit) confirmed the clinical record findings for Patient #6.

Based on clinical review, policy review and interview, it was determined for four (#3, #4, #6 and #8) of ten (#1-#10) patients the "Interdisciplinary Plan of Care" did not include measurable goals or address plans of care for respiratory difficulty, sedation, renal failure, hypothermia and a deep vein thromboses. The failed practice did not assure the plan of care was kept updated in accordance with the ongoing assessment of the patient. The failed practice had the potential to affect all patients admitted to the facility. The findings were:

A. Patient #3 had a diagnosis of COPD (chronic obstructive pulmonary disease). Review of the "Interdisciplinary Plan of Care" revealed difficulty breathing was checked as the need. Under "Desired Outcome/Goal", the RR (respiratory rate) goal and O2 (oxygen) Sat (saturation) goal was left blank. In an interview on 02/14/12 at 1109, the Nurse Manager of CCU confirmed the findings for Patient #3.

B. Patient #4 had a diagnosis of Pneumonia, CHF (Congestive Heart Rate), anemia, altered mental status, hypothermia and renal failure. Review of the "Interdisciplinary Plan of Care" revealed the renal failure and hypothermia was not addressed on the plan of care. In an interview on 02/14/12 at 1134, the Nurse Manager of CCU (Critical Care Unit) confirmed the findings for Patient #4.

C. Patient #6 Review of the "Interdisciplinary Plan of Care" revealed:
a) There was no goal established for the identified need of Cardiovascular/ CHF. On 02/09/12, the nursing staff did not fill in the blank for how often the patient was to be weighed.
b) The respiratory rate goal was WNL (within normal limits) for patient was identified for the need of inadequate oxygenation or ischemia. There was no evidence of what the patient's normal respiratory rate was.
c) The Propofol and Fentanyl was not addressed as the sedating medications. There was no guidance on what light and complete sedation meant. The Nurse Manager of MICU confirmed the clinical record findings for Patient #6.

D. Patient #8: Review of the "Interdisciplinary Plan of Care" revealed the left upper extremity deep vein thromboses was not addressed.