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Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure prompt resolution of patient complaints/grievances for one (1) of ten (10) sampled patients (Patient #1) after the patient's family complained that Patient #1 had not received a bath for a week and the patient had skin breakdown as a result of not being bathed. The facility's Patient Representative met with Patient #1's family regarding the family's concerns on 10/06/14; however, the facility failed to conduct an investigation, failed to enter the complaint into their computer system and failed to provide a written notice (response) to the family regarding steps taken to resolve the complaint as required by the facility's policy.

The findings include:

Review of the facility policy titled "Customer Complaint/Grievance Process," revealed the facility had guidelines for protecting and promoting the rights of each patient by documenting and trending patient complaints/grievances, and instituting corrective action. According to the policy, complaints were categorized as a concern or a formal complaint. A concern was defined as a complaint that could be resolved by staff at the time of notification of the incident and did not require a written response; for example, the need for a bedding change, housekeeping needs, or dietary needs. Those examples were addressed and resolved by staff using the service recovery program "REACT." Concerns did not require a resolution letter, but an acknowledgement letter was required to be sent by the Patient Representative, by mail, to the patient or their representative, within two business days of receiving the concern and documented in the database informing them their concern was being communicated to and addressed by the appropriate parties. Further review of the policy revealed formal complaints were defined as a complaint/grievance that the patient or their representative wished an investigation be initiated for and the findings of the investigation communicated to the complainant.

Review of facility protocol titled "Chlorhexidine (CHG) Cloth Bathing," undated, revealed facility staff was required to bathe patients in critical care units daily.

Medical record review revealed the facility admitted Patient #1 to the Critical Care Unit (CCU) on 09/25/14 with diagnoses that included Pneumonia. Patient #1 was transferred to the Cardiac Vascular Unit (CVU) on 09/28/14. Review of the nursing notes revealed no evidence that staff bathed Patient #1 on 09/28/14, 10/01/14, and 10/02/14 per facility policy/protocol and there was no documented skin breakdown.

Interview with Patient #1's family member on 10/14/14 at 1:30 PM revealed she voiced a complaint to the facility regarding the family's concerns that Patient #1 had skin breakdown as a result of staff not bathing the patient. The family member stated that on 10/05/14, she spoke with Registered Nurse (RN) #1, the nurse who was responsible for Patient #1's care, and told the RN of her concerns. The family member stated the facility did nothing to resolve any of the family's concerns/complaints. Patient #1's family member stated RN #1 gave patient #1 a bath after the family member made the complaint and stated that RN #1 delivered a fruit basket to the family as a gift. However, Patient #1's family member stated, "but the fruit basket did not heal the bed sores," and the fruit basket did not solve the family's concern/complaint. The family member stated the facility Patient Representative also spoke with the family about their concerns on 10/06/14 but there was no resolution made regarding the family's concern/complaint.

Review of the facility's Actions Taken in Response to a Service Breakdown "REACT" revealed a form dated 10/05/14 on which RN #1 documented Patient #1's family complained that Patient #1 had not received a bath; however, there was no documentation that the patient's family alleged the patient had skin breakdown as a result of not being bathed. Further review of the form revealed RN #1 documented that a follow-up with the wife was conducted and a time was established for Patient #1 to receive a bath; however, there was no documentation that the complainant was satisfied with the actions taken.

On 10/14/14 at 3:00 PM, an interview was conducted with RN #1, who provided care for Patient #1 on 10/05/14. RN #1 stated Patient #1's family told the RN that the patient had not been bathed in a week and that the patient had a reddened area around his/her groin area. RN #1 stated she bathed the patient and provided a fruit basket to the family as a gift "to help make it right." RN #1 stated the family's complaint was forwarded to the House Patient Care Manager (HPCM) and Patient Representative and the Wound Care Nurse was consulted for the reddened area. RN #1 gave no explanation why the skin breakdown was not addressed on the REACT form. RN #1 further stated she thought the family's concern/complaint was resolved.

Review of the facility's investigation log revealed the facility failed to provide documentation that verified the facility conducted a family meeting regarding Patient #1's care to resolve the family's complaint. In addition, the facility failed to follow up with a written notice to the patient's family regarding actions taken to resolve the complaint.

Interview with the Patient Representative on 10/14/14 at 11:20 AM revealed the Patient Representative met with Patient #1's family on 10/06/14 and told the family they could file a formal complaint; however, the Patient Representative stated the family member did not file a formal written complaint. The Patient Representative stated she spoke with the family member about their concern, but did not enter the concern as a complaint. The Patient Representative stated since the complaint was not logged into the system as a "formal complaint," a written response was not sent to the family regarding their complaint and there was no facility investigation conducted.

Based on interview, record review, and review of the facility's policies/protocols, it was determined the facility failed to bathe three (3) of ten (10) sampled patients (Patients #1, #2, and #8) daily as required by the facility's protocol.

The findings include:

Review of facility protocol titled "Chlorhexidine (CHG) Cloth Bathing," undated, revealed facility staff was required to bathe patients in critical care units daily.

1. Medical record review revealed the facility admitted Patient #1 to the Critical Care Unit (CCU) on 09/25/14 with diagnoses that included Pneumonia. The facility transferred Patient #1 to the Cardiac Vascular Unit (CVU) on 09/28/14. Review of the nursing notes dated 09/28/14 through 10/08/14 revealed no evidence that staff bathed Patient #1 on 09/28/14, 10/01/14, or 10/02/14.

Interview with Patient #1's family member on 10/14/14 at 1:30 PM revealed she made a formal complaint to hospital staff on 10/05/14. The family member stated she told Registered Nurse (RN) #1 that Patient #1 had not been bathed for a week and that the patient had a raw area around the groin that was discovered on 10/05/14, when a family member bathed the patient.

On 10/14/14 at 3:00 PM, an interview was conducted with RN #1, who provided care for Patient #1 on 10/05/14. RN #1 stated the family complained that Patient #1 had not been bathed for a week and the RN bathed the patient. RN #1 stated she had not cared for the patient prior to 10/05/14 and did not know why staff had not bathed the patient. RN #1 stated the Wound Care Nurse was consulted regarding patient #1's reddened groin area.

A telephone interview was conducted on 10/15/14 at 8:45 AM with the House Patient Care Manager (HPCM) who stated she received a complaint on 10/05/14 that Patient #1 had not received a bath for four days. The HPCM stated the medical record was reviewed and there was no evidence the patient had received a bath for three days. The HPCM gave no explanation why the patient had not been bathed daily per protocol. The HPCM stated the Wound Care Nurse was consulted regarding Patient #1's reddened groin area. The HPCM did not know if the reddened groin area was the result of staff's failure to bath the patient daily.

2. Medical record review for Patient #2 revealed the facility admitted Patient #2 on 10/06/14 with diagnoses that included Cerebral Vascular Accident (stroke). Further review of the medical record revealed no evidence that staff bathed Patient #2 on 10/07/14 and 10/08/14 per facility policy/protocol.

3. Medical record review for Patient #8 revealed the facility admitted Patient #8 on 10/05/14 with diagnoses that included Pneumonia. Further review of the medical record revealed no evidence that staff bathed Patient #8 on 10/09/14, 10/10/14, and 10/13/14 per facility policy/protocol.

Staff interviews with CNA #1 on 10/16/14 at 11:00 AM, CNA #2 on 10/16/14 at 11:50 AM, CNA #3 on 10/16/14 at 2:20 PM, and CNA #4 on 10/16/14 at 2:20 PM revealed all staff had been trained on the facility protocols for bathing. Staff gave no explanation why baths had not been provided and/or documented for Patients #1, #2, and #8.