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Based on record review, and staff interview, the facility failed to ensure all patient records must document all nursing notes and other information necessary to monitor the patient's condition for one of 10 patients reviewed (Patient #2). The census was 122.

Findings include:

On 11/02/23 at 11:11 A.M. a review of the Grievance List for December 2022 revealed grievances were submitted on 01/27/23, 06/05/23, 07/10/23, and 07/27/23 concerning issues related to Patient #2 and events that took place between 12/13/22-12/18/22, and all were investigated and closed. A review of the conclusion of each grievance revealed multiple issues were addressed and no concerns were substantiated because of the hospital investigation, but multiple dictation documentation errors were noted/documented in the investigation conclusion packet.

On 11/06/23 at 1:17 P.M. an interview with Staff B and Staff D revealed there was unclear documentation concerning code status, but communication with the family was difficult.

On 11/07/23 at 11:53 A.M. an interview with Staff O and Staff A during Patient #2's medical record review revealed that on 12/13/22 there was no documentation supporting the hospital staff attempted to contact the patient's spouse who was listed as the next of kin. Further review and interview revealed a Registered Nurse attempted to call the patient's daughter at 6:00 A.M. on 12/15/22 and another Registered Nurse documented a physician attempted to call the daughter at 6:00 P.M. on 12/15/22. No other information was documented about the family being notified. An interview with Staff A, Staff D and Staff O revealed all three agreed that there should have been better documentation to clarify who specifically attempted to contact the patient's family instead of multiple staff members documenting someone else attempted to contact the family and whether or not they reached the family regarding the patient's changes in condition. Further interview revealed all three staff members believed the family was notified, but they could not confirm the family was notified based on the documentation provided in the medical record.

Based on record review, staff interview, and policy review, the facility failed to provide outpatient services that meet the needs of the patients for one of 10 patients reviewed (Patient #1). The census was 122.

Findings include:

On 11/06/23 at 2:40 P.M. a review of the discharge instructions provided for Patient #1 at the time of discharge after surgery on 09/14/23 revealed the signed discharge instructions instructed the patient to call the after-hours nurse hotline if he had concerns like pain. Further review of the email thread/discharge instructions and an interview with Staff D during the record review confirmed the patient's wife called the after-hours nurse line at 6:29 P.M. on 09/14/23 to report the patient was having post-surgical pain, but the nurse working the call line sent a message to the office for them to read the next day during business hours.

On 11/06/23 at 3:08 P.M. an interview with Staff M revealed patients were instructed to call the after-hours nursing line as described on the discharge instructions. She stated 6:29 P.M. would be considered after hours. Further interview confirmed that the nurse took a call after hours on 09/14/23 at 6:29 P.M., but she did not document the call, and did not follow the process for the after-hours call center policy.

On 11/07/23 at 9:52 A.M. a review of the policy titled, Memorial Health System Nurse Line, reviewed 08/26/21, revealed the nurse line is open to Marietta Memorial Hospital (as well as all Memorial Health System facilities) 24 hours per day. An interview with Staff D at the time of the policy review confirmed this was the policy that was not followed by the nurse working the call center. Further review of the policy revealed all triage calls were documented in the "NCentaurus" system with a report generating the electronic medical record. An interview with Staff D confirmed that the nurse did not document anything about the call. Further interview revealed there was an investigation completed on 11/07/23 and Staff M listened to the recording of the nurse and Patient #1's spouse discussing the patient having increased pain levels. Further interview with Staff D and a review of the investigation revealed all contact center nursing staff were educated and the policy was reviewed about documentation of all calls, and the situation involving the nurse was discussed after the surveyor identified the call was not documented, and the policy was not followed.

This deficiency represents non-compliance investigated under Substantial Allegation OH00146592.