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Based on policy review, document review, and interview, the hospital failed to have a grievance listed on its grievance log in accordance with hospital policy for one of one grievance reviewed (Patient 1). This failure had the potential to affect all patients receiving services at this hospital.

Findings Include:

Review of the policy titled "Patient and Customer Complaint or Grievance," effective 08/26/20, indicated ". . . All grievances must be recorded in the hospital grievance log. The entry into the log must include: date received nature of grievance who responded action(s) taken date of final written response (and initial response, if necessary) . . ."

Review of the "Grievance Log," presented by the Administrator when a request was made to view the grievances from 01/01/21 to 07/26/21, showed there was not a grievance listed regarding Patient 1.

Review of documentation presented by the Administrator showed Patient 1's daughter submitted a grievance to Former Associate Administrator (FAA) on 01/06/21 at 10:15 AM.

During an interview on 07/26/21 at 12:12 PM, the Administrator verified there was not a grievance involving Patient 1 on the grievance log. The Administrator stated there was an error in not having Patient 1 added to the grievance log.

Based on policy review, medical record review, and interviews, the hospital failed to ensure patients had the right to participate in implementing their plan of care. The hospital failed to inform patients of the physician he/she was scheduled to see for outside hospital appointments to determine if the patient was willing to see that physician or to ask the patient which physician the patient would like to see. This failure was evident for two of six patients with scheduled appointments outside the hospital (Patients 1 and 2). This failure had the potential to affect all current inpatients and any future patients admitted to the hospital.

Findings Include:

Review of the policy titled, "Informed Consent," effective 12/02/20, showed ". . . The patient has the right to participate in decisions involving his/her health care, including collaboration with his/her physician in making these decisions. The following forms will be used to memorialize consent: 1. Consent to Treat and Conditions of Admission . . ."

Review of the policy titled, "Patient Rights and Responsibilities," effective 11/20/19, showed ". . . It is the policy of the hospital to at all times, and in accordance with applicable state and federal laws and regulations, observe and respect a patient's rights and responsibilities without regard to age, race, color, gender, national origin, religion, culture, physical or mental disability, personal values, or belief systems. . . All patients will be informed of their rights in a manner he/she can understand. The full Patients [sic] Rights and Responsibilities shall be provided upon admission as part of the admission paperwork."

Review of the undated "Patient rights and responsibilities," the list of rights and responsibilities included in the paperwork presented to each patient at admission, indicated the list included the right to ". . . Be informed if the hospital has authorized other healthcare and/or educational institutions to participate in the patient's treatment. The patient shall also have a right to know the identity and function of these institutions and may refuse to allow their participation in his or her treatment. . . Participate in the care that you receive in the hospital. Receive reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of the persons providing the care. . ."

1. Review of Patient 1's electronic medical record (EMR), showed Patient 1 was admitted on 12/24/21 and discharged on 01/09/21 with a diagnosis of critical illness myopathy.

Review of Patient 1's physician orders showed an order on 01/05/21 at 7:41 AM from Physician (MD) 1 that read "please work with nurse supervisor [name of nurse supervisor] to contact her vascular surgeon at [Hospital A]."

Review of Patient 1's "Progress Notes" documented by MD1 on 01/05/21 at 7:50 AM, showed, ". . . discussed with nurse supervisor to contact patients vascular surgeon today concerning the arterial doppler results which showed monophasic flow [ characterized by presenting a unique antegrade deflection with a decrease or absence of the other two components of the triphasic spectrum due to the decrease in the peripheral vascular resistance] of the left SFA [superficial femoral artery] thru [sic] ankles. . ." There was no documentation by MD 1 of the name of Patient 1's vascular surgeon.

Review of the documentation of the investigation of the grievance submitted by Patient 1's daughter related to Patient 1 not being informed that she was not scheduled to see her vascular surgeon showed, ". . . NM 2 stated that they called the [Hospital A] office vascular surgery group and there was no availability, but got the patient in for an appointment at another location within the same group (in St. Joseph, MO [Missouri]). . ." Further review of the investigation showed documentation by Registered Nurse (RN) 1 that included ". . . this writer explained to patient where the appointment was, why [MD1] wanted her to be seen by vascular surgeon, what time it would be at, and when she was leaving. . ."

There was no documentation in Patient 1's EMR that indicated MD 1 or RN 1 discussed with Patient 1 that her requested vascular surgeon was not available to determine if she was willing to see the other vascular surgeon physician at Hospital A.

During an interview on 07/26/21 at 2:15 PM, NM 2 stated she did report to Former Associate Administrator (FFA) during FAA's investigation of the complaint that RN 3 had attempted to make the appointment with Patient 1's vascular surgeon who was not available that day and that the appointment was made with another vascular surgeon in the same medical practice group as Patient 1's vascular surgeon. NM 2 confirmed there was no documentation in Patient 1's EMR that Patient 1 was informed that the physician Patient 1 was scheduled to see was not the vascular surgeon Patient 1 had requested to see.


2. Review of Patient 2's EMR showed physician orders by MD 1, for a urology appointment on 07/22/21 at 11:30 AM and a cardiology appointment on 07/26/21 at 2:15 PM.

Review of Patient 2's EMR showed the urology and cardiology appointments were made by the hospital from which Patient 2 was transferred prior to his admission to this hospital.

There was no documentation in Patient 2's EMR that showed MD 1 or any nurse discussed the physicians Patient 2 would be seeing for his urology and cardiology appointments to determine if Patient 2 was aware and agreed to see these physicians.

During an interview on 07/28/21 at 9:00 AM, Patient 2 stated neither MD 1 nor the nursing staff spoke with Patient 2 about who Patient 2 would be seeing for the cardiology and urology appointments. Patient 2 stated that he was not satisfied with the physician Patient 2 saw for cardiology. Patient 2 stated the cardiologist was "not very good."

During an interview on 07/28/21 at 9:12 AM, NM 1 stated Patient 2's cardiology and urology appointments were made by the transferring hospital prior to Patient 2's admission. NM 1 stated, after reviewing the EMR, there was no documentation that a discussion with MD 1 or the nursing staff had been held with Patient 2 regarding the physicians Patient 2 would be seeing for the scheduled outside appointments. NM 1 stated the unit secretary speaks with the patient about appointments that are scheduled, but the unit secretary does not document in the medical record. NM 1 stated the nursing staff should be speaking with patients about the physicians they are scheduled to see on outside appointments, so the patient can be involved in their plan of care.

Based on policy review, medical record review, document review, and interviews, the hospital failed to ensure patients were free from neglect for one of 11 patient records reviewed (Patient 1) for neglect. The hospital failed to transfer Patient 1, who required a mechanical lift for transfers, to bed for 50 minutes after requested. This failure had the potential to affect the four current inpatients who required a mechanical lift for transfer and any future patient admitted to the hospital that required a mechanical lift for transfers.

Findings Include:

Review of the policy titled, "Allegations of Abuse/Neglect," effective 05/22/19, indicated neglect was defined as "Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. . ."

Review of Patient 1's "DC [discharge] Info/Summary," documented by MD 1 on 01/07/21 at 1:19 PM showed Patient 1 was "totally dependent for lower body dressing as well as toilet hygiene and toilet transfer. Substantial maximal assistance for shower and bathing herself, totally dependent for tub and shower transfer and bed to chair transfer as well as using a wheelchair at 150 feet. . ."

Review of Patient 1's "Outside service / Scheduled / Urgent appointment form," documented on 01/05/21 at 11:30 AM by Registered Nurse (RN) 3, showed Patient 1 was picked up for the appointment with the vascular surgeon on 01/05/21 at 1:45 PM.

Review of "Progress Notes," documented by RN 1 on 01/05/21 at 6:58 PM showed, "Patient still not back from appointment, facility called here to let us know that transport to get there at 5:30 PM and she would be on her way back. Appointment was in St. Joseph, MO [Missouri]. Family aware. Dinner left in room for patient when she gets back. . ."

There was no documentation in the EMR of the time that Patient 1 returned to the hospital from the medical appointment and the time Patient 1 was transferred to bed on 01/05/21.

Review of the documentation of the investigation of the grievance submitted by Patient 1's daughter related to Patient 1 not being transferred to bed for 50 minutes after requesting to return to bed and after having been in a wheelchair since she left for a medical appointment on 01/05/21 at 1:45 PM, showed the transport company reported that Patient 1 was back at the hospital by 7:10 PM on 01/05/21.

Review of the documentation of an interview conducted by NM 2 with RN 2, that was submitted as part of the hospital's investigation of the grievance, showed RN 2 stated Patient 1 ". . . was tired after having sat in the wheelchair the whole day . . . [RN2] offered to put her in bed but the patient said she wanted to eat first and would call when she was through. . . [RN2] says, [Nurse Technician (NT) 1] found her about an hour later and told her the patient was ready for bed. When she was finished with what she was doing, [NT 1] was busy helping someone else . . . they helped the patient to bed sometime after 2100 [9:00 PM] . . ."

Review of the "2 South Assignment Sheet," presented by the Administrator when a request was made to review the staffing for the night shift (7:00 PM on 01/05/21 to 7:00 AM on 01/06/21) on 01/05/21, showed the unit that Patient 1 was on had 16 patients. RN 2 and NT 1 were assigned eight patients. Four of the eight patients had an acuity level of three (highest acuity level), three patients were at acuity level two, and one patient was at acuity level one. Two of the eight assigned patients required assistance with transfer, and one of the two required the assistance of two staff to transfer with the mechanical lift. Four of the eight assigned patients required assistance for one-to-one feeding.

During an interview on 07/26/21 at 2:15 PM, NM 2 stated NT 1 was ready to transfer Patient 1, but two staff were needed to transfer with the mechanical lift. NM 2 stated she spoke with the staff, because RN2 should have found NT 1 to attend to Patient 1, since Patient 1 had been up all day. NM 2 stated when RN 2 saw that NT 1 was busy when RN 2 became free, RN 2 didn't go to the patient to explain the delay and rather went to care for another patient which contributed to the communication breakdown.

During a telephone interview on 07/27/21 at 12:43 PM, NT 1 stated that NT 1 was interviewed by NM 2 after the grievance was submitted on 01/06/21. NT 1 reported that Patient 1 didn't return to bed until about 9:30 PM. NT 1 stated the other nurse technician and RN on the unit besides RN 2 and NT 1 were also busy when Patient 1 called to return to bed. NT 1 stated two RNs and two NTs was the usual staffing on the night shift, but "at times we're understaffed." NT 1 stated NT 1 meant they have a high acuity of patients. NT 1 stated sometimes "we have 10 patients and may be in a patient's room for about 15 even 30 minutes." NT 1 stated for them to find another available staff member is difficult sometimes. NT 1 stated the time of shift change starts about 7:15 PM to 7:30 PM, and "we have to follow the nurse to get report on each patient [means they go room-to-room with the nurse]." NT 1 stated that can take about 15 to 30 minutes, and sometimes after that they have to get a call light and touch base with the nurse later. When asked by the surveyor if NT 1 was saying the staff present is not enough on the night shift to provide care for the number and acuity of patients present, NT 1 stated "yes." NT 1 stated it's "not the norm" to have to wait for a patient to be transferred, but Patient 1 had to wait, because it required two staff to transfer her with the mechanical lift. NT 1 stated Patient 1 did complain to her about having to wait to be put to bed, and NT 1 stated NT 1 again informed Patient 1 that NT 1 had to wait for someone to help NT 1 transfer with the lift.

During an interview on 07/27/21 at 1:00 PM, the Administrator stated the staffing usually included two RNs and two NTs on the night shift. The Administrator offered no explanation to explain whether increased staffing could have alleviated Patient 1 from having to wait 50 minutes to return to bed once Patient 1 requested to do so. The Administrator confirmed the hospital's policy defined neglect as the ". . . failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Administrator, when asked if Patient 1's having to wait 50 minutes to return to bed after having been in Patient 1's wheelchair for approximately seven hours and 45 minutes would be considered neglect, the Administrator paused and didn't offer a response.