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Based on record review and interview, the hospital failed to follow its policy and procedure for grievances as evidenced by failing to properly identify a grievance and failing to inform a patient of any resolution to their grievance per hospital policy and procedure for 1 (Patient #1) of 3 patients (Patient #1, 3, 4) reviewed for complaints/grievances in a total sample of 4.
Findings:

Review of the hospital policy and procedure titled, Patient Grievance Management (no date), revealed in part that when a patient or family member express a concern or issue to a staff member, the staff member will attempt to promptly resolve the issue as soon as possible. When an issue cannot be promptly resolved, the Patient and Provider Advocacy representative will initiate the grievance process. The Patient and Provider Advocacy Department will send out an initial letter to the patient within 7 business days confirming receipt of the grievance and explaining the grievance process. A written resolution letter will be sent to the patient that addresses the substance of each compliant made. All grievances should be closed within 30 business days.

Review of the patient complaint log, provided by S1Compliance, revealed that Patient #1's daughter filed a complaint on 04/12/2024 (no time) to S2Patient Advocate. Review of the complaint report revealed that the patient's daughter had concerns regarding: dressings not being changed, patient not being turned often enough, patient having a fall due to staff shortage and family not being notified, bad attitude of a staff member, and an IV being pulled out of the patient's arm.

Further review of the complaint report revealed that on 04/12/2023 at 8:50 a.m., S2Patient Advocate met with the nursing supervisors on the floor the patient was on and verbally shared information regarding the daughter's concerns and requested review, follow-up and feedback. The report further stated that on 04/12/2024 at 11:18 a.m., the nursing supervisor contacted the Patient #1's daughter and discussed the patient's fall and dressing changes. There was no documented evidence that the other issues were addressed.

There was no documented evidence that the complaints made by Patient #1's daughter were treated as a grievance, per the hospital's grievance policy and procedure. There was no evidence that an initial letter was sent to the patient's daughter within 7 days or that a written letter was sent to the patient's daughter upon resolution.

On 05/21/2024 at 9:45 a.m., interview with S3Patient Advocate revealed that due to the complexity of the complaints made by Patient #1's daughter, it should have been treated as a grievance. S3Patient Advocate stated that a thorough investigation should have been completed and letters (initial and resolution) should have been sent to the patient's daughter. S3Patient Advocate confirmed that the grievance procedure was not followed.

Based on record review, observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the side rails of 36 of 36 patient beds on the 4th floor medical/surgical unit.
Findings:

Review of the patient complaint log revealed that on 05/15/2024 at 12:03 p.m., Patient #4's daughter complained about staff not answering the call light. Review of the complaint report revealed that the patient's daughter complained to the patient advocate that after pressing the call button multiple times the night before, and no staff came to check on her mother.
The report further revealed that on 05/15/2024 at 12:30 p.m., the patient advocate and the manager of the 4th floor, where the patient was located, went to speak to the family regarding their concerns. The daughter stated that at approximately 9:00 a.m. and 11:00 a.m. that day, she needed assistance from an aide to check on her mother, but no one responded after pressing the call light. The report revealed that during the visit, it was discovered that the patient was not actually hitting the correct call bell. She had been using the one on the bed that does not work.

On 05/21/2024 at 10:20 a.m., observation of two empty patient rooms on the 4th floor with S1Compliance and S4Director of 4th floor revealed that the patient beds had non-functional nurse call buttons on the side rails of the beds. The nurse call button on the beds were pressed by the surveyor during the observations and no alert of any type was generated when it was pressed. An interview at that time with S1Compliance and S4Director of 4th floor reported that patients/patient families were instructed to use the nurse call feature on the corded call light located at the patient's bedside to call for staff assistance. The surveyor discussed the possibility of patient/patient family confusion with having the non-functional nurse call feature on the bed available for use as well as the nurse call feature on the corded call light and the potential of the non-functional nurse call feature being pressed to summon help from staff. They agreed that having the non-functional nurse call feature available for use could result in potential confusion when calling for staff assistance.
Further interview revealed that all 36 beds on the 4th floor medical/surgical unit had non-functional nurse call buttons on the side rails of the beds.