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Based on review of hospital policy, medical record review, grievance log review and staff interviews, the facility staff failed to recognize and respond to a grievance for 1 of 3 grievances reviewed (Patient #1).

The findings included:

Review of policy titled, "(Facility) Patient and Visitor Complaint/Grievance Policy and Procedure" effective 10/07/2018, revealed "...Definitions: Grievance: A written or verbal request by a patient ...presented to (facility) to formally review the patient's concern or objection about the quality and/or appropriateness of patient care when a patient issue cannot be resolved while the patient is still in-house by informal means ...Issues that are not resolved promptly by staff present are grievances... RESPONSIBILITIES OF DEPARTMENTS: All (facility) employees and volunteers are responsible and held accountable for accepting complaints and initiating the complaint management process by: 1. Listening attentively to the complainant; 2. Resolving the complaint promptly or referring the complaint to the appropriate party for resolution; 3. Informing the complainant of the next step(s) in the complaint process if resolution is not satisfactory; 4. Give any supporting documentation related to complaint/grievance investigation and/or resolution to the Patient Relations Department..."

Review of closed medical record for Patient (Pt) #1 revealed she was a 39-year old female with a diagnosis of Patellar instability of left knee (displaced kneecap). Medical record review revealed on 01/31/2019 at 1242, Pt #1 was admitted to the facility and underwent a Medial patella-femoral ligament reconstruction (surgery to correct dislocation of kneecap). Review of the Case Management Assessment note dated 02/01/2019 at 1347 revealed, "...Patient alerted CM of some concerns re: her fall yesterday evening and this information was passed along to RN manager and patient advocate. CM to follow." Record review did not reveal evidence that a member of management or the patient advocate documented contact with Pt #1.

Review of grievance log on 02/28/2019 revealed there was no grievance filed for Patient #1.

Interview on 02/27/2019 at 1445 with Case Manager (CM) #3 revealed that on 01/31/2019 Pt #1 notified CM #3 about concerns with the care she received while admitted to the hospital. CM #3 reported she messaged the Manager of Service Excellence (MSE) to notify her of Pt #1's reported concerns with the care she received during admission. CM #3 reported she received a response from the MSE that the MSE was out of the facility that day. CM #3 reported she did not recall if she notified the Patient Advocate or unit Nurse Manager of Pt #1's care related concerns.

Interview on 02/28/2019 at 1100 with MSE revealed that on 01/31/2019 she received a text message from CM #3 that Pt #1 reported concerns with the care she received while at the hospital. MSE reported she informed CM #3 that she was not working that day. MSE reported she did not receive any information about Pt #1's grievance when she returned to the hospital. MSE stated her expectation is that the staff members will notify the unit Nurse Manager or Operations Administrator if a patient reports a complaint while she is out of the facility.

Based on policy and procedure review, medical record review, and staff interview, the nursing staff failed to ensure falls interventions were in place for patients identified as "High Risk" with falls in 1 of 4 patients (Patient #10).

The findings include:

Review of policy on 02/27/2019 titled "Falls: Management, Assessment, Intervention, Reporting" with effective date of 03/28/2018, revealed "Fall: A patient fall is a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor...INPATIENT: A. Assessment: 1. The (named facility) Fall Assessment Tool is used to identify those patients at high risk for falls...Reasons for High falls risk...mental alteration, bowel/bladder alterations...Interventions for High Risk Inpatients: a. Place yellow armband and yellow non-skid slippers on patient. b. Document falls risk...c. Institute rounding with a Purpose/safety checks approximately every two hours...d. Use bed alarm to alert staff that patient is attempting to exit bed...."

Review on 02/27/2019 of a history and physical dated 02/13/2019 at 2112 of Patient #10 revealed an 86 year old male admitted on 02/13/2019 with a history of CAD (Coronary Artery disease), atrial fibillation (irregular heart rate), chronic kidney disease, elevated lipids, hypertension, pulmonary fibrosis, spinal stenosis, and Congestive Heart failure. "His present medical history is remarkable for hospitalization for Atrial Fibrillation and related dizziness and weakness...."

Review of nurse's assessment dated 02/23/2019 at 2042 revealed "Patient at HIGH risk for falls: Yes. Reason(s) for HIGH fall risk: Gait alteration." Review of a Nursing note written by RN #1 dated 02/24/2019 at 0744 revealed "This shift was eventful for: Elevated HR (heartrate) at midnight vitals, put on tele (telemetry) and found to be in Afib (Afibrillation-irregular heart rhythm) 135-155, paged for stat (immediate) EKG (electrocardiogram) showing Afib with RVR (rapid ventricular rhythm)...Pt found on the floor 10 minutes after hourly rounding. Slight abrasion to knee..."

Interview on 02/28/2019 at 1130 with RN #1 revealed patient #10 had been "incontinent all night and a little confused." Interview revealed patient's roommate called because patient was on the floor. Interview revealed patient #10 was not wearing a falls bracelet and bed alarm was not on when the patient was found on the floor. Interview revealed the bed alarm and falls bracelet should have been on the patient due to his high risk of falls.

Interview on 02/27/2019 at 1440 with Director of Patient Safety revealed all interventions should be in place for high risk fall patients.

NC00148351