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Based on a review of facility documentation, medical record review (MR), and staff interview (EMP), it was determined the facility failed to provide the patient or guardian with a written notice of its resolution to a grievance for one of one medical records (MR 1) reviewed.

Findings include:

On February 1, 2022, a review of the policy "Patient Complaint Management and Grievance Process, dated: April 22, 2021," revealed, "IV Definitions...D...Written Complaint: A written complaint is ALWAYS considered a grievance...4. Response to Grievances...c. On average a written response addressing resolution of the grievance will be sent to the patient/family within 7 business days of the receipt of the grievance."

A review of MR 1 was completed on February 1, 2022, and revealed an admission date of May 6, 2021, and a discharge date of July 22, 2021.

On February 1, 2022, a review of the facility grievances revealed that the guardian of MR1 filed a grievance with the facility on August 19, 2021. Further review revealed that the guardian did not receive a letter regarding the resolution of the grievance.

During an interview on February 1, 2022, at 10:10 AM, EMP 2 confirmed there is no evidence that a letter of resolution to the grievance filed for MR 1 was ever sent to the guardian.

Based on review of facility policies, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to document daily vital signs or patient refusal for four out of 10 medical records (MR1, MR4, MR9, and MR10), failed to document the daily care interventions section in its entirety for four out of 10 medical records (MR4, MR6, MR9, and MR10), and failed to document weekly weights or patient refusal for four out of 10 records (MR1, MR2, MR7, and MR9).
Findings include:
1. On February 1, 2022, a review of facility policy titled, "Orthostatic Blood Pressure, Vital Signs, and Weights," which was last reviewed July 2021, revealed, "...I. Monitoring of Vital signs and weights ...B....Thereafter the patients' vital signs are monitored daily which includes blood pressure, pulse, respirations, and temperature...C. Documentation of weights and vital signs or the patient refusal of weights or vital signs should be documented in the e-Record."
Record reviews were completed on February 1, 2022, and revealed the following:
Review of MR1, admission date May 6, 2021, and discharge date of July 22, 2021, revealed failure to document daily vital signs for the dates June 2, 5, 7 10, and 19; July 7, 8, 9, 2021 with no patient refusal documented.
Review of MR4, admission date of June 12, 2021, and discharge date of June 17, 2021, revealed that daily vital signs failed to be documented for the dates June 12, 13, 14, 15, 16, and 17, 2021, with no patient refusal documented.
Review of MR9, admission date of May 15, 2021, and discharge date of June 18, 2021, revealed that daily vital signs failed to be documented on May 16, 17, and 18, 2021; May 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30, 2021; June 1 and 2, 2021; June 5, 6, and 7, 2021; June 9, 2021; and June 11, 12, 13, 14, 15, 16, 17, and 18, 2021, with no patient refusal documented.
Review of MR10, admission date of June 18, 2021, and discharge date of June 21, 2021, revealed that daily vital signs failed to be documented on June 19, 2021, with no patient refusal documented.
Interview with EMP5 on February 1, 2022, at 11:15 am, confirmed that vital signs are to be completed daily as per policy and protocol.
Interview with EMP4 on February 1, 2022, between 9:00am and 11:30am confirmed the above findings.

2. On February 1, 2022, review of facility policy titled, "Nursing Documentation," which was last reviewed October 2021, revealed, "...VIII. Nursing Documentation: Nursing daily documentation is completed in the IView section of the patient's e-record. A. RN daily documentation 1) The following bands and sections in IView should be documented on once a shift:...c. Care Intervention Band i. Activities/positions ii. Patient care (hygiene/bathing) iii. Treatment iv. Nutrition information (meals/percent rate)..."
Record reviews were completed on February 1, 2022, and revealed the following:
MR4, admission date of June 12, 2021, and discharge date of June 17, 2021, revealed that the daily care interventions section failed to be documented in its entirety on June 12, 13, 14, 15, 16, and 17, 2021.
MR6, admission date of June 10, 2021, and discharge date of June 29, 2021, revealed that the daily care interventions section failed to be documented in its entirety on June 19, 2021.
MR9, admission date of May 15, 2021, and discharge date of June 18, 2021, revealed that the daily care interventions section failed to be documented in its entirety on May 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28, 2021; May 31, 2021; and June 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18, 2021.
MR10, admission date of June 18, 2021, and discharge date of June 21, 2021, revealed that the daily care interventions section failed to be documented in its entirety on June 18, 19, 20, and 21, 2021.
Interview with EMP4 on February 1, 2022, between 9:00am and 11:30am confirmed the above findings.

3. On February 1, 2022, review of facility policy titled, "Orthostatic Blood Pressure, Vital Signs, and Weights," which was last reviewed July 2021, revealed, "...I. Monitoring of Vital signs and weights...B....Weights are also monitored per unit protocol or as ordered by the physician...C. Documentation of weights and vital signs or the patient refusal of weights or vital signs should be documented in the e-Record."
Record reviews were completed on February 1, 2022, and revealed the following:
MR1, admission date of May 6, 2021, and discharge date of July 22, 2021, revealed that the patient was weighed nine times during the admission. However, on three occasions the weights exceeded the prescribed time frame: May 9 to May 22, 2021, (12 days); May 30 to June 27, 2021 (27 days) and June 27 to July 9, 2021 (11 days) without documentation of patient refusal.
MR2, admission date of May 2, 2021, and discharge date of May 17, 2021, revealed that weekly weights were not documented with no documentation of patient refusal.
MR7, admission date of June 3, 2021, and discharge date of June 14, 2021, revealed that weekly weights were not documented with no documentation of patient refusal.
MR9, admission date of May 15, 2021, and discharge date of June 18, 2021, revealed that weekly weights were not documented with no documentation of patient refusal.
Interview with EMP5 on February 1, 2022, at 9:30 am, confirmed that per the unit protocol where the patients were admitted, weights are to be done weekly.
Interview with EMP4 on February 1, 2022, between 9:00am and 11:30am confirmed the above findings.