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Based on interview and document review, it was determined the facility failed to provide patients/complainants with written notice of the results of the grievance process after an allegation of abuse or neglect.

Findings:

On 1/23/2023, the surveyor reviewed the facility's "Grievance" log. The "Grievance" log contained no documentation of the allegation of abuse by other patients related to Patient #1 or the report of abuse/neglect related to Patient #2.

The surveyors interviewed SM4 (Patient Advocate), who handles the facility's grievances, on 1/23/2023 at 3:17 p.m. SM4 stated that reports of abuse and neglect are not contained in the grievance log. SM4 stated that, as per corporate, abuse and neglect gets escalated to the risk manager, and the risk manager takes over those complaints. SM4 follows up with the risk manager a few days later, but the risk manager enters the information for abuse and neglect complaints into their system. SM4 stated that SM4 does not have access to the abuse and neglect complaints, only the risk manager has access to those.

On 1/24/2023 at 12:41 p.m., the surveyor reviewed the facility's "Patient/Family Complaint" log from January 2022 through December 2022. The Patient/Family Complaint log contained no documentation of the allegation of abuse related to Patient #1,

During an interview on 1/24/2023 at 1:23 p.m., SM3 stated that because the incident related to Patient #1 was an allegation of neglect, it was not a grievance and would not be on the grievance log. SM3 stated that the allegation was reported under "abuse and neglect". SM3 stated that a grievance and abuse/neglect are two (2) different categories. SM3 stated that there was no follow-up letter sent to Patient #1's family, and that the follow-up with the family was verbal. There was no documentation of the incident or follow-up noted in Patient #1's chart.

The surveyor attempted to clarify why reports of abuse and neglect were not documented in the grievance log, as per the facility's policy, and SM3 stated that reports of abuse and neglect were not grievances. The survey reviewed the facility's policy titled "Patient/Resident/Family Concern and Grievance Process" with SM3 and noted where the policy stated that any reported abuse/neglect would be logged on the grievance log, and that the definition of a grievance clearly states that grievances specifically include abuse or neglect allegations. SM3 replied that the "policy would be changed by the end of the week."

During an interview on 1/24/2023 at 3:16 p.m., SM2 stated that as far as SM2 knows, SM3 does not send a grievance written notice of decision or follow-up letter for any complaints of abuse or neglect. SM1 stated that SM3 provides a monthly report to SM1 and SM4. SM1 stated that anything that is sent to a regulatory agency goes through SM1 first. SM2 stated that any trends that SM3 notes would be reviewed in patient safety and appear in quarterly reports.

A review of the facility's policy titled "Patient/Resident/Family Concern and Grievance Policy" states in part that "2. The definition of: a. "Patient Grievance" is a formal or informal written (letter, email, fax, etc.) or verbal complaint (face-to-face and/or phone) that is made to the hospital by a patient, or the patient's representative, regarding the patient's care or a Medicare beneficiary billing complaint. This specifically includes but is not limited to any abuse or neglect allegations, issues related to the hospital's compliance with CMS Hospital Conditions of Participation (COPs), the Affordable Care Act, and any patient and family concerns that cannot be resolved "immediately". "Immediately" is defined as by the end of the shift during which the concern was received...GRIEVANCE PROCEDURE...If an immediate resolution to the complaint is not possible then staff is to begin the Grievance process, by assisting the complainant with completing a Grievance Form. After filing [sic] out the required fields, Staff will ensure that the form is submitted to Nursing Supervisor after business hours, or Unit Coordinator during business hours, The Nursing Supervisor will ensure that the Administrator on Call (AOC) is contacted and informed of any new Grievances filed after hours. The Unit Coordinator will inform the CNO [Chief Nursing Officer] of the grievance for review. The CNO will submit the grievance to the Patient Advocate. Grievance forms and drop boxes are also readily accessible on each unit for any patient or family/guardian who wishes to submit a grievance form independently from the unit staff. The Patient Advocate will review the grievance, notify the Risk Manager of all abuse or neglect allegations for investigation, and begin the investigation or assign a Senior Manager to oversee the investigation. The Senior Manager or designee will:...e. Immediately review and assess any reported abuse/neglect. Log on the grievance log and forward to the Risk Manager for investigation...9. In its resolution of the grievance, [the facility] will provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion . The Patient Advocate will service [sic] as the contact person, and as such, will ensure that the adequate information to address each item stated in the grievance is addressed..."

Based on interview and document review, it was determined the facility failed to, after an internal investigation related to abuse and neglect, effectively implement a corrective action plan to provide retraining to involved staff.

The findings include:

On 1/23/2023 at 9:30 a.m., the surveyors conducted the entrance conference with Staff Member (SM) 1 and SM2. The surveyor requested all documentation of the self-reported complaint by the facility related to Patient #1. The surveyor received a copy of the "Internal Investigation Form" that was reported to the Office of Licensure and Certification. The facility was unable to provide any additional documented information related to the investigation of the allegation.

A review of the "Internal Investigation Form" for the abuse/neglect report related to Patient #1 contained a corrective action item that included staff education regarding patient supervision to be provided by Nursing Leadership.

On 1/24/2023 at 12:54 p.m., SM2 provided the surveyor with documentation of the in-service that was presented to staff as the follow-up corrective action related to the allegation of abuse from Patient #1. The in-service sign-in sheet contained documentation that it was a "Nursing In-service" titled "Patient observation - Blind spots" and was dated 1/2023. The targeted audience was "Unit Staff". There was no speaker, length of program, or additional in-service content noted or attached to the form. Sixteen (16) staff members signed the in-service form. SM9, SM10, and SM11, who were noted to be involved with the incident related to Patient #1, had not signed the in-service form, hence, had not received the training. As per SM2, there was no documentation of information presented during this in-service, but that SM12 provided the information verbally to increase awareness of patient observation and blind spots. SM2 stated that SM12 was still working on educating the rest of the staff.