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Based on observation and interview, the critical access hospital (CAH) failed to ensure signage was posted in the Emergency Department (ED) identifying a medical doctor was not on duty 24/7. This had the potential to affect all admitted patients and/or those seen in the ED.

Findings include:

Observation on 3/11/24 at 5:21 p.m., of the ED identified there was no posted notification identifying a medical doctor was not on duty on a 24/7 basis. The only posted notification identified was in the main entrance of the hospital which would not be seen by individuals entering the designated ED.

On 3/11/24 at 5:30 p.m., registered nurse (RN)-A stated the only notice was posted at the front entrance and she was not aware it was supposed to be posted in areas of the ED where patients requiring emergency services would enter or receive treatment.

On 3/12/24 at 8:30 a.m., the chief nursing officer (CNO) identified she was not aware there was not signage in the ED identifying an MD/DO was not present in the CAH 24/7. Following review of the regulation, DON confirmed the signage was not present in the ED and would correct it immediately.























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Based on interview and document review, the hospital failed to provide An Important Message from Medicare (IM) within two days of admission, and/or two calendar days prior to discharge, for 7 of 14 patients (P4, P5, P7, P9, P11, P14, P16, P20) reviewed who had Medicare coverage while an inpatient at the hospital.

Findings include:

P11's face sheet indicated P11 admitted inpatient on 10/12/22 and discharged on 10/15/22. Primary insurance was Medicare.

P11's medical record identified a signed admission IM on 10/12/22 and another IM on 10/15/22. The medical record lacked evidence a discharge IM was provided within the required timeframe.

P5's face sheet indicated P5 admitted inpatient on 12/9/23 and discharged on 12/14/23. Primary insurance was Medicare.

P5's medical record identified P5 was provided with the IM on 12/11/23 and he refused to sign. P5's medical record lacked evidence an IM was provided on 12/9/23 or 12/10/23, nor that a discharge IM was provided.

P16's face sheet indicated P16 admitted inpatient on 12/17/23 and discharged on 12/22/23. Primary insurance was Medicare.

P16's medical record identified an admission IM was signed on 12/17/23 and another IM on 12/22/23. The medical record lacked evidence a discharge IM was provided within the required timeframe.

P4's face sheet indicated P5 admitted inpatient on 12/29/23 and discharged on 1/5/24. Primary insurance was Medicare.

P4's medical record lacked evidence P4 was provided an admission or discharge IM. The facility provided an IM notice that identified an admission date of 12/29/23; however, the IM signature section was blank.

P7's face sheet indicated P7 admitted inpatient on 1/28/24 and discharged on 1/31/24. Primary insurance was a Medicare advantage plan.

P7's medical record identified P7 signed an IM on 1/31/24. P7's medical record lacked IM issuance details from 1/28/24 through 1/29/24, or that a discharge IM was provided prior to the 1/31/24 discharge.

P9's face sheet indicated P9 admitted inpatient on 2/2/24 and discharged on 2/6/24. Primary insurance was a Medicare advantage plan.

P9's medical record identified a signed IM on 2/3/23; however, the record lacked a discharge IM.

P14's face sheet indicated P14 admitted inpatient on 2/25/24 and discharged on 2/28/24. Primary insurance was Medicare.

P14's medical record identified P14 signed an admission IM on 2/25/24 and another IM on 2/28/24. The medical record lacked evidence a discharge IM was provided within the required timeframe.

Medical record progress note documentation related to IM issuance/phone conversations was requested for all seven patients; however, none was provided.

When interviewed on 3/13/24 at 4:11 p.m., RN-G stated the health unit coordinators (HUCs) were responsible for IM issuance.

During interview on 3/13/24 at 4:29 p.m., HUC-A stated an IM was provided to patients, or their representatives when applicable, "as soon as possible" after admission. She explained in-person IM presentation was preferred; however, there were times a telephone call was required to discuss the IM. In those situations, documentation of the call was entered into the patient's medical record and processes were followed for mailing and receiving the IM back. She stated audits were completed to ensure the admission IM was completed; however, based on when this audit was completed during the patient's stay, a missed admission IM notice may not be caught until the day of discharge, at which time a signature procurement was attempted. HUC-A stated she explained the IM and was expected to ensure the patient, or the representative understood the IM as the IM notice ensured the facility could bill Medicare. In addition, it was important for the patient and/or representative to know their discharge rights and who to contact for appealing the discharge if needed.

When interviewed on 3/14/24 at 9:20 a.m., HUC-D stated an IM was provided to patients, or their representatives when applicable, on the admission date. If that was unsuccessful, an attempt was completed by the oncoming HUC shift. If an in-person IM presentation was unable to be completed, a telephone call was conducted, and a progress note was completed that identified the call information. HUC-D denied an IM was provided in relation to discharge. She explained IM issuance was audited during the discharge process to ensure all forms were completed. If the IM was not completed, this was completed on the day of discharge, or after discharge, depending on when the audit was completed. HUC .... Stated she was unsure what the IM issuance regulations were, but she followed the education she was provided. She identified the IM provided rights about discharge and the appeal process.

During interview on 3/14/24 at 9:37 a.m., the patient access manager (PAM) stated she supervised the HUCs and the HUCs provide the IM notices. She expected patients to receive the IM on the day of admission unless there were documented circumstances that delayed the process, such as a representative lived out of state or was unable to personally visit. PAM explained the discharge IM was expected to be completed within two days after discharge for patients/representatives to dispute concerns that occurred during the stay. She was unable to state IM issuance time frame regulations.

When interviewed on 3/14/24 at 10:00 a.m., the chief nursing officer (CNO) stated the HUCs provided the IM notice as part of the registration process. She expected an IM to be provided to Medicare patients upon admission and was "one of the first things they do." In addition, she expected the IM notice to again be provided two days before discharge as the patients/representatives had a right to appeal. If an IM was unable to be completed on admission, or prior to discharge, she explained a note would be entered into the medical record which detailed rationalizations and follow-up. The CNO denied knowledge of any concerns related to IM issuance.

A HUC - Task Outline policy, dated 12/13/23, directed the HUC staff to have all patients, who were admitted to "acute care," that were Medicare covered, or who had Medicare product insurance, sign the IM electronically. If paper form was needed, the HUC was to print the notice from the patient encounter, attach patient labels, have the patient sign, and place the form in the patient's chart. The policy lacked direction on requirements for IM deliverance or processes of issuance prior to discharge.

A policy related specifically to IM notices was requested; however, none was provided.

Based on interview and document review, the critical access hospital (CAH) failed to ensure 1 of 8 registered nurses (RN)-B had a valid nursing license while working in the hospital facility.

Findings include:

Review of sampled personnel records for hospital staff identified RN-B was licensed by the Minnesota Board of Nursing and his license contained a date of expiration of 12/31/23.

Review of the nursing schedules for January, February, and March 2024, identified RN-B was scheduled at a .8, (64 hours/2 weeks) and he had worked his scheduled shifts until 3/12/24, when it was discovered, his license had expired. Following identification of the issue, RN-B was immediately removed from the schedule until the issue could be resolved.

On 3/13/24 at 10:35 a.m., the human resources (HR) manager and director reported upon retrieval of personnel records for review on the afternoon of 3/12/24, it was discovered RN-B did not have a current nursing license. The lapse was confirmed by checking the Board of Nursing web site and confirming with RN-B. Immediate notification was made to administrative staff and RN-B was removed from the schedule until the issue could be resolved. Immediate audit of all licensed staff failed to identify any additional staff with a lapse in certification or licensure had been completed. The HR director and manager identified the lapse had occurred due to a change in computer systems and failure to add RN-B to the list which should have flagged the expiration of his license.

On 3/13/24 at 11:55 a.m., the chief nursing officer (CNO) identified her expectation was all nursing staff maintained a current nursing license when employed by the hospital. She stated her expectation was for any lapse to be immediately reported to the supervisor and CNO. The CNO indicated a staff nurse was not eligible to return to work until their license was current and able to be confirmed. The CNO confirmed review of incident reports and grievance reports from January 1, 2024, through March 12, 2024, failed to identify any concerns or incidents involving RN-B. She reported she would be working with HR to determine actions related to the identified incident and to ensure this type of incident did not reoccur.

On 3/13/24 at 2:56 p.m., ED manager (RN)-A stated she had no concerns with RN-B, his competency or work history. She indicated she had not been aware of the incident until she was notified on the afternoon of 3/12/24. RN-A identified RN-B worked in ED 50% of his schedule and averaged shift length of four to twelve hours.

On 3/13/24 at 3:09 p.m., RN-B stated he had forgotten to renew his nursing license and denied having received a notice that it was expiring. He indicated he had immediately contacted the Board of Nursing, submitted the required information and had been informed his license would be reinstated on 3/13/24 or 3/14/24. RN-B stated he had been scheduled and worked consistently 32 hours/week since January 1, 2024, and had not had any incidents or medication errors involving patients.

Review of the undated facility policy titled Mandatory Certification Requirements listed authority and responsibilities: Leaders: Leaders had the authority and responsibility to ensure staff was compliant with their required certifications.

Human Resources had the responsibility to verify certifications of new employees and inform leaders and employees if certification was needed.

Employees had the responsibility of knowing when certifications expired, scheduling themselves in classes, and ensuring all classes were completed before expiration of the certification to avoid individual instruction needs.
Failure to comply with HR policies and procedures may result in disciplinary action, as applicable, up to and including termination, in accordance with the Policies or Collective Bargaining Agreements.

Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure 2 of 2 LifePak defibrillators (device used to restore a normal heart rhythm), were checked daily to ensure proper function. This had the potential to affect all patients coming to the hospital for treatment.

Findings include:

Observation of the Emergency department (ED) daily checklist from January to March 11, 2024 identified:
January 2024, the defibrillator had not been checked for function on 7 of 30 days listed- 1/7, 1/11, 1/20, 1/23, 1/27, 1/28, and 1/29/24. February 2024, the defibrillator had not been checked for function on 2 of 29 days listed - 2/8 and 2/20/24. March 2024, the defibrillator had not been checked for function on 5 of 11 days listed- 3/2, 3/5, 3/6, 3/7, and 3/10/2024.

On 3/11/24 at 5:21 p.m., the ED manager identified the defibrillator and crash cart located in the Trauma room was to be checked for function on a daily basis and documented on the monthly log. She confirmed checks were missing for the months of January, February and March of 2024, and had likely not been completed.

On 3/11/24 at 5:30 p.m., registered nurse (RN)-B reported the defibrillator and crash cart were supposed to be checked for function at the beginning of each shift and documented on the log located on the crash cart.




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On an observation of the nursing unit on 3/12/24 at 1:28 p.m., registered nurse (RN)-C stated the emergency room nurse would come daily and check the defibrillator on the crash cart to ensure the self test passed.

During an interview and review of the emergency room daily checklists January through March 2024, on 3/12/24 at 1:33 p.m., RN-D stated the ED nurse would come to the inpatient nursing unit and make sure the defibrillator had passed the self test. Both RN-C and RN-D verifed this task was expected to be completed on the night shift and that the checklists were missing several dates that would have identified the tests had been completed.

During an interview on 3/12/24 at 1:55 p.m., RN-B verified the automatic defibrillator self tested needed to be checked daily to ensure the equipment was in working order and ready for use.

Review of the undated Olivia Hospital & Clinic Frequency of Emergency Equipment Checks policy listed the responsibility of the assigned ED nurse to check the Life Pak Defibrillators every shift on both the inpatient and ED units and initial the checklist to assure readiness in the event of an emergency situation.

Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: K0351, K0712, K0901 and K1608 for additional information.

Based on interview and document review, the critical access hospital (CAH) failed to ensure health information management system (HIMS) policies of the CAH were reviewed biannually as directed by CAH regulations.

Findings include:

On 3/12/24 at 2:39 p.m., health information manager (HIM)-J confirmed the CAH used HealthPartners corporate policies for HIMS. HIM-J indicated HealthPartners corporate polices were reviewed every three years corporate wide. HIM-J stated she was not aware policies for the CAH needed to be reviewed biannually. HIM-J revealed changes would need to be made to meet the CAH regulations.

During an interview on 3/12/24 at 8:30 a.m., chief nursing officer (CNO) confirmed the HIMS used HealthPartners corporate policies and the CNO was not aware when the last time the policies were reviewed. CNO indicated HIMS was overseen on a corporate level. CNO indicated she was aware policies were required to be reviewed biannually.

Requested facility policy or HealthPartners corporate policy on policy review however, one was not provided.

Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure policies and procedures were followed related to non-pharmacy staff compounding low level sterile preparations (CSPs) for non emergent use. In addition, the CAH failed to ensure controlled substances were stored and secured and that an inventory count was completed at the end of each shift.

Findings include:

COMPOUNDING

On 3/12/24 at 8:17 a.m., registered nurse (RN)-E entered the locked medication room and removed P12's 8:00 a.m. medications which included furosemide (a diuretic used to treat fluid retention) two bottles of the furosemide 40 milligram (mg) and a 50 milliliter normal saline (NS) intravenous fluid (IV) bag. RN-E gathered supplies which included syringes, needles, IV tubing and alcohol wipes.

-at 8:28 a.m. RN-E entered P12's room, put on gloves, scanned P12's wrist band, asked them to state their name and birth date. RN-E scanned all of the medications, placing all of the oral medications in a cup and opened the IV tubing, closed the clamp and placed the tubing on P12's bedside table. RN-E then opened the furosemide bottle, swabbed the top of the container with an alcohol wipe, opened the syringe and needle packages, removed the furosemide liquid from the bottle, swabbed the port on the NS 50 ml bag and injected the furosemide into the bag. RN-E then repeated the steps with the second bottle of furosemide. RN-E gently rotated the NS bag and connected the tubing to the bag, hung the bag on the IV pole and primed the IV tubing. RN-E programmed the IV pump to have the furosemide drip run over 15 minutes. RN-E then flushed P12's saline lock (IV access) however found it was leaking so removed the saline lock. RN-E gave P12 their oral medications and said she would need to place another saline lock.

-at 8:58 a.m., RN-E returned to the medication room and printed a label for the IV furosemide drip.

-at 9:00 a.m., RN-E returned to P12's room and placed the label on the NS furosemide drip that was hanging on the IV pole.

On 3/13/24 at 8:38 a.m. RN-F stated it was not uncommon for nurses to prepare IV drip medications and antibiotic piggybacks (medication given intermittently). RN-F stated she had drawn up some IV ondansetron (a medication used to control nausea) that morning.

On 3/13/24 at 8:40 a.m., RN-C stated it was typical to mix IV drips and antibiotics on the day shift.

On 3/13/24 at 1:55 p.m., pharmacist (P)-E stated nursing should have called pharmacy to mix the furosemide drip. P-E stated the danger with nursing mixing medications included the possibility they would not follow the procedure, not use the laminar hood (the hood protects the working environment from dust and other airborne contaminants by maintaining a constant, unidirectional flow of HEPA-filtered air over the work area) and may not follow basic infection control practices.

On 3/13/24 at 3:13 p.m. the chief nursing officer (CNO) stated during daytime hours, the pharmacy should have mixed the furosemide drip. The CNO stated pharmacy should have been mixing all IV medications during business hours. The CNO verified having nursing staff mix medications was a high risk task.

The Medication Preparation policy undated, identified "Only Pharmacy Services should compound or admix sterile medication, intravenous admixtures or other drugs except in emergencies or when not feasible."

CONTROLLED SUBSTANCES

On 3/11/23 at 4:40 p.m., during a tour and interview of the nursing unit. RN-G stated hospice patient's medications were stored in the medication room in a locked filing cabinet. RN-G removed the key to the filing cabinet from an unlocked drawer at the nurse's station. The key was labeled as the medication room lock box. RN-G stated no one ever carried the key. Upon entering the locked medication room, RN-G unlocked the cabinet designated for hospice patients controlled medications. RN-G found a bottle of liquid morphine (a controlled substance used to treat moderate to severe pain and also has a high risk for addiction and dependence) 100 mg per 5 ml for P10 and a bottle of liquid lorazepam (a controlled substance used to relieve anxiety) 2 mg per 1 ml for P10. Both medications had controlled medication logs however neither drug had a starting amount listed and doses had not been signed out with a running total of the amount in the bottles. The morphine had nine recorded removals of medication for P10 and the lorazepam had five recorded removals of medication for P10. RN-G verified P10 was not a current patient and further investigation revealed P10 was deceased on 2/26/24. RN-G brought the medications and the control logs to the pharmacy. Pharmacist (P)-E verified the amounts removed and the total volume of both medications and stated there was not any medication missing. Both RN-G and P-E verified the medication control logs were not filled out correctly with amounts of the medications remaining. Both verified no one had been counting the medications or verifying they were in the locked box since 2/26/24, a total of 14 days, and both were unaware the medications were in the locked cabinet. P-E stated the location of the key "was not ideal". P-E stated staff should have carried the medications to the pharmacy on 2/26/24, for destruction. P-E and RN-G went thought the process for destruction.

On 3/13/24 at 3:22 p.m., the CNO stated the facility had a locked medication cabinet because hospice patients might have brought in their own medications however she would have expected staff to sign the medications out properly and complete counts at the change of each shift. The CNO stated there was a process for reconciling medications after a death occurred and it had not been followed.

Controlled Substance policy no date, identified all controlled substances would be stored in an automated dispensing machine (ADM) whenever possible. The policy indicated when controlled substances were stored in a locked storage area, the storage area would be locked at all times and the key if used would be secured at all times. In addition, the areas of storage without an ADM wound need to have a complete inventory done at the end of each shift.

Based on interview and document review, the critical access hospital (CAH) failed to implement a policy and procedure to prevent specimen transport issues from the CAH to receiving hospital laboratories which resulted in viability issues of the lab samples.

Findings include:

On 3/13/24 at 8:54 a.m., review of the facility's incident reports identified the CAH laboratory had eight specimen transport issues in 2024. Chief nursing officer (CNO) confirmed the laboratory had several incidents in 2024, however was unaware eight of incidents were related to specimen transport issues.

On 3/13/24 at 3:27 p.m., senior laboratory manager (SLM) confirmed the CAH had specimen transport issues. SLM indicated the CAH started a new process for transporting specimens which went live on 10/23, and there had been an increase in incidents regarding the transportation of specimens since that time. SLM indicated the CAH was the farthest laboratory from the receiving laboratories and specimens had arrived to the receiving laboratories with issues. SLM stated the issues included: the length of time the specimen was in transit, arrival of frozen specimens and/or arrival of thawed specimens. Specimens had to be discarded due to the viability of the specimen once it arrived at the receiving laboratory and as a result, patients were required to provide specimens again. SLM revealed during the new process of shipping and transport, shipping containers were changed and packaging had been updated however transport issues continued. SLM stated the next meeting was scheduled for 4/4/24, to discuss the transport issues identified in the incident reports. SML stated the transporting process had continued to remain the same since implementation of the new process.

On 3/13/24 at 3:51 p.m., chief executive officer (CEO) and CNO confirmed the above findings. CNO indicated at a local level the CAH was responsible for patient safety issues and the issues with specimen transporting needed to be addressed sooner than later. CNO stated waiting until 4/4/24, could result in further issues. CEO stated "we need to develop a plan now and continue to work on it in the future".

Review of facility policy titled Specimen Packing and Transport Procedure reviewed 1/23, lacked specific packing and transport procedures from CAH to receiving facilities.

Review of facility policy titled Specimen Transportation Procedure reviewed 1/23, lacked specific transportation procedures from CAH to receiving facilities.

Based on observation, interview and document review, the critical access hospital (CAH) failed to maintain the confidentiality of medical record information and provide safeguards against potential loss, destruction, or unauthorized use in the CAH medical record storage area.

Findings include:

On 3/12/24 at 2:39 p.m., health information manager (HIM)-I identified the CAH had paper medical records stored on the facility grounds. HIM-I indicated the medical records were being stored in an outbuilding on the facility property. HIM-I stated the medical records were from 2019, and older. HIM-I revealed there was one door into the storage area of the medical records that was locked and HIM staff had a key for the door. HIM-I was not aware if others had keys or how many keys were available to unlock the door.

During an interview and observation on 3/12/24 at 3:45 p.m., health information assistant (HIA) confirmed medical records were stored in the back room of the maintenance garage and had been dated from the opening of the hospital in the 1950's until 2011. HIA stated some medical records from 2011 to 2019, had been uploaded into an electronic health record (EHR) and now all health records were being stored online in an EHR. HIA indicated there was a key in the HIM room that unlocked the back garage door in the maintenance garage. HIM stated maintenance, hospice and the business office also stored items in the locked medical storage area. The first door entered in the maintenance garage was unlocked and items used for facility maintenance were located throughout the garage. The second door was located to the back right of the garage and was unlocked with a single standard door lock. Upon entering the storage area, additional maintenance supplies and medical supplies were stored in the area. To the right, several shelves were lined up and contained a large amount of numbered manilla paper medical files. HIA stated there was not a storage area in the CAH for medical records.

On 3/13/24 at 9:55 a.m., chief executive office (CEO) and chief nursing officer (CNO) confirmed the above findings and indicated there was not a storage area for paper medical files inside the CAH. CEO indicated the storage location was not secure and was not being monitored for unauthorized access. CEO stated his expectations were the CAH needed to find a secure location for the medical records within the facility and monitor who had access to the paper medical files. CEO indicated only authorized personnel should have a key to access the medical records.

Review of facility policy titled Confidentiality of Patient/Member Information - Colleague Access and Use Policy The purpose of the Policy was to provide all colleagues with specific guidance and expectations regarding the appropriate access to and use of "Protected Information" in order to perform their work. Systems without automatic security functions may be monitored manually.

Review of facility policy titled Medical Records Purpose undated, the medical record was to be maintained and stored according to HealthPartners Record Retention Policy Medical records are considered confidential and only authorized personnel shall have access to the records.

Review of facility policy titled Process: Historical Information of Location of Patient Medical Records (paper, microfiche, EMR, data repository, etc.) undated, the CAH was required to use facility-specific access to records across the HealthPatners organizations.

Review of facility policy titled Process: Olivia Historical Information of Location of Patient Medical Records (paper, EMR, data repository, etc.) revised 8/28/2023, Data Repository: All clinic records were moved to the repository with date ranges from 2001-2014. All hospital records were moved to the repository with date ranges from 2011-2014.

Based on interview and document review, the critical access hospital (CAH) failed to ensure the process for mail delivery to the swing bed patients was followed on Saturdays. This had the potential to affect all swing bed (SB) patients.

Findings include:

On 3/13/24 at 12:40 p.m., patient access manager (PAM)-C stated if mail arrived on Saturday before 12:00 p.m. the mail would be sorted and distributed to all inpatients which would include SB patients. PAM-C stated if the mail was delivered after 12:00 p.m. ,the mail would be delivered to the Health Unit Coordinator (HUC) in the emergency room (ER). PAM-C stated she was unsure if the mail was sorted and delivered or if it was sorted and delivered on the following Monday.

On 3/13/24 at 12:48 p.m., HUC-D stated when mail was delivered to the ER registration desk on Saturday's after 12:00 p.m., the mail would be brought to the mail room and it would be sorted and delivered on Monday.

On 3/13/24 at 2:45 p.m., registered nurse (RN)-A stated mail should have been delivered on Saturday's to SB patients. She stated she was not aware that mail delivered after 12:00 p.m., was not delivered until Monday. She stated this was a concern for any SB patients not receiving their mail timely.

On 3/13/24 at 3:35 p.m., the chief nursing officer (CNO) stated mail should have been sorted and delivered on every Saturday regardless of the delivery time before or after 12:00 p.m..

The policy Mail Distribution-Incoming & Outgoing & Interdepartment no date, identified Saturday mail delivered after 12:00 p.m. would have been brought to the HUC via the emergency room entrance. The HUC would then sort the mail and bring the patients their mail.

Based on interview and document review, the hospital failed to provide written grievance resolution decision letter(s) to 1 of 1 (P40) reviewed who filed a facility grievance.

Findings include:

Grievance summary reports for the past three months, and from 10/1/22 through 11/30/22, were requested. One hospital related complaint was provided dated 1/23/24.

Detailed grievance information, and follow-up grievance letter(s) were requested related to the 1/23/24 incident. Detailed information was provided; however, written follow-up letter(s) were not.

An AWARE grievance report, entered 1/24/24, identified P40 notified staff in-person on 1/23/24 and verbalized concerns related to her emergency department (ED) encounter on 1/21/24. The report indicated staff investigated P40's grievance right away and the ED provider spoke with P40. P40 and P40's family were grateful for the follow-up and presentation of a local store gift card. In addition, on 1/24/24, staff worked with ED nurses and providers with education ED providers would deliver test results to patients, unless this was delegated to nursing. The resolution date was identified as 1/24/24. The report lacked evidence a written resolution notification was mailed to P40.

When interviewed on 3/13/24 at 2:10 p.m., patient experience (PE)-A stated she was responsible for grievance processes going back to roughly 2021. She explained P40's grievance was taken care of "at that time" upon P40's verbalized grievance and "everyone was happy right after" staff spoke to her. She denied any additional follow-up, verbal or written, with P40 after that day. PE-A explained any follow-ups with complainants were done via phone, or in-person communication, and did not send out written grievance resolution notices. PE-A stated the chief nursing officer (CNO), or the quality manager (QM)-A, was her back up for grievances.

During interview on 3/13/24 at 4:49 p.m., QM-A stated all grievances were put into the AWARE program and any updates to the complainant were done either verbally in person or via a phone call depending on what the complainant preferred. If a grievance was not resolved, a phone call to the complainant was completed and an estimated resolution time frame was vocalized. She denied complainants were provided written grievance resolution letter(s).

When interviewed on 3/14/24 at 10:00 a.m. the CNO stated if a complainant desired a written follow-up, one would be provided; however, overall grievance communication factors with complainants was completed via in-person meetings and/or via a phone call. The CNO was unaware of the regulation for written follow-up notification and stated she had always felt the facility had up to 24-hours to follow-up via a phone call.

A Complaint Grievance Process policy, dated 5/4/23, directed within five working days after the filing of a formal grievance, the patient/family must receive notification of the steps taken to investigate the grievance, as well as the results of the investigation. If the investigations were still in process, a status report was to be provided. If the grievance was resolved at that point, the person conducting the investigation was to document the conversation with date, time, and summary of the conversation. If the information was communicated by phone, a note was to be made in AWARE (grievance software) and a phone number was to be noted so a follow up call could be made if deemed appropriate. The policy lacked direction that a written grievance resolution decision notice which contained the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion was a required step in the grievance resolution process.