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Based on record review, document review and interview, the hospital failed to provide the patient/family with written notification of the facility's investigation into the grievance that included the steps and results of the grievance process for each of the concerns voiced by the complainant and the date of the completion for 1 of 3 (Patient #1) sampled patients reviewed.

The findings included:

Medical record review revealed Patient #1 was admitted to the hospital on 1/30/17 with readmissions on 4/16/17, 10/30/18, 5/18/19, 6/4/19 and 6/15/19 with diagnoses to include Acute on Chronic systolic Congestive Heart Failure, Acute Respiratory Failure with Hypoxia, Risk for falls, Benign Prostatic Hyperplasia, and Alzheimer's Disease.

Review of a patient complaint document received by the hospital on 6/18/19 revealed, "...During Leader rounding 6/18/19...on the patient [#1] in room...the daughter [Complainant and Power of Attorney]...was at bedside with multiple complaints stemming from current and several previous admissions of her father...she is his POA [Power Of Attorney]...She stated she "was his voice, fed up, had enough and wanted her concerns to be known..." The document revealed the following concerns and the hospital's response to each concern.
1. "States she [complainant/POA] has been waiting 3 days for the M.D. [Medical Doctor] to update her." The hospital documented that Nurses took her number each day.
2. "States patient is on Keppra for seizures and patient has not received any since admission [6/15/19]" The hospital documented that the patient was getting this.
3. "States no sitters available" The hospital documented that sitters were not ordered.
4. "States this morning she [complainant/POA] found patient freezing with no covers or gown." The hospital documented that she [complainant] did not tell us.
5. "States last admission patient had large skin tear to forearm from fall in room." The hospital documented previous.
6. "States previous admission the patient was found in bathroom with foley pulled out and blood all over bathroom. She [complainant/POA] showed photos from her cell phone." The hospital documented previous.
7. "States last admission IV was pulled out and patient was left in bloody soiled gown for hours." The hospital documented previous.
The hospital documented the following conclusions/recommendations/ actions for the above concerns: "Used therapeutic communication to ensure patient's daughter knew the above concern would be forward/address to the respected management."

Review of the certified letter dated 6/25/19 mailed to the complainant from the hospital revealed, "...We want to inform you that your concerns were forwarded to the appropriate department leaders for review and based on their review any recommended actions will be completed..."
The hospital did not provide written notification to the complainant that included the steps and results of the grievance process for each of the concerns voiced nor the date of completion.

The Risk Manager confirmed the hospital did not have a grievance policy.

Based on policy review, record review and interview, the hospital failed to ensure care was provided in a safe setting when a Foley catheter was inserted incorrectly, resulting in complications from an improperly placed catheter, and the hospital failed to implement interventions to prevent future falls during readmissions for 1 of 3 (Patient #1) patients reviewed.

The findings included:

1. Review of the Urinary Catheter policy revealed, "...slowly insert the catheter through the urethral meatus...advance the catheter until urine flows through the tubing...Continue to advance the catheter to the bifurcation of the tubing...When the catheter is in the bladder, as indicated by the flow of urine...Inflate the balloon of the indwelling catheter with sterile water to the volume indicated in the manufacturer's instructions. Do not inflate the balloon until urine flow appears; early inflation may injure the urethra...After inflating the balloon, pull gently on the catheter tubing until resistance is felt. Rationale: Pulling until resistance is met ensures that the catheter tip is anchored and positioned at the bladder neck..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 1/30/17 with readmissions on 4/16/17, 10/30/18, 5/18/19, 6/4/19 and 6/15/19 with diagnoses to include Acute on Chronic systolic Congestive Heart Failure, Acute Respiratory Failure with Hypoxia, Risk for falls, Benign Prostatic Hyperplasia, and Alzheimer's Disease.

Review of the Emergency Department Clinical Summary dated 1/30/17 at 5:59 PM for Patient #1 revealed, " ...At 12:20 [PM], I was informed by the nurse that no urine was coming from the 3-way Foley catheter. I asked if we were sure if the Foley catheter was in the bladder. She states that the balloon inflated without difficulty, so she thought that they were likely in the bladder. At this time I ordered an ultrasound to confirm placement. At 13:30 [1:30 PM], ultrasound shows that the Foley catheter is not in the bladder..."

Review of a GU [Genitourinary] final report dated 1/30/17 revealed, "...Prostatic catheter tip is within the prostatic urethra and does not appear to extend into the urinary bladder...possible urethral injury from foley..."

Review of a physician progress note dated 1/31/17 revealed, "...CT [Abdomen Pelvis] scan shows enormous prostate...Reason for Exam...Hematuria...Impression: Markedly enlarged prostate gland with mass effect on the urinary bladder...urethral trauma from ER [Emergency Room] RN [Registered Nurse] inflating foley balloon in urethra and then pt pulling on catheter..."

Review of the discharge summary dated 2/6/17 revealed, "...POSTOPERATIVE DIAGNOSIS: Gross hematuria, urethral injury from Foley catheter balloon..."

The hospital was unable to provide documentation of an event report or an internal investigation summary for the incorrect Foley placement on 1/30/17.

Review of a physician's order dated 6/17/19 revealed, "...Urinalysis...Straight cath, Routine collect..."

Review of a patient care note dated 6/18/19 revealed, "Bladder scanned pt due to no urine output during in and out cath [catheter]. Bladder scan showed 275mL [milliliters]. Pt has new onset hematuria..."

Review of a progress note dated 6/20/19 revealed, "...Assessment...hematuria 2/2 [secondary] trauma..."

Review of a physician's order dated 6/21/19 revealed, "...Intermittent Catheterization (In & Out Cath)..."

Review of a patient care note dated 6/21/19 revealed, "New orders received to complete straight cath...Straight cath performed and half way this nurse met resistance. Straight cath insertion was stopped and catheter removed and [Named Physician] notified..."

During a telephone interview on 7/3/19 at 8:31 AM with the complainant who is Patient #1's daughter. This daughter is also his Power of Attorney. She stated that she told the ED staff and the nursing staff each time he was admitted that she did not want her father to have a catheter (Urinary). She stated that the hospital staff inserted a urinary catheter on more than one occasion even though she told them he cannot have a catheter.

During an interview on 7/2/19 at 10:55 AM in the Quality conference room, the Nurse Manager was asked what would be done if a nurse improperly inserted a Foley catheter. The Nurse Manager stated, "I would have them call the doctor. I tell them if they have trouble with anything to call the doctor." She was asked if she would re-train the nurse. The Nurse Manager stated, "I would pull them aside and tell them we need good return and then inflate the balloon, and if there are issues or problems, deflate the balloon, remove it and call the physician."

During an interview on 7/3/19 in the administrative conference room, the Risk Manager was asked if the incident on 1/30/17 was reported to Risk Management and investigated. The Risk Manager stated, "No..."

3. Review of the hospital's Fall Prevention policy revealed, "...Types of Falls...Anticipated Physiological Falls: Factors associated with known fall risks as indicated on the Morse Fall Scale are predictive of a fall occurring...impaired cognition/confusion...Falls that we anticipate will occur due to the patient's existing physiological status, history of falls...Implement "Preventive" Interventions for Morse fall score less than or equal to 44. No/Low risk to fall...Implement "Protective" and "Preventive" Interventions for Morse fall score of greater than or equal to 45 for all High risk to fall patients... Interventions... Evaluate patient for Safety Watch (the need to increase rounding Q (every) 30/15 minutes) per the Safety Watch. algorithm/Criteria... PROCEDURE FOR RESPONDING TO PATIENT FALLS...Conduct Post Fall Huddle as soon as possible after the fall. During the Post Fall Huddle determine the potential cause of the fall and ways to ensure the fall will not occur again...Upon completion, Post Fall Huddle form to be reviewed by department leaders/Quality/Risk for further evaluation and follow up...Complete patient fall event report..."

Review of the hospital's event note of the fall that occurred on 4/16/17 at 7:00 PM revealed, "...approximately 1905 [7:05 PM]...heard patient's bed alarm...Patient appeared to be at his baseline...pt instructed to stay in bed and to use his call light if he needed anything...pt is alert to self only, forgetful of recent instructions given...does not follow directions as instructed...continues to attempt to get out of bed, refuses to follow instructions..."

Review of the hospital's event summary of the fall that occurred on 4/16/17 at 7:00 PM revealed, "...Manager investigated and found that all precautions were in place. Fall occurred during shift change. Unit was appropriately staffed at time. Patient had been rounded on within 5 minutes of fall..."

Patient #1 fell on 4/16/17 which was the day of admission.

Review of the discharge summary dated 4/17/17 revealed, "...He was also felt to be dehydrated and was admitted in observation for IV fluids...The pt did have some difficulty with "sundowning" and confusion and required sedation and a sitter..."

Patient #1 was admitted through the Emergency Department (ED) on 10/30/18 due to seizure activity.

Review of a progress note dated 11/1/18 revealed, "...Per nursing, patient was found on ground yesterday night, confused, MD was called and patient was placed back in bed. Sitter at bedside...Right elbow with abrasion..."

Patient #1 fell on 10/30/18 which was the day of admission.

Review of a progress note dated 11/2/18 revealed, "...Sitter still at bedside since patient is sometimes impulsive to get out of bed..."

Review of the falls information dated 10/31/18 revealed Patient #1 fell on 10/30/18. There were no Morse fall scores documented on 10/30/18 or 10/31/18. The Morse fall scores were documented from 11/1/18 through 11/4/18 from 75 to 95, indicating high risk for falls.

Review of the discharge summary dated 11/6/18 revealed, "...Pt had a fall on the night of 10/31. A sitter was placed at the bedside... Pt's sitter was removed on 11/2 d/t [due to] return to mental baseline..."

During an interview with the Risk Manager on 7/3/19 at 5:15 PM, she stated she was unable to find an investigation for the fall that occurred on 10/30/18.

Review of an ED Triage Note dated 5/18/19 revealed, "...pt's daughter reports pt c/o [complained of] back pain following a fall. pt's daughter reports pt has fallen three times today. [at home] unknown if pt hit is head..."

Review of the ED physician documents dated 5/18/19 revealed diagnoses that included multiple falls.

Review of the falls information dated 5/18/19 through 5/22/19 revealed Patient #1 fell on 5/18/19. The Morse fall scores were documented from 70 to 110 indicating high risk for falls.

Review of the hospital's event summary of the fall that occurred on 5/18/19 at 4:30 PM revealed, "...Pt had yellow socks, bed alarm on, bed in low position, bedside floor mats in place, fall risk signs on door frame. Staff aware that patient was admitted for history of falls, took appropriate precautions prior to fall. Reported to this nurse that patient uses bathroom about every 30 minutes and does not call for help. Has dementia and just jumps out of bed...sitter assigned post fall. Family aware and had mentioned to staff that he will probably need a sitter per his history..."

Patient #1 fell on 5/18/19 which was the day of admission.

Review of the discharge summary dated 5/22/19 revealed, "...s/p [status post] fall, CT [computerized tomography] head was obtained and non-acute and sitter was placed at bedside to ensure patient safety..."

During a telephone interview on 7/3/19 at 8:31 AM with the complainant who is Patient #1's daughter and Power of Attorney, she stated that she told the ED staff and the nursing staff each time he was admitted that he needed a sitter, but the hospital would only get a sitter for him after he would fall.

During an interview on 7/3/19 at 10:00 AM in the administrative conference room, Physician #1 was asked about Patient #1 and any interactions or issues with the family. Physician #1 stated, "...I admitted him, and she was unhappy. She was unhappy about his last fall. He stated he did not remember if the daughter asked for a sitter.

Based on record review and interview, the facility failed to ensure a provider (Physician #1) reported a potential mislabeling of a blood specimen that would prevent any future occurrence of potential adverse events for 1 of 3 (Patient #2) patients reviewed.

The findings included:
Medical record review revealed Patient #2 was admitted to the hospital on 11/2/18 with diagnoses to include Dizziness, Nausea and tingling in hands.

Review of the ED (Emergency Department) Physician Documentation dated 11/2/18 at 12:58 AM revealed an initial Troponin level elevated at 0.074 ng/mL. (nanograms per millilitre)(Normal range: 0.000 to 0.056 ), and a low Potassium level of 3.1 mmol/L (millimoles per Liter). (Normal range: 3.5-5.0) The ED physicians felt Patient #2 could remain in observation for serial troponins.

Patient #2 was transferred via ambulance to the main hospital to the Observation Telemetry Unit on 11/2/18.

A second Troponin level was drawn on 11/2/18 at 6:50 AM at 0.03 mmol/L (within normal range).

Review of the Discharge summary dated 11/2/18 revealed, "...PAtient was placed in observation due to elevated troponin in absence of chest pain. later was found due to lab error/mislabeling. repeat troponin was negative. PAtient stable for discharge to home..."

During a telephone interview on 7/3/19 at 8:18 AM, Patient #2 revealed her concern was she was sent to the hospital from the free standing emergency room because her heart enzymes were elevated. Patient #2 stated the next morning the doctor came in to see her and told her there was a mixed up or mislabeled of her blood work. Patient #2 stated they drew blood that morning after they told me it was mislabeled.

During an interview on 7/3/19 at 12:24 PM in an administrative office, the Administrative Director of the Laboratory (ADL) was asked if he was aware of the possibility that a blood vial was mislabeled for Patient #2. The ADL stated that the first troponin level was drawn at the free standing emergency room across town at 12:58 AM. The ADL stated that a vial of blood was drawn for a CMP (Comprehensive Metabolic Panel) and troponin (cardiac enzyme). The vial of blood hemolyzed (ruptured red blood cells) and the CMP was not released. Troponin was not part of the CMP panel and not affected by hemolysis and it was released. The ADL was asked what the normal lab value was for Troponin. He stated, "0.000 to 0.056 and should be drawn at 0, 3 and 6 hours" The ADL was asked if the lab was notified of the error of mislabeling or the accuracy of the result. He stated they lab was never notified of anything. The ADL stated that the free standing emergency room have different manufactures for lab results and they use different methodologies. He stated the results could be different but not significant. He stated that if there is any question of error with labeling or sample quality, the sample is errored out and re-drawn. There was a re-draw ordered for Patient #2 for 11/3/18 at 4:00 AM, but she was discharged prior to 11/3/18.

During an interview on 7/3/19 at 1:00 PM in an administrative office, Physician #1 was asked how she was made aware of the lab error/mislabeling for Patient #2's troponin level. Physician #1 stated, "...I do remember something that it was an error. I think I got a call from someone that they realized it wasn't hers. I do not remember who, but it wasn't the ER doctor..." Physician #1 was asked if she reported it to administration. Physician #1 stated, "I was in a care management meeting, I vaguely remember [Named Case Manager] said she heard there was some mislabeling, I said it first. It was nothing definite, it was just relayed to me. I could not confirm that..."

Based on policy review, medical record review and interview, the facility failed to ensure a complete medical record of fluid intake and output for 1 of 3 (Patient #1) records reviewed.

The findings included:

1. Review of the hospital's intake and output (I & O) policy revealed, "...Intake and Output will be done per physician's order...If the Physician Orders I & O more frequently than every 12 hours, it will be completed as ordered and documented in the electronic record in the Flow Sheet...Intake includes: liquids by mouth...IV [intravenous] fluid...Output includes: urine..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 1/30/17 with readmissions on 4/16/17, 10/30/18, 5/18/19, 6/4/19 and 6/15/19 with diagnoses to include Acute on Chronic systolic Congestive Heart Failure, Acute Respiratory Failure with Hypoxia, Risk for falls, Benign Prostatic Hyperplasia, and Alzheimer's Disease.

Review of a physician's order dated 6/15/19 revealed, "Intake and Output...q4hr [every 4 hours]"

Review of the Intake and Output record dated 6/15/19 through 6/24/19 (10 days) revealed a total intake of 746 mL and a total output of 1800 mL which resulted in a negative fluid balance of -1054 mL.