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Based on interview and record review, the facility failed to operationalize its policy and procedure to ensure 1 of 1 grievance brought to the facility's administrative staff was responded to in writing in a timely manner. Patient #1


Findings:

Review on 03/27/2017 of Patient #1's clinical record ( Demographic data) revealed he was admitted to the facility via the emergency department on 09/13/2016 with presenting signs and symptoms of shortness of breath and chest pain.

Review of the Patient's discharge summary dated 10/26/2016 revealed, the patient with a history of Hypertension, Diabetes Mellitus presented to the ER with shortness of breath and chest pain on 09/13/2016. He was found to have "Acute bilateral extensive saddle pulmonary embolism."


On 03/27/2017 the following allegations written as a complaint was investigated related to Patient #1 who was a patient at the facility from September 13, 2016 to September 27th 2016:

Patient's spouse was treated with lack of respect, concerns and request for information were ignored. Questions and concerns were not taken seriously.
Patient Intravenous site was sore, friend notified staff. Staff was resentful of notification.
There are safety risks to patients. On September 25, 2016 there were significant neglect regarding patient's mobility, education needs, and prescriptions in the patient's planned discharged which cause him to remain an extra night in the facility.
A sequential compression device (SCDs) was applied to the patient's legs prior to an ultra sound for deep vein thrombosis. Patient had TPA September 2016 to treat pulmonary embolism. A nurse said the SCDs were contraindicated.
Patient was put at risk for falls. A nurse encourage the patient to use toilet in the room with the nurse's assistance. Patient was instructed not to get out of bed until evaluated by the physical therapist. Physical therapist recommended use of a bedside commode.
The call button in the patient's room was broken along with several other patients' rooms. Patient's call light was not repaired until patient's spouse complained.


Review of the Facility's record revealed documentation of a written complaint dated September 26, 2016 which was e-mailed to the facility's Former Chief Nursing Officer.
The complaint outlined some of the above allegations. In the facility's complaint, the complainant documented the following:" Please consider this letter a formal complaint regarding the care of my husband."


ON 03/27/2017 at 10:00 a.m the Surveyor requested documentation from the Facility's AVP for Quality ( C) of investigation done by the facility regarding the formal complaint e-mailed to the facility regarding Patient #1. None was provided.


Interview on 03/27/2017 at 11:40 a.m with the facility's AVP for Quality (C) revealed she had spoken to the former CNO who is no longer hired by the facility. She said the CNO told her, she had received the complaint from the family, that she had met with the complainant but after speaking with the complainant she thought the issues were addressed. She said the facility has no record of formal response to the grievance. She said at the approximate time of the complaint, the facility had changed their grievance process in that the Director for the unit is responsible for investigating the complaint and writing the response letter. The letter is then sent to Administration where the Chief Nursing Officer is responsible for reviewing and signing off on the letter. She said the Facility's Administrative Assistant was responsible for coordinating the process.


Interview on 03/27/2017 at 12:42 p.m. with the Former Chief Nursing Officer (G) revealed she remembered talking to the Patient's wife. She said the wife was concern about the care of the Patient's SCDs (sequential compression device) and call light issues. She said she followed up with the Director of the unit who assured her that the concerns were handled and that she was not aware of any other issues.
She said all conversation with the Patient's wife was in person or via the telephone. She said the facility's grievance process included responding to the complainant in writing. She stated "I did not write or respond back to her in writing."


Review of the Facility's current Patient Grievance and Complaint Management Policy, # 2788460, originated 07/2015 and revised 12/2016 directed staff as follows:
" A written complaint is always considered a grievance, whether from an inpatient, out patient, released /discharged patient or their representative. A written complaint also includes those complaints received via electronic mail or facsimile. Regardless of the form in which a complaint is received, whenever a patient or patient's representative requests a response from the facility, the issue is defined as grievance."
(5) "In resolution of the grievance , a written notice of decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the result of the grievance investigation and date of completion."