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Based on policy review, document review, record review, and interview, the Hospital failed to identify and acknowledge a patient and/or patient representative's care concerns as a grievance for 1 of 6 sampled patients (Patient 1). This deficient practice places any patient or patient care representative who had care concerns at risk of not having his/her concerns reviewed, investigated, and resolved.

Findings Include:

Review of a policy titled, "Patient Grievance and Complaint Management Policy," revised 08/02/20, showed that the purpose of the policy was to establish a process for timely referral, prompt review, investigation, and resolution of patient complaints and grievances. Per policy, the definition of a complaint is, "A concern represented by a patient or patient's representative that can be addressed or resolved promptly by staff members who are present at the time of the complaint. "Staff present" includes those individuals close to the complaint situation or who can quickly be at the patient's location (i.e. nursing, administration, nursing supervisors, patient advocate, etc.) to resolve the patient's complaint. Generally, complaints can be resolved timely while the IT is still receiving care at the facility." Per policy the definition of a patient grievance is, "A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care ...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 a grievance." Further review of the policy showed the grievance resolution process included, " ...Upon receipt of a grievance, the Risk Management Coordinator (or designee of the organization) shall confer with the appropriate department manager to review, investigate, and resolve with the patient and/or patient representative within seven (7) days of receipt of the grievance with the exception of complaints that endanger the patient (i.e., abuse or neglect) ...If the grievance will not be resolved, or if the investigation is not or will not be completed within seven (7) days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days ...As appropriate to the grievance being investigated, the following investigative approach will be used: Contact the patient or patient representative to acknowledge their unresolved complaint or grievance ...Interview staff involved in the direct care of the patient or with firsthand knowledge of the grievance event ...Review medical record ...Regardless of the nature of the grievance, the substance of each grievance must be addressed while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance ...a written notice of the decision must be provided to the complainant ...A grievance is considered resolved when the patient and/or patient representative is satisfied with the actions taken on their behalf. There may be situations where the organization has taken appropriate and reasonable actions on the patient's behalf in order to resolve the patient's grievance and the patient or the patient's representative remains unsatisfied with the actions taken by the organization. In these situations, the designated facility leaders may consider the grievance closed for the purposes of the requirements of the Conditions of participation. However, the organization must maintain documented evidence of compliance with all regulatory requirements ..."


Review of Patient 1's discharged medical record showed a 73-year-old female that was admitted through the Emergency Department (ED) for observation on 07/16/23 at 5:35 PM with a chief complaint of chest pain and was then admitted to in-patient status on 07/16/23 at 5:44 PM. Review of the medical record showed an admission diagnosis of aspiration pneumonia and a past medical history that included a history of aspiration pneumonia, esophageal stricture, Roux-en-Y gastric bypass (weight loss surgery), ovarian cancer, chronic anemia requiring blood transfusions, and malnutrition.


Review of a document titled, "Patient Safety Analysis," dated 07/28/23 at 10:46 AM by Staff P, showed that F2 had filed a verbal grievance/complaint on 07/27/23 on behalf of Patient 1 with a primary complaint of "Quality of Care and Treatment." Staff P's documentation showed, "Family members of patient unhappy with medical care provided. [F2], who identified herself as the patient's daughter, informed me on 7.27.23 of events occurring the previous day ...I called [F2] back on 7.27.23 and she expressed to me that many of her concerns were addressed, aside from the patient being dry and needing to have tube feeding resumed ...In the afternoon of 7.27.23, I was informed that the patient's family had spoken to the house supervisor and were having further issues ...[F2] states that [F1] is the patient's DPOA ...I received a VM (voicemail) from [F1] detailing similar concerns as listed above ..." Further review showed an "Investigation Note" dated 08/02/23 by Staff K, Med/Surg Director, " ...7/31/23 [Staff K] asked [F1] to communicate concerns with department leadership verses calling various departments with care concerns. Unable to meet all requests of [F1] ..." Another "Investigation Note" dated 08/06/23 by Staff Q, Med/Surg Manager, showed, "Reviewed and aware of all above stated. Assisted [Staff K] with all grievances and resolutions." Further review of the document showed the hospital classified Patient 1's care concerns as an unsubstantiated complaint versus a grievance and that the standard of care was met.


Review of a document titled, "Patient Safety Analysis," dated 07/31/23 at 4:36 PM by Staff K, Med/Surg Director, showed that F1 had filed a grievance/complaint on 07/31/23 at 1:10 PM on behalf of Patient 1 with a primary complaint of care concerns. Staff K's documentation showed, "Daughter calling house sup with care concerns. July 31, 2023, 1143 (11:43 AM) [F1] called and spoke to house supervisor. House Sup [supervisor] spoke to daughter for approx. 18 min ...1310 (1:10 PM) [F1] left VM (voicemail) for house sup ...VM played with Med-Surg director and patient advocate ...Daughter [F1] states that daughter [F2] is requesting help and is at her 'wits end today" and wants to "speak to the head of the doctors" today ...Director sent information to [physician] with concern ..." Further review showed an "Investigation Note" dated 08/02/23 by Staff K, Med/Surg Director, " ...Completed nurse leader rounding with patient on 08/01/23 (day of DC [discharge]). No further issues to address. Another "Investigation Note" dated 08/06/23 by Staff Q, Investigator, showed, "Reviewed, all issues reported were addressed in real time with [Staff K], patient advocate, nurse, house sup. Not a grievance." Further review of the document showed the hospital classified Patient 1's care concerns as "No Action Required" and as unsubstantiated and that the standard of care was met.

Review of a document titled, "Complaint/Grievance Log," showed two entries for Patient 1, " ...Date Reported 07/28/23 ...Date of Event 07/26/23 ...Type of Event Patient Experience ...Status Assigned ...Assigned To (none documented) ...Date Reported 07/31/23 ...Date of Event 07/31/23 ...Type of Event Patient Experience ...Status Assigned ...Assigned To (none documented)".


During an interview on 08/15/23 at 4:12 PM, Patient 1's family member (F1) stated that he/she was the Durable Power of Attorney (DPOA) for Patient 1 and that Patient 1, "being alert and oriented [Patient 1] makes most of his/her own medical decisions." During the interview F1 stated that he/she had voiced multiple concerns/complaints to various hospital staff regarding Patient 1's medical care. F1 stated that he/she had voiced complaints to the nurses, House Supervisor, Director of the Medical Surgical (Med/Surg) unit, physician, and left a voice message with the assistant administrator. F1 stated that he/she had not received a return call from administration nor received any written communication from the hospital regarding his/her concerns.


During an interview on 08/16/23 at 3:47 PM, Staff K, Med/Surg Director, stated, "I was heavily involved with the family concerns, they had been here for several days ...The family was calling various people with concerns ...I talked to the daughter several times ..." When asked to explain the difference between a complaint and a grievance, Staff K stated, "A complaint will be something that can be resolved before they leave or in real time." When asked why F1's concerns were not escalated to the level of grievance, Staff K stated, "I can't speak to why her concerns were not raised to the level of a grievance. I talked to the daughter the day before discharge and there did not appear to be further needs or actions to be taken at that time. Risk Management and the Patient Advocate would determine if it is a complaint or a grievance."



The hospital failed to acknowledge F1's multiple patient care concerns as a grievance. F1 expressed the concerns to multiple hospital staff including nurses, house supervisor, the Medical/Surgical Manager and Director, physician, and a Risk Specialist and requested a response. The hospital's failure to follow its "Patient Grievance and Complaint Management" policy resulted in a lack of investigation, medical record review, and written resolution response to the complainant.

Based on policy review, record review, and interview, the Hospital failed to ensure that nursing staff evaluated the care for each patient by failing to provide ongoing pain assessments and patient's response to pain intervention for 2 of 6 sampled patients (Patient 1 and 3). This deficient practice puts any patient receiving services at the hospital at risk of having ongoing severe pain.


Findings Include:

Review of a policy titled, "Pain Assessment and Reassessment," revised 06/2021, showed that the comprehensive pain assessment for an adult inpatient includes intensity utilizing an age-appropriate pain scale when appropriate, location, and nature of pain such as dull, sharp, throbbing, stabbing, or radiating. The focused pain reassessment includes assessment of pain intensity using an age-appropriate pain scale. The policy stated, " ...An age and ability-appropriate pain assessment will be conducted for any patient reporting or suspected of having pain ...Comprehensive pain assessment should be documented on admission, each shift, and with each new complaint/location of pain ...A pain focused reassessment needs to be completed within one hour of a pharmacologic intervention(s) intended to lessen the patient's pain."

Review of a policy title, "Pain Management," dated 12/08/21, showed the purpose of the policy is to provide guidelines for caregivers in the screening, assessment, reassessment, and treatment of pain. The policy stated, "Unrelieved, non-ischemic pain is defined as a pain scale intensity rating of equal to or greater than four (4) or, causes the patient distress or, is unacceptable to the patient or, limits the patient's physical, cognitive or psychological function. Pain relief is considered the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient and is demonstrated by a decrease in the patient's pain scale rating and an improvement in physical, cognitive, behavioral, and/or psychosocial functioning. The process for pain assessment showed, "Assess every patient for presence of pain: On initial assessment; At regular intervals, with a minimum of once per shift; On hourly rounding; With each new reporting of pain before, during and after any known pain-producing event; With unrelieved pain; Re-assess pain intensity after each pain management intervention ...30 minutes for IV, 60 minutes for PO/IM, and 15-60 minutes for non-pharmacological ...Adult pain rating scales used include: Numeric, (0-10; 1-3=mild pain, 4-6=moderate pain and 7-10=severe pain ...The physician should be notified of pain that is unrelieved with available/ordered modalities ..."


Patient 1

Review of Patient 1's discharged medical record showed a 73-year-old female that was admitted through the Emergency Department (ED) for observation on 07/16/23 at 5:35 PM with a chief complaint of chest pain. Patient 1 was admitted to in-patient status on 07/16/23 at 5:44 PM. Review of the medical record showed an admission diagnosis of aspiration pneumonia and a past medical history that included a history of aspiration pneumonia, esophageal stricture, Roux-en-Y gastric bypass, ovarian cancer, chronic anemia requiring blood transfusions, and malnutrition.


Review of an order dated 07/24/23 showed, "oxycodone HCL (a pain medication) 5 milligrams (mg), PO (by mouth), every six (6) hours as needed for Pain Scale 4-6 (Moderate)".


Review of an order dated 07/24/23 showed, "fentanyl (a pain medication) 50 micrograms (mcg), IV (intravenous), every three (3) hours as needed for Pain Scale 7-10 (Severe)."


Review of Patient 1's Electronic Medication Administration Record (EMAR) showed the following:


On 7/24/23 at 3:36 PM, Patient 1 received oxycodone 5mg for a pain severity rating of 6. At 5:43 PM, Patient 1's pain was reassessed with a pain severity rating of 6. The reassessment was not completed within one hour of medication administration as required per hospital policy. At 9:52 PM, Patient 1 received oxycodone 5mg for a pain severity rating of 8 instead of fentanyl as needed for severe pain (Pain Scale 7-10). Documentation failed to show evidence of a pain reassessment as required per hospital policy.


On 07/25/23 at 4:10 AM, Patient 1 received oxycodone 5mg for a pain severity rating of 7 instead of fentanyl as needed for severe pain (Pain Scale 7-10). Documentation failed to show evidence of a pain reassessment as required per hospital policy. At 11:39 AM, Patient 1 received oxycodone 5mg for a paint severity rating of 6. At 12:52 PM, Patient 1's pain was reassessed with a pain severity rating of 4. The reassessment was not completed within one hour of medication administration as required per hospital policy. At 8:10 PM, Patient 1 received oxycodone 5mg for a pain severity rating of 7 instead of fentanyl as needed for severe pain (Pain Scale 7-10). At 9:43 PM, Patient 1's pain was reassessed with a pain severity rating of 8. The reassessment was not completed within one hour of medication administration as required per hospital policy and nursing staff failed to administer fentanyl when Patient 1 reported being in severe pain. Nursing staff failed to provide fentanyl until 11:41 PM when Patient 1's pain level had increased to 10 (~2 hours after Patient 1 reported a pain severity level of 8.)

On 07/26/23 at 2:47 AM, Patient 1 received oxycodone 5mg for a pain severity rating of 8 instead of fentanyl as needed for severe pain (Pain Scale 7-10). Documentation failed to show evidence that nursing staff reassessed Patient 1's pain status between 6:44 AM and 1:05 PM. At 1:05 PM, Patient 1 received oxycodone 5mg for a pain severity rating of 8 instead of fentanyl as needed for severe pain.




Patient 3

Review of Patient 3's discharged medical record showed a 20-year-old male, admitted on 05/03/23 for a gunshot wound resulting in traumatic injuries to the left hand and chest including a fractured right scapula, fractured right 7th rib, right lung pneumothorax, and fractures to the left hand first and third digit metacarpals.


Review of an order dated 05/03/23 at 9:11 PM showed, Ibuprofen 600 mg, by mouth four times daily at 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM for pain.

Review of an order dated 05/03/23 at 8:49 AM showed, Fentanyl 50 mcg, IV, every two hours as needed for pain severity level 7-10.

Review of an order dated 05/03/23 at 9:11 PM showed, Oxycodone 5 mg, by mouth every three hours as needed for pain severity level >5.

Review of an order dated 05/03/23 at 9:11 PM showed, Oxycodone 10 mg, by mouth every 4 hours as needed for severe pain (7-10.)


On 05/04/23 at 5:53 AM, Patient 3 received fentanyl 50 mcg, IV, for a pain severity level of 10. Documentation failed to show evidence that a licensed nurse completed a pain reassessment within 30 minutes as required per hospital policy. At 9:11 PM, Patient 3 received 10 mg oxycodone by mouth for a pain severity level of 5. Documentation failed to show evidence of a pain reassessment within one hour as required per hospital policy.


On 05/05/23 at 1:31 AM, Patient 3 received oxycodone 10 mg by mouth for a pain severity rating of 8. Documentation failed to show evidence of a pain reassessment within one hour as required per hospital policy. At 8:20 AM, Patient 3 received oxycodone 10 mg by mouth for a pain severity rating of 5. Documentation failed to show evidence of a pain reassessment within one hour as required per hospital policy.


On 05/05/23 at 12:57 PM, Patient 3 received scheduled dose of ibuprofen 600 mg by mouth with a pain severity rating of 4. Documentation failed to show evidence of a pain reassessment within one hour as required per hospital policy. At 2:46 PM, Patient 3 received oxycodone 10 mg by mouth for a pain severity rating of 6. Documentation failed to show evidence of a pain reassessment within one hour as required per hospital policy.


During an interview on 08/16/23 at 3:47 PM, Staff K, RN stated that pain assessments are required once per shift and pain reassessments are required within one hour following oral pain medication administration and within 30 minutes following IV pain medication administration.

During an interview on 08/17/23 at 11:20 AM, Staff L, RN, stated that pain assessments are required per shift and follow-up pain reassessments are required within 15-30 minutes following IV pain medication administration and within 45-60 minutes following oral pain medication administration.

During an interview on 08/17/23 at 11:48 AM, Staff M, RN, stated, "Pain assessments are done with the full assessment and on-going especially when administering pain medication." Staff M stated that a pain reassessment is required within 15-30 minutes following IV pain medication and within 30-60 minutes following oral pain medication.