HospitalInspections.org

Based on document review and interview, the facility failed to follow its grievance policy and ensure all complaints involving the quality of care provided to the patient were identified as grievances and investigated and reviewed for 1 occurrence (Patient #6).

Findings include:

1. Review of the policy/procedure Patient Complaints and Grievances (approved 9-19) indicated the following: "Grievance means a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative when a patient issue cannot be resolved promptly by staff present. It should be related to patient care issues... It is the responsibility of the department director or his/her designee to write a written letter to the patient/legal representative at the conclusion of the investigation when an event is classified as a grievance."

2. Review of grievance documentation for the period surrounding the allegations indicated a concern involving the quality of care provided for Patient #6 was reported on 12-11-21 and lacked documentation indicating the patient care issue was investigated, reviewed, and/or resolved.

3. On 2-25-2022 at 1140 hours, the VP Chief Quality Officer A3 confirmed the quality of care concern reported on 12-11-22 regarding Patient #6 was not categorized as grievance in the event reporting system and the issue was not investigated and/or resolved.

Based upon document review and interview, the Registered Nurse failed to supervise and evaluate the care provided to each patient for 3 of 10 medical records (MR) reviewed (Patient's #6, 7 and 8).

Findings include:

1. Review of the policy/procedure Standards of Patient Care Medical Surgical (reviewed 4-19) indicated the following: "All patient's unable to turn self shall be repositioned a minimum of every two hours and document on ADL flowsheet."

2. Review of the MR for Patient #6 lacked documentation indicating the patient was routinely repositioned every 2 hours on 12-6-21 from 1618 hours until 2200 hours, on 12-8-21 from 1100 hours until 2250 hours, on 12-8-21 from 2250 hours until 12-9-21 at 0700 hours and on 12-9-21 from 1500 hours until 2245 hours.

3. On 2-24-22 at 1455 hours, the Clinical Informaticist A9 confirmed the MR for Patient#6 lacked the above.

4. Review of the policy/procedure Hygiene (approved 6-19) indicated the following: "Hygiene will be maintained... Provide daily opportunity for daily and prn hygiene and assist as needed."

5. Review of the policy/procedure Linen Utilization Policy (approved 4-19) indicated the following: "Linen changes will occur on a daily basis and prn."

6. Review of the MR for Patient #6 lacked documentation of bathing and/or bed linen changes on 12-5-21, 12-6-21 and 12-9-21.

7. Review of the MR for Patient #7 lacked documentation of bathing and/or bed linen changes on 12-8-21 and 12-9-21.

8. Review of the MR for Patient #8 lacked documentation of bathing and/or bed linen changes on 12-10-21 and 12-11-21.

9. On 2-24-22 at 1455 and 1650 hours, the Clinical Informaticist A9 confirmed the MR for Patient's #6, #7 and #8 lacked the above.