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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 documented, investigated and reviewed for 1 occurrence (Patient #3).

Findings include:

1. Review of the policy/procedure Complaint Grievance Process (approved 3-21) indicated the following: "A grievance is defined as "a written or verbal complaint... by the patient or the patient's representative regarding the patient's care... A grievance may involve a situation where the patient or his or her representative phones the hospital with a concern that constitutes a grievance (i.e., the care provided to the patient...)...When a complaint/grievance is initiated/received from the patient/patient's representative, staff who received the complaint or grievance report the event online in the Event Reporting System (Service Failure)..."

2. Review of grievance documentation for the period surrounding the allegations failed to indicate a concern involving the quality of care provided for Patient #3 was reported, investigated and/or resolved.

3. On 6-16-21 at 1145 hours, the 5T Nurse Manager A10 confirmed they had been contacted after the Code Blue event involving Patient #3 by a family member (FM32) who expressed quality of care concerns about the patient event and the staff confirmed they (A10) had not documented the patient grievance in the event reporting system.

Based on document review and interview, the facility failed to follow its policies and procedures and ensure documentation of cardiac rhythm strip recordings was maintained in the permanent medical record (MR) for 1 of 10 MR reviewed (Patient #3).

Findings include:

1. Review of the policy/procedure Authentication of Entries into the Medical Record (reviewed 8-20) indicated the following: "All medical record entries, including handwritten and electronic, must be legible, complete, documents accurately the course of treatment and results, dated, timed and authenticated by the person responsible for providing or evaluating the services provided ..."

2. Review of the policy/procedure PT03.26 Code Blue (approved 5-21) indicated the following: "STAT RN/Critical Care/ED RNs... Responsible for rhythm strip documentation... Responsible for review of documentation for accuracy; all strips signed and placed in patient chart."

3. Review of the 4-29-21 Code Resuscitation entry for Patient #3 by the T5B Registered Nurse N11 indicated a Code Blue response was activated at 1820 hours and the first rhythm requiring chest compressions was asystole and no documentation of cardiac rhythm strip recordings created during the Code Blue event was identified.

4. Review of the nursing narrative entry on 4-29-21 at 1900 hours by the STAT Registered Nurse N13 indicated the following: "Code Blue called... Arrived floor staff performing CPR... First pulse check and rhythm check: none and V-tach..."

5. Review of all of the cardiac rhythm strip recordings and electrocardiogram documentation present in the permanent medical record for Patient #3 failed to indicate any cardiac rhythm strip documentation created during the Code Blue event on 4-29-21 was signed and placed in the patient record by N13.

6. On 6-15-21 at 1330 hours, the Quality Manager A3 and the Director of Health Information Management A6 confirmed the above.