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Based on record review (RR), document review and interviews, the facility failed to acknowledge, investigate and resolve one patient's (P)1 family members (FM)1 grievance of a sample size of three. The day before P1's discharge, Social Worker (SW)1 spoke with FM1 on the phone when FM1 verbalized being upset regarding P1's care. SW1 was not able to resolve the concerns on the phone call, but did not identify the conversation as a grievance and process it appropriately. As a result of this deficiency, FM1's complicated ongoing concerns, they were not all acknowledged, reviewed, investigated or resolved in a timely manner.

Findings include:

1) P1 was a 62 year old female had a history of advanced COPD (chronic obstructive pulmonary disease/pulmonary fibrosis ) chronic respiratory failure, anxiety disorder, chronic pain syndrome, suspected lung cancer, and severe malnutrition. She had a Stage III Pressure Ulcer (PU) and was on home oxygen and BiPAP (breathing device that delivers air pressure when you breath in and out). P1 has had multiple Emergency Department (ED) visits and hospital admissions due to her chronic condition. On 04/04/2024, she presented to the ED for shortness of breath and was admitted for further care. P1's hospitalization was complicated by a fall on 04/07/2024 resulting in a fracture of the left hip that required surgical repair. In addition, P1 was diagnosed positive with a Hospital Acquired COVID infection on a specimen collected 05/06/2024, 32 days after admission. She was discharged home on 05/23/2024 with Home Health Referrals.

2) Review of Nursing Progress Notes revealed the following entries:
04/29/2024 03:14 PM Medical Unit Registered Nurse (RN)1 note: "family concerns patient (P)1 was speaking with Family Members (FM1 and FM2) on the phone and asked to speak with this RN. FM1 asked if oxygen was being monitored and titrated as needed. I explained to FM's that P1's oxygen was monitored. FM1 then asked how often, explained with vitals every 4 hours and when RT (respiratory therapy) assesses and administer treatments. FM1 then started getting upset and stated that told all the doctors that he wants continuous Telemetry and oxygen monitoring of P1. ...FM1 said he has been taking care of P1 for "years" and that she is on continuous heart and oxygen monitoring at home at all time [sic]. Explained to FM1 I would give Provider (MD)1 the message to call back. ...When asked FM1 did not know that the patient was downgraded to team W (medical unit) and that they did not want this for the patient. When they were asked, who did they speak to with all these concerns ..., they stated that they spoke with everyone that took care of the patient. ...MD1 in to talk with patient and MD1 did call family back."
Review of Social Services notes revealed the following entry:
05/22/2024 at 11:06 AM: "This SW (Social Worker)1 met with pt at bedside to discuss DC (discharge) planning and provide psychosocial support. ...This SW shortly after received a call from FM1 and discussed home health vs SNF (skilled nursing facility). ...FM1 with multiple complaints regarding pt's care at facility, this SW offered phone number for patient advocate office, FM1 declined and continued to say that he is very upset and frustrated with pt's care and this SW ended call d/t (due to) FM1 yelling at this SW."

3) Reviewed a facility incident number #HL2024-000857 regarding P1 initiated on 04/29/2024, documented as "Event Code: Grievance." The reports included:
04/29/2024 at 03:55, initiated by Medical Unit RN: "family concerns patient (P)1 was speaking with FM's on the phone and asked to speak with this RN. FM1 asked if oxygen was being monitored and titrated as needed . I explained to FM's that P1's her oxygen was monitored FM1 then asked how often, explained with vitals every 4 hours and when RT (respiratory therapy) assess and administer treatments FM1 then started getting upset and stated that told all the doctors that he wants continuous Telemetry and oxygenation of P1. ..."
This is the same nursing note listed above in RR.

04/30/2024 09:15 AM. Addendum by MD1: "I called and spoke to FM1 for 50 minutes after receiving message from RN. We discussed patient's downgrade status, current treatment plan, and discharge planning. I advised that there is specific criteria which needs to be met for telemetry and continuous pulse oximetry as we have limited units. We could justify placing her back on this temporarily since we just started digoxin (heart medication). FM1 was grateful and very pleasant throughout conversation. FM1 did not mention any disagreements with nursing or with current care plan. Spoke to patient prior to calling FM1 and she had no complaints and is also happy with her current care plan. ...FM1 advised that Team W has high patient census and we are unable to contact family members daily for updates. Recommend that FM1 contact nursing or patient's CM (Case Manager) when he would like updates or to discuss concerns and they will be happy to relay message to us. FM1 satisfied with this and grateful for time spent on call."

05/01/2024 01:18 PM. Addendum by Patient Advocate (PA): "FM1 called today to voice his concerns-I can see the unit and MD1 have spent an extensive amount of time speaking with FM1 and FM2. I asked FM1 if his questions had been answered and his concerns resolved-he did not provide direct answers, but rather responded with statements of staff is not taking proper care of P1. I asked for specific issues QM (quality management/RM (Risk Management) can look into for him. Per FM1:
- "P1 is on bipap at home and should be on bipap at hospital, instead her level of care was downgraded and she is now given CPAP (CPAP provides a constant air pressure to keep airways open, BiPAP offers two pressure levels, one for inhalation and and one for exhalation.). Medical Unit staff has explained to FM1 that they don't do Bipap, only CPAP-which FM1 feels is not appropriate."
- "FM1 feels P1 should be on telemetry-but needs higher level of care to receive. He states her saturation levels dropped to 50%." -"FM1 is concerned about pressure injury-says the surgeon is also worried saying her PU could be causing her back pain. FM1 feels wound care is not properly cared for the wound and noone else seems to be worried about it, but he is worried." -"FM1 feels there is an issue with the dehumidifier, the air is not going through."
-"FM1 made aware that analyst is looking into his concerns and will update him. ..."

05/01/2024 02:07 PM: Addendum by Wound Nurse: "Wound team saw P1 yesterday with FM1 at bedside. Her wound looks good, clean. It is more open than it was when she was admitted. ...We amended wound care orders and he is happy with that. ..."

05/03/2024 01:44 PM. Addendum by PA: "FM1 called with several concerns-reviewed with NM2 on steps taken the last two days to address FM1's concerns. ...Today's concerns:
-P1 is not on pulse ox, ...
-P1 is not being changed quickly enough after having a bowel movement, he believes her PI (pressure injury) now has an infection. ...
-Noise outside of window is to much, P2 has a headache.
Additionally, transfer order to PCU has been placed. ... FM1 has been called and updated, thankful for the information. ..."

05/03/2024 02:24 PM. Addendum by NM2: "I spoke with FM1 on the phone 5.02.2024 and let him know Physician (MD2) would be reviewing the list he gave to PA. He said he would be coming to the hospital later that day, and I suggested he connect with the nurse and dr. [sic] regarding plan going forward. He agreed."

05/07/2025 08:45 AM: Addendum by PA: "P1 has been transferred to PCU- FM1 not pleased P1 is not on continuous pulse/ox (oxygen level monitoring) but rather bedside and being checked every 2 hr. I contacted ..., who confirmed spoke with FM1, explained level of care PCU provides. ... Discussed with MD3, FM1 in agreement that new saturation levels can range from 86-94% vs previous 88-92%. FM1 questioned if the unit has appropriate staffing-we assured him PCU is adequately staffed for PCU staff to patient ratio, but not 1:1, this would be ICU. ..."

05/07/2024 08:49 AM: "Final disposition: Closed, Corrective Action Completed."

FM1's grievance had not been resolved as noted in the conversation with SW1 on 05/22/2024.

4) Reviewed the facility policy titled "Patient Complaint and Grievance Policy" last revised 05/2022. The policy included the following:
"Purpose: To establish a process for prompt response and resolution of patient complaints and grievances consistent with Federal Centers for Medicare and Medicaid Services."
Definitions:
A. Complaint: Concern raised by the patient or his/her legal representative (hereafter referred to as "patient") about the quality of care or services provided by staff, practitioners, or contracted agents of the organization that is addressed or resolved promptly by staff (generally within 24 hours), while the patient is in our facility and services are being provided. ...A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf.
B. Grievance: According to the Interpretive Guidelines for CMS Hospital Conditions of Participation, "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..."
Procedure Addressing and Resolving Grievances:
"C All patient complaints that are unable to be resolved at the point of service, either by unit staff, or department management, will be referred to the Patient Advocate by staff through prompt entry of the incident in the incident reporting system. ...1. The investigation of the grievance shall be conducted by the manager(s) of the areas involved. Managers should respond to grievances promptly... 4. All grievances will have a prompt written response, within 7 business days if possible, depending on the nature of the grievance. 5. If the grievance is unable to be resolved within 7 business days, the grievance will receive a final written response stating the organization is working to resolve the grievance and a final written response within 30 days will be provided. ..."

Reviewed the policy titled "Patient Rights & Responsibilities" last revised 03/2022. The policy included "B. Grievance Process. A clearly explained grievance process shall be implemented which specifies the time frames for review of and response to the grievance. C. Notice of Grievance Results. The response to the grievance shall be communicated to the patient in writing with the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the process and the date of completion."

Reviewed the Patient Handbook provided to all admission. The handbook included a section titled "Your Rights," which included "Concerns and complaints-You have the right to make a complaint without fear of retribution. Reasonable attempts will be made to resolve the complaint to your satisfaction. If a resolution cannot be achieved, the complaint will be handled as a grievance and you will receive a response in writing. ..."

5) On 06/20/2024 at 01:50 PM, during an interview with the PA, she said P1 lived with FM1 and FM2, and FM1 has been caring for her for several years. FM1 is very concerned about her oxygen levels and likes her to have more care. Has had complaints about not titrating the oxygen properly to 88-92% and lower level of care on medical unit and wants her on telemetry monitoring. P1 has had several admissions and FM1's "common concerns are about her pressure injury and O2 saturation. He feels staff are not monitoring the oxygen levels enough." PA said she is responsible for coordinating the follow up on the grievances. Inquired why FM1's grievance was not listed on the grievance log and she said she had considered them complaints because she felt they had been resolved.

6/20/2024 at 02:45 PM, during an interview with NM1, she said P1 was left on telemetry (PCU) due to family concerns of monitoring. NM1 said P1 was very labile and desaturates (oxygen level drops) quickly when eating or any type of exertion. If you put her back on BiPaP, her oxygen saturation level comes right back up. She went on to say there hadn't been issues when P1 was on PCU recently, but when changed units (medical), FM1 was upset. Inquired if there had been a care conference with the family and NM1 replied no. NM1 confirmed P1 had a fall, resulting in a fractured hip while in PCU.

6/21/24 at 09:11 AM, during interview with the Director Patient Services (Case Managers, Socials Services), reviewed the progress note entered by SW1 on 05/22/2024, when FM1 expressed frustration and concerns regarding P1's care. At that time she said although FM1 declined taking the number for the Patient Advocate, an incident report should have been made per hospital policy so follow up could have been done.

Based on interviews, record review (RR) and document review, the hospital did not update one Patient's (P2) Care Plan (CP) out of a sample size of four. When nursing staff reassessed P2 throughout his inpatient stay, they identified new skin problems that required treatment to promote healing and strategies to prevent further injury. P2's CP was not revised to include the skin integrity problem to reflect his needs and goals.

Findings include:

1) P1 was a 64 year old male transferred to the Hospital (H)1 from another Emergency Department for a higher level of care on 09/24/2023. He had renal failure and had been on dialysis. P2's medical history included congestive heart failure, chronic bilateral pleural effusions (collection of fluid around lungs) with episodes of respiratory distress. P2 was admitted to the Intensive Care Unit (ICU) for acute on chronic hypoxic (low oxygen level) and hypercapneic respiratory failure (too much carbon in your blood). He remained in ICU until he was discharged on 10/03/2023.

2) Review of P2's medical records revealed the following entries.
09/25/23 at 10:30 AM: Initial Nursing Assessment in ICU documented "Skin Condition WNL (within normal limits)."

Review of P2's Nursing Wound Assessments included but not limited to:
09/25/2023 at 09:00 PM: Skin tear identified on Left Lower Arm, treated with adaptic and kerlix dressing.
09/26/2023 at 09:00 AM: New skin issue identified. "Location: Medial Distal Sacrum, Skin type injury: shear, ...Dressing Status Dry and intact.
09/28/2024 at 09:00 AM: Description of Sacrum wound: Covered, Reddened, Draining, Partial Thickness, Blister, Errythema (redness), Friable Skin, Peeling skin, Edematous, with drainage.
09/29/2023 at 09:00 AM: "Stage of Pressure Injury (sacrum) 2-Partial Thickness. ...Comment: Previous shear/blister wound on sacrum, but now wound is open and appears to be a partial thickness injury."
09/29/2023 at 03:14 PM, Wound Care (Registered Nurse) consult: "he (P1) has the following pressure injuries:
- sacrum sDTI (Suspected Deep Tissue Injury)-wound with full and partial thickness skin loss. Wound bed dark purple/red with minimal serosang drainage.
- Lateral heel sDTI- skin intact, wound dark red/purple.
- nasal bridge st 2 (stage 2) PI (pressure injury) 2/2 biPap usage (due to pressure from mask over the nose).
- He has a skin tear to his L FA (Left forearm) ..."
Recommendations for treatment included:
- "Phytoplex zinc oxide paste BID (twice a day) and PRN (as needed) to the sacral wound."
- "mepilex q3D (every three days) and PRN to L FA skin tear"
10/02/2023 09:00 AM: Wound locations:
- Left hand skin tear, Covered, bleeding bandaid applied
- Right forearm skin tear, dressing covered
- Left lower arm skin tear, dressing covered
- Sacrum, "drainage minimal ...covered"

Reviewed P2's orders, which included the following:
09/29/2023 at 03:21 PM: "Wound Skin Protection Measure Q (every)Shift." Intervention: "zinc oxide paste BID and PRN to sacrum."
09/29/2023 at 03:21 PM: "L FA skin tear-cleanse with NS (normal saline), Mepilex q3D and prn if soiled."

Review of P2's active CP revealed it was initiated on 09/24/2023 at 10:30 AM. The nursing staff failed to identify he was a high risk for pressure ulcer, and did not include interventions in the initial CP. In addition, the CP was not revised to when P2's skin problems were identified.

3) Reviewed the hospital policy titled "Interdisciplinary Patient Care Plan" last revised 01/2023. The policy included:
Policy: "A. Each patinet admitted into the acute section ...will have a Plan of Care (Care Plan/CP) in the Patient EMR (Electronic Medical Record) , based on his/her individualized needs. ...D. The Plan of Care will be periodically evaluated and revised according to the patient's progress."
Procedure: "...D. If a problem is identified, it will be indicated on the Plan of Care. ...E. As the patient's progress is periodically evaluated, changes in patient needs and goals will be reflected in the Plan of Care.

4) On 06/20/2024 at 10:45 AM, during an interview and concurrent RR with the ICU Nurse Manager (NM)3, she confirmed P2's initial assessment did not identify any skin issues, but they were found later during routine reassessments. NM3 said the new skin problems should have added to the CP when they were identified.

Based on interviews, record review and document review, the hospital failed to provide a comprehensive discharge instructions for one patient (P)2, out of a sample size of four. P2 developed skin wounds while hospitalized that required treatment and ongoing care post discharge. P2 and the designated Caregiver (Family Member(FM)3) were not provided education to immediately address the wound care needs on discharge. As a result of this deficiency, P2 was a higher risk of an adverse outcome related to his wounds.

Findings include:

1) P2 was a 64 year old male transferred to Hospital (H)1 from another Emergency Department for a higher level of care on 09/24/2023. He lived with FM3 and FM4, who assisted with his activities of daily living. P2 had renal failure and had been on dialysis. His medical history included congestive heart failure, chronic bilateral pleural effusions (collection of fluid around lungs) with episodes of respiratory distress. He was admitted to the Intensive Care Unit (ICU) where he remained until discharged home with FM3 on 10/03/2023.

2) Reviewed P2's medical records, which revealed he developed several skin problems while hospitalized. Entries included the following:
09/25/23 at 10:30 AM: Initial Nursing Assessment in ICU- "Skin Condition WNL (within normal limits)- Yes"
09/29/2023 03:14 PM: Wound Care Consult (Registered Nurse): "he (P2) has the following pressure injuries:
- sacrum sDTI (Suspected Deep Tissue Injury)-wound with full and partial thickness skin loss. Wound bed dark purple/red with minimal serosang drainage.
- Lateral heel sDTI- skin intact, wound dark red/purple.
- nasal bridge st 2 (stage 2) PI (pressure injury) ... biPap usage (pressure from mask on bridge of nose).
- He has a skin tear to his L FA (Left forearm) ..."
Recommendations for treatment included:
- "Phytoplex zinc oxide paste BID (twice a day) and PRN (as needed) to the sacral wound."
- "mepilex (absorbent dressing) q3D (every three days) and PRN to L FA skin tear"

10/02/2023 09:00 AM: Wound locations:
- Left hand skin tear, Covered, bleeding bandaid applied
- Right forearm skin tear, dressing covered
- Left lower arm skin tear, dressing covered
- Sacrum, "drainage minimal ...covered"

3) Reviewed the provider discharge summary dated 10/03/2023. The record included an entry on 09/29/2023 at 10:40 for wound care consult for pressure injury with notation to "Please indicate location of wound: Left heel DTI and sacral pressure injury."
The discharge summary section titled "Discharge Plan" included "Patient Instructions: Anemia of inflammation (anemia of chronic disease), Diastolic Heart Failure (CD), Chronic Kidney Disease (DC), General Emergency Department Discharge Instruction, SPEAK UP: Antibiotics. There were no other entries or reference to the wounds, or instructions for the care required post discharge.

Reviewed the discharge instructions the ICU Registered Nurse provided to P2 and FM3 at the time of discharge. The information included: "Patient instructions: Received with this packet on 10/03/2023 at 06:09 PM.
Anemia of inflammation (anemia of chronic disease)
Chronic Kidney Disease Discharge Instructions
Diastolic Heart Failure Discharge Instruction
General Instruction
SPEAK UP: Antibiotics (education about overuse of antibiotics)"
FM3 was identified as the designated caregiver in the discharge instructions.

Reviewed the "Nurse Note" entered on 10/03/2023 at 06:35 PM, which included: "Bipap (breathing device) and wheelchair delivered to room, RT (respiratory therapy) educated family member (FM)3 and pt (P2) on how to use bipap, they state they are comfortable. and competent. Discharge instruction provided with time for questions, pt IV's (intravenous therapy) removed and pt taken to personal car ..."

3) Reviewed the policy titled "Discharge Policy and Procedure" last revised 01/2023. The policy included:
- "1. Each patient shall have the opportunity to identity a designated Caregiver..."
- "2. ...There are no specific requirements for the designated Caregiver expect that he or she be capable of performing the necessary care. Post-discharge assistance includes help with basic and instrumental activities of daily living and support tasks (e.g. wound care, medication administration, and medical equipment use) in accordance with the patient's written discharge plan signed by the patient or his or her representative."
- "9. The Caregiver will be included in all phases of the discharge process including planning for follow-up and direct education and hands-on training, when necessary."
- "10. The patient will be provided with comprehensive discharge instructions at the time or discharge. These instructions shall include but not be limited to: ...c. wound care. ..."

4) On 06/20/2024 at 10:45 AM, during an interview with the ICU Nurse Manager (NM)3, she confirmed P2 was discharged home from the ICU. At that time a RR was done and she explained the discharge process. NM3 said the Provider documents the specific discharge instructions to be given to the patient. She went on to say the information populates into the discharge education documents provided to the patient and family. The RN who discharges the patient ensures all the handouts identified by the Provider are included and reviews the instructions with the patient and family. NM3 confirmed there was no documentation of wound care discharge instructions. The RN who discharged P2 was unavailable for interview.

On 6/20/2024 at 01:00 PM, during an interview with the Case Manager (CM)1, she said P2's discharge planning included a referral for home Physical Therapy, but there was not a referral for wound care. She said if the Caregiver would be doing the wound care, the RN that dicharges the patient would be responsible to educate the patient and caregiver.