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Based on interview and document review, it was determined that the hospital failed to implement it's policy and procedure regarding the prompt resolution of patient grievances. The hospital's failure to do so resulted in one patient/representative complaint not being incorporated into the complaint/grievance process and deprived a family member of the right to complaint resolution.

Findings include:

A complainant stated that a family member of Patient #1 had relayed her/his concerns about the care of Patient #1 to both the Vice President Chief Nursing Officer (VPCNO) and the Chief Medical Officer. The complainant stated that the family member had not received any information in writing that the concerns about Patient #1 had been addressed by the hospital.

Interview with the VPCNO revealed that s/he had discussed the concerns about the patient's care with the patient's family member. The VPCNO was unable to state why the concerns had not been incorporated into the grievance process, since the identified concerns did meet the hospital's definition of a "grievance".

Interview with the Patient Safety Consultant confirmed that the hospital grievance process did not contain any grievances made on behalf of Patient #1.

Review of the hospital's policy and procedure "Patient Complaint and Grievance Policy" gave the following definition of a grievance:
"Grievance: A grievance is a formal or informal written or verbal complaint that is made to PRMCE by an individual when the issue cannot be resolved promptlye by staff present or is referred to administration or Organizational Quality".

Based on interview, review of medical records and review of hospital documents, it was determined that the hospital failed to ensure that nursing staff developed, and kept current, a nursing care plan for each patient. The hospital's failure to do so resulted in 4 (Patients #1, 2, 5 and 9) of 10 patient medical records reviewed not containing a nursing care plan that was individualized for the patient, and/or a plan of care that was kept current, based on assessment of the patient's response to interventions. The hospital's failure to do so potentially resulted in patients having unmet care needs and inconsistent and/or ineffective nursing care.

Findings include:

All medical records were selected from a list of patients who were identified as having initially been seen in the Emergency Department (ED) and subsequently admitted to Nursing Unit 3A.

Patient #1
Patient #1 had been brought to the ED after displaying suicidal and homicidal behaviors at home. The patient also had mental health diagnoses and had not been taking her/his medications for several months.

The patient's medical record was reviewed and found to not include a care plan. The patient had been admitted to the Nursing Unit at approximately 9 PM on June 9, 2015. As of approximately 3 PM June 10, 2015, when the patient made a suicidal gesture, no care plan had been developed.

Patient #2
Patient #2 was admitted with suicidal ideation and a mental health diagnosis. The patient had a care plan which included a one identified problem, which was Fall/Trauma/Injury/Risk. The care plan did not identify any problems or needs related to the reason the patient's suicidal ideation or specialized needs associated with the mental health diagnosis.

Patient #5
Patient #5 was admitted due to suicidal ideation as well as a mental health diagnoses and multiple medical diagnoses, including diabetes mellitus. The plan of care was initiated 10 hours after the patient was admitted, not within 8 hours per hospital policy. The plan of care identified problems/goals as "identify signs and symptoms and related risk factors", "compromised coping, individual", "fall and trauma risk" and "pressure ulcer risk". The plan of care did not identify the patient's suicidal ideation and other mental health issue, nor did the plan of care specifically mention the patient's diabetes mellitus and possible signs, symptoms and complications that could be associated with the condition.

Patient #9
Patient #9 was admitted due to a being an involuntary psychiatric hold as well as having a mental health diagnosis, in addition to diabetes mellitus. The patient's plan of care had multiple problems/goals identified for the patient. None of the problems/goals identified addressed how the patient with "acute psychosis" would be kept safe, nor did the problems/goals address the patient's diabetes mellitus and possible signs, symptoms and complications that could be associated with the diabetes mellitus.

The online medical records were reviewed in the company of the hospital's EPIC [software program for electronic medical records] specialist. The specialist identified during online review of the records that the program had a template to use for patients who were potentially suicidal; however, that template had not been consistently utilized for patients who were admitted for suicidal ideation.

Interview with the Patient Safety Consultant revealed that the hospital did not have a policy regarding the development and implementation of nursing care plans. The investigator was provided with a pamphlet for nurses which was titled "EpicCare Inpatient", which provided guidance on how to utilize the computer;