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Based on record review and interview, the facility failed to ensure a response from Patient Relations (Staff L) to patient (Pt. #1) regarding the grievance process, timeframe and grievance resolution per facility policy for 1 of 2 patients (Pt. #1) in a sample of 2 grievances reviewed.

Findings include:

A review of the facility policy titled, "Responding to Patient/Family Complaints and Grievances", effective date: 01/13/2021, revealed: "...B. Grievance: The expression of dissatisfaction by a patient or the patient's representative with any aspect of their care or service that cannot be promptly addressed by staff or management present or would have been addressed if communicated during the stay/visit. Grievances also include:...iii. Written correspondence regarding dissatisfaction with patient care is generally handled as a grievance...C. Responding to Patient/Family Grievances...iii. The Patient relations Department will notify the patient of their rights, inform them about the grievance process, and set a timeframe of up to 45 days for completion of the grievance process. If additional time is needed, the patient will be notified, and a new timeframe will be agree upon and documented..."

A review of the facility policy titled, "Patient Rights and Responsibilities", effective date: 07/20/2022, revealed: "...B. Resolution of patient and Family Concerns i. Patients and families are encouraged to discuss any concerns regarding their medical care and treatment experience...Patients and/or families who feel their concerns have not been adequately addressed should contact the Department of Patient Relations. Inquiries will be reviewed in a timely manner and resolved whenever possible..."

A review of the facility's grievance investigation report regarding Pt. #1's complaint, revealed the following documented timeline:
- On 10/10/2022 Patient Relations Representative L received Pt. #1's email complaint regarding "Delay/Response Time" to call lights.
- On 10/10/2022 at 8:55 AM Representative L sent an email to Pt. #1 that stated, "Thank you for reaching out to Patient Relations regarding your experience with the delay in response that you have experienced when asking for assistance. We apologize that staff have not been responsive and that you have been left in these situations as you have described. We want to address this with staff that you described that have been involved. Would you be able to confirm your date of birth as the message sent to our office appears to have a typo regarding your date of birth. We thank you for taking the time to reach out to Patient Relations regarding your experience with [Facility Name]. Please know that once we have this information we will be connecting with the staff involved to address your concerns. If you have any questions, or would like to speak with Patient Relations further, we can be reached at [Telephone Number]."
- On 10/10/2022 at 9:27 AM Pt. #1 sent an email back to Representative L with his/her date of birth and in addition Pt. #1's email stated, "I want you to know that it has not gotten any better. I stayed last night in hopes of having a schedule for meds somewhat down before going home, without the IV (intravenous) ones. I didn't receive any overnight until I called and asked for them, and/or woke up screaming then still waited for them. Please know I understand being short staffed, but this is a whole other level."
- On 10/13/2022 at 1:40 PM Representative L sent an email to D6/4 Unit Manager G that stated, "Patient Relations received a message from [Pt. #1] regarding their experience with response by staff once on D6/5 [sic] when they were admitted to [Facility Name] on 10/10/2022." Representative L then copied and pasted Pt. #1's original complaint in the body of the email to Manager G. Conclusion of the email from Representative L to Manager G then stated, "I have apologized to [his/her] regarding [his/her] experience and response by staff. I understand that staff are very busy and are trying their best on unit with large number of patients who are admitted. This is feedback as this is the patients experience and they wanted this documented. If you have questions, or if I can be assistance, please let me know." Signed by Representative L.
- On 10/14/2022 at 12:10 PM an email was sent from Manager G to Representative L that stated, "I am sorry to hear of these comments. I did speak to this patient on [sic] in [his/her] stay on D6/4 as I was informed when [he/she] arrived on the unit [he/she] was frustrated with [his/her] care. When [he/she] and I spoke I listened to [his/her] concerns and followed up with staff. I told [him/her] to please let me know if there are other concerns from [him/her]. Family was present during my visit. I asked them to please let me know of any issues during the remainder of the stay. I did not hear any concerns. Again, sorry to hear this and will follow up with staff." Signed by Manager G.

During an interview with Patient Relations Representative M on 11/18/2022 at 10:15 AM, Representative M stated that Pt. #1's complaint email came through to Patient Relations on "Saturday 10/08/2022 at 8:07 PM", Representative M sent Pt. #1's email to Representative L to respond to Pt. #1.

During an interview on 11/18/2022 at 10:20 AM with Representative L, when asked if anyone has reached back out to Pt. #1 regarding the status of his/her complaint, Representative L stated "Nobody has reached back out to the patient." Representative L stated that he/she acknowledged confirmation of the complaint and that Unit Manager [G] was working with staff. When asked if there was any intention to reach back out to the patient to close the case, Representative L stated, "There was no intention to reach back out, my understanding was the case was closed and no more communication would be made."

During an interview with D6/4 Unit Manager G on 11/18/2022 at 10:50 AM in regards to follow-up to Pt. #1's complaint, Manager G stated that he/she talked to Pt. #1 while inpatient on 10/07/2022 (late morning) regarding her needs not being met, "I then followed-up with the Care Team Leader to make sure his/her call lights are being answered."

During an interview on 11/18/2022 at 2:15 PM with Patient Relations Representative M, when asked if there was any intention to reach out to the patient again and close this case out in 45 days per facility policy, Representative M stated there was "no intention to close in 45 days." When asked if there was additional communication received from Pt. #1 to Representative L asking about the status of the case, Representative M stated he/she would follow-up with Representative L.

During an email interview on 11/21/2022 at 2:31 PM with Accreditation and Regulatory Specialist E, when asked if there was any other additional communication between Pt. #1 and Patient Relations (in addition to what was documented on the original grievance facility form) regarding Pt. #1's complaint status that was submitted on 10/08/2022, Accreditation and Regulatory Specialist E stated that Patient Relations Representative M just "provided an updated record for [Patient #1] that includes the email the [sic] patient (#1) sent on 10/15, Patient Representative [M] indicated she is in the process of responding to the patient (#1) today." The email sent from Pt. # 1 to Patient Relations on 10/15/2022 at 7:34 PM revealed, "I would like to know what happened with this. Thank you" signed by Pt. #1.

Based on record review and interview, the facility failed to follow the call light escalation facility protocol for 1 of 1 patients (patient #1) in a sample of 10 records reviewed.

Findings:

Phone contact was made with Pt. #1 on 11/16/2022 at 4:12 PM, Pt. #1 was transferred from the ICU (intensive care unit) to the Neurosurgery unit (D6/4) on 10/04/2022, this is where he/she received "poor care, waited for an hour laying in urine after pushing his/her call light."

A review of the facility protocol titled, "[Facility Name] Nurse Call and GE Alarm Escalations" for Responder 5 units (includes D6/4 Neurosurgery unit), effective date 08/06/2021, revealed: "RN (Registered Nurse) Service" type is paged 1st to the "RN Assigned" to the patient, the 2nd page (after 5 minutes) escalates to "RN OT (Overtime)" type to the "RN Assigned & RN Buddy" and to the "CTL (Care Team Leader/Charge Nurse)."

A review of Pt. #1's Nurse Call Light Activity Audit for Pt. #1's room on D6/4 unit, regarding urinary catheter care request, revealed the following timeline on 10/04/2022:
- At 12:55 PM, unit clerk sent page to RN (R) for "RN-check catheter service" that was initiated by Pt. #1's call light.
- At 5 minutes and 1 second after Pt. #1's call light initiation, the page was escalated to "RN OT-check catheter" and RN (R) was notified.
- At 55 minutes and 21 seconds after Pt. #1's call light initiation, unit clerk (H) escalated page to notify Nursing Assistant (H).
- At 55 minutes and 29 seconds after Pt. #1's call light initiation, unit clerk (H) escalated page to notify RN (R) and type was set as "RN-check catheter service."
- At 1 hour and 43 seconds after Pt. #1's call light initiation, unknown "staff arrived."

During an interview on 11/17/2022 at 1:28 PM with D6/4 HUC (health unit clerk) H, when asked what happens when he/she receives a call light page from a patient, HUC H stated "I ask the patient what they need, then I page a CNA (certified nursing assistant) or the assigned RN (registered nurse)-it depends on what their need is." HUC H stated that he/she can see all the call light times on his/her computer screen and can see when call lights are being answered. When asked what happens if a patient's call light isn't being answered timely, HUC H stated, "If I see its been 5 minutes, I call the assigned nurse on their pager and let the Charge Nurse know."

During an interview on 11/17/2022 at 1:40 PM with D6/4 unit Charge Nurse (I), when asked what happens to call lights when an 'RN Assigned' cannot answer a patient call light page after 5 minutes, Charge Nurse (I) stated, "If I can't answer the page in 5 minutes it goes into overtime, it escalates to the Charge Nurse or CNA (certified nursing assistant)-if they can't get to it, the Charge Nurse may ask someone else to help."

Pt. #1's medical record was reviewed and revealed:
Date of Admission on D6/4 unit: 10/04/2022 at 12:30 PM
Date of Discharge from D6/4 unit: 10/10/2022 at 1:52 PM

A review of "Receiving RN Unit Hand Off Note" by RN (R), created on 10/04/2022 at 6:47 PM, revealed: "...Pt. (patient) received in transfer...at 12:35 (PM). Patient oriented to room and surroundings. Safety check completed upon transfer, call light in reach...Patient encouraged to call with any needs.." Pt. #1's vital signs were taken by Nursing staff on 10/04/2022 at 12:37 PM.

A review of Pt. #1's "Catheter: External Female" nursing flowsheet revealed that a Purewick (female external catheter) was placed on 10/03/2022 at 3:40 PM prior to Pt. #1's transfer to the D6/4 unit, and remained on the D6/4 unit until 10/05/2022 at 8:00 AM for "end of therapy" removal reason.

A review of Pt. #1's "I/O (input/output) Drains-Adult" nursing flowsheet revealed that Pt. #1 had first urinary care on the D6/4 unit on 10/04/2022 at 2:00 PM with documented "Urine Unmeasured Occurrence" by RN (R), then Pt. #1 had a sponge bath and focused assessment on 10/04/2022 at 2:50 PM. During chart review, Director of Quality and Safety A confirmed that first urinary catheter care for Pt. #1 was done on on 10/04/2022 at 2:00 PM.

A review of Physical Therapy Note by Physical Therapist V, date of service on 10/04/2022 at 1:53 PM, revealed: "Physical Therapy visit was not completed at this time. When PT (physical therapy) entered the room, pt. (patient) reported [he/she] has had [his/her] call light on for a very long time, is waiting for help to get cleaned up, and she needs pain meds. PT notified HUC (unit clerk) with request to send nrsing (nursing) staff. Plan: Attempt visit later today vs tomorrow as schedule allows."

During an interview on 11/18/2022 at 12:12 PM with Director of Quality and Safety A, when asked if there was documentation of any care performed for Pt. #1 from the time vitals were taken on 10/04/2022 at 12:37 PM until first urinary care performed on 10/04/2022 at 2:00 PM, Director A stated "There is no documentation."

*Pt. #1 waited 1 hour 43 seconds after initiating his/her call light for urinary catheter care, and there was no documentation that a 2nd page (after 5 minutes) was escalated to a CTL for assistance-per facility protocol.