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Based on interview, policy review, document review, and record review, the hospital failed to have an effective grievance process. The hospital failed to conduct timely and thorough investigations. The hospital failed to notify patients or their representatives of the need to extend a grievance investigation per the hospital's policy, and the hospital failed to ensure corrective actions were implemented upon completion of their investigation for seven of nine grievances reviewed (Patients 3, 8, 9, 10, 11, 12, and 14).

These deficient practices affected have the potential to affect all patients and may cause harm or other adverse outcomes.


Findings Include:

Document review of the hospital's policy titled "Grievance Resolution Process," revised on 10/09/20, showed grievance was defined as "written or verbal complaint made to the hospital by patient or representative related to . . . abuse or neglect, noncompliance with CoPs [Conditions of Participation] . . . The hospital must attempt to resolve all grievances as soon as possible and must demonstrate the capability to resolve almost all grievances within the 7-day calendar timeframe. If unable to complete the investigation within 7 business days, the hospital will notify the patient in writing of ongoing investigation with completion of investigation and written notification in 30 days . . . provides in writing to the patient who filed the grievance: name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the grievance process." Further review showed, "Should the grievance involve more than one specific concern, each concern will be addressed individually within the written response." The policy failed to define thorough investigation and an investigational procedure to be followed.

Document review of the hospital's policy titled, "Abuse and Neglect," revised on 01/14/21 showed, "The hospital supports the patient's right to receive care in a safe setting and will act to protect vulnerable patients, including protection of the patient's emotional and physical health and safety. The hospital maintains a policy to prevent or respond to allegations of abuse, neglect, mistreatment, and prompt reporting of any alleged abuse incident to hospital leaders and applicable state agencies . . . Patient abuse, neglect, and/or mistreatment is defined as any incident of physical, sexual, or verbal abuse, neglect, and/or mistreatment that is reported . . . Investigation of the incident and allegations will be conducted in a timely manner . . . For the state of Kansas: the report of the findings will be sent do [State Agency] within 5 (five) working days of the [allegation]."

During an interview on 09/09/21 at 1:50 PM Staff B, Director of Quality Management (DQM) stated that they did not have any abuse or neglect reports since the initial survey (01/11/21 through 01/14/21) and that they did not have any grievances for the months of August (2021) and September (2021).

Review of the hospital's document titled "Grievance Log," on 09/09/21 at 1:50 PM, showed no recorded grievances for the month of August or September 2021.

Patient 3

Review of the hospital's document titled "Patient Incident Report," dated 09/05/21 showed that F1, Patient 3's Durable Power of Attorney (DPOA) and daughter (Family, F1) had called the hospital at 9:15 PM and spoke to Staff M, Registered Nurse (RN), informing her that a staff had thrown a slipper at Patient 3. Staff M reported the incident to Staff B, DQM, who then called F1 and received the same information. Staff B called F1 back on 09/05/21 at 9:50 PM, after interviewing Staff F and documented, "I informed her that no one could corroborate her dad's story of the staff throwing the slipper at him . . . I also informed the daughter that the staff will be re-assigned."

Review of Patient 3's medical record on 09/10/21 showed Staff F, Certified Nurse Aide, CNA, provided care to Patient 3 on 09/05/21 at 8:00 PM, 9:01 PM, 11:40 PM and 12:59 PM and on 09/06/21 at 2:35 AM and at 6:10 AM. Staff F had documented that he had assisted the patient to the bathroom each time that he logged care provided. Patient 3's medical record showed that, Staff F, CNA was not removed from Patient 3's care after F1 was informed that Staff F would be removed from Patient 3's care on 09/05/21 at 9:50 PM.

During an interview on 09/10/21 at 11:32 Patient 3 stated that an aide [Staff F, CNA), had retrieved his missing slipper from under the bed and threw it at him. Patient 3 stated that the slipper hit him in the stomach and chest area. He stated that he didn't need this treatment and that he was "beside himself," and called his daughter to request that she get him out here [Facility]. Patient 3 stated that they [the Hospital] "moved the fella [Staff F]." Patient 3 stated that he was scared and that he's never been scared but that he was scared that night and was not able to sleep.

During an interview on 09/10/21 at 11:55 AM F1 stated that on 09/05/21 at 9:15 PM her father [Patient 3] called her upset and reported that he had a slipper thrown at him. F1 stated that the aide [Staff F, CNA] had questioned her father [Patient 3] about the reasons he wanted to call his daughter before he assisted him with the phone call. F1 stated that the staff was not re-assigned and appeared in Patient 3's room again after the incident.

During an interview on 09/13/21 at 10:05 AM Staff F, CNA stated that he was removed from Patient 3's care and was assigned to work with other patients on another floor.

The hospital failed to log the alleged abuse on their grievance log and failed to implement corrective actions.

Patient 8

Review of the hospital's document titled, "Patient Incident Report," dated 06/14/21 showed Patient 8's DPOA and mother (F5), had reported the hospital was "not taking care of him [Patient 8] as she would like" and wanted to discharge him from the hospital earlier than planned. F5 reported that the last two visits she made to Patient 8 she had found his depends soiled. Review of the resolution letter to F5, dated 06/29/21 showed, "After receiving the report of you and your son choosing to leave against medical advice (AMA) from our hospital, we conducted a chart review and we met with the staff members involved in his care. We determined there was an opportunity for us to improve. The nursing aide involved was educated on cleaning and frequent brief changes when a patient's brief is wet or soiled."

During an interview on 09/13/21 at 12:45 PM Staff A, CEO stated that she was close to F5, Patient 8's mother and that she (F5) had reported she wanted her son home because she felt that no one can care for him as she could, being his mother. Staff A stated that we [the Hospital] didn't see a deviant in his care.

The hospital failed to provide a letter to Patient 8's DPOA after it passed the seven day completion time frame as outlined in their policies and procedures.

Patient 9

Review of the hospital's document titled, "Patient Incident Report," dated 04/29/21 showed Patient 9 had accused Staff G, CNA, of pulling and tugging on her gait belt causing back and neck pain and that staff had made offensive remarks regarding her last name. Review of the resolution letter dated 05/12/21 showed, "Please know that we take all allegations of abuse very seriously and that this matter has been thoroughly investigated . . . we are unable to substantiate any staff's intention to cause you pain during your transfer . . . additionally we were unable to confirm that any staff members made any sarcastic or otherwise offensive reference to your last name."

During an interview on 09/13/21 at 12:45 PM Staff A, CEO stated that they did not know to pull staff from patient care and that she didn't think they knew the involved staff in this incident who had made comments about her [Patient 9]'s name. Staff A stated that she knows that the aide [Staff G] was not removed from patient care.

The hospital failed to provide a letter to the patient after it passed the seven days completion time frame as outlined in their policies and procedures and failed to implement corrective actions.

Patient 10

Review of the hospital's document titled, "Patient Incident Report," dated 07/19/21 showed Patient 10 reported that his aide [Staff J, CNA] had left him sitting in his chair for two hours after he had a bowel movement (BM) in his disposable brief. Patient 10 had stated that the aide "isn't very compassionate and wants something addressed." Review of an interview that Staff B, DQM had with Staff J, CNA on 07/20/21 showed that Staff J reported "she remembered taking care of this patient last night and three other times. The patient told her that the patient had to stay up as long as he can. The patient yelled at [Staff J], he went ballistic when she told him he had to stay up after his therapy. [Staff J] then gave the patient 30 minutes after lunch . . . she [Staff J] also asked the RN [unidentified] how to make him feel comfortable . . . She [Staff J] stated the cold food complaint was probably last night 07/19/21 when the dinner came in late at 6:15 pm (sic) when the brother came to feed him his dinner." Review of the resolution letter dated 08/20/21 showed "On the day of your complaint, July 20, 2021, our records indicate that . . . the physical therapist had placed you sitting up in a wheelchair at the end of your session at 10:30 am (sic). The occupational therapist noted that you had increased fatigue due to increased time in chair , and your session ended at 2:00 pm (sic). When you were seen by the rehab (sic) nurse practitioner at 3:00 pm (sic), you complained of fatigue. The occupational therapist that saw you the previous day had noted that she educated you on the importance of staying out of bed. The certified nurse assistant who cared for you stated that the therapists did recommend you to sit up on the chair longer to increase your sitting balance . . . In regard to your food situation, staff members reported that your food comes out warm from the tray lines and they reheated them for you prior to assisting you for meals, per your request."

The letter failed to address Patient 10's complaint of being left in BM soiled briefs for two hours and complaint of not being laid down upon his request. The letter failed to identify whether or not Patient 10's complaints were substantiated or not. The letter failed to address the cold meal that he may have received on 07/17/21 as Staff J indicated. The investigation showed that the unidentified nurse that Staff J referred to in her interview, was not interviewed. The investigation failed to show results of a chart reviews for repositioning or toileting assistance.

The hospital failed to provide a letter to the patient after it passed the seven day completion time frame as outlined in their policies and procedures, and failed to provide federally required information in their final letter to the patient that included the resolution date, whether or not the complaints was substantiated and the corrective actions taken on the patient's behalf.

Patient 11

Review of the hospital's document titled, "Patient Incident Report," dated 08/26/21 showed Patient 11 had reported that Staff L, CNA, had used a tone of voice that made her feel uncomfortable when he stated that she should not put her pants, that were soiled, onto the floor. The report showed that the DQM informed Patient 11 that Staff L would no longer be assigned to her care. During an interview completed by Staff N, RN, showed that Staff L stated, "I was there to help her, and I was just wanting her to call so I could help her. I didn't mean for it to come out in a mean way." A written statement from Staff N, showed, "I talked to [Staff L] about the need to watch how he talks to the patient. He said he would watch how he says things but in no way meant to come across as mad or mean."

During an interview on 09/13/21 at 10:25 AM, Staff B, DQM, stated that the patient was satisfied with removing the staff from her care. If the patients are satisfied with the real time resolution, that the incident is not further investigated.

During an interview on 09/13/21 at 12:45 PM, Staff A, CEO stated that Patient 11 went to acute care the following day after the incident and that there is no evidence that Staff L, CNA was removed from other patient's care.

The hospital failed to complete a thorough investigation by failing to recognize the incident as possible abuse and handling the complaint as a grievance as written in the hospital's policy, failed to provide a letter to the patient after it passed the seven day completion time frame as outlined in their policies and procedures, and failed to provide a final letter to the patient regarding their grievance process.

Patient 12

Review of the hospital's document titled, "Patient Incident Report," dated 08/31/21, showed Patient 12's son (F2) "reports that [Patient 12] was not sent home with any medications. Son reports that he thinks that [Patient 12] took old medications and that the patient became unresponsive and he had to call 911." Attached to the report was a sign in sheet with the topic, "Process 'Care Coordination Incidents'" that was held on 09/08/21 at 12:00 PM. Meeting minutes showed "Issues: Care coordination incident filed regarding patients not getting their prescription medications when being discharged." Review of documentation showed that the hospital had not provided an initial letter or a follow up letter that the investigation was passing the seven-day allowance per their policies and procedures.

During an interview on 09/13/21 at 10:25 AM Staff B, DQM, stated that she had not sent out a letter to the patient or the patient representative. She stated that she didn't know if the patient came with medications from home and that she would have to check to see if there is a secure area where patient valuables are kept safe in the hospital to determine if the patient had medications left behind at the hospital. Staff B stated that it was still an ongoing investigation.

The hospital failed to provide a letter to the patient after it passed the seven day completion time frame as outlined in their policies and procedures.

Patient 14

Review of the hospital's document titled, "Patient Incident Report," dated 07/20/21 showed that Patient 14's daughter (F4) reported that Patient 14 had to call out three times to get back into bed and that the nurse (unidentified) kept coming in and telling him that she had to finish passing medications. F4 reported that the last time that the nurse had gone in, she took the call light away from Patient 14. Further review showed, "per review, issue has been resolved and addressed." Attached to the incident report provided by the hospital were two documents titled, "In-service Sign-in sheet," dated 06/30/21 to 07/01/21, "Topic: Empathy." Staff that attended signed off. This in-service was completed prior to the incident.

During an interview on 09/13/21 at 10:25 PM, Staff B, DQM stated that F4 was satisfied after speaking to the head nurse about the issue, so it was not investigated. The hospital failed to recognize the complaint as possible abuse/neglect and failed to initiate the grievance process per their policy and procedures.

During an interview on 09/13/21 at 12:45 PM Staff A, CEO, stated that the staff involved in the incident (unidentified) was not removed from patient care.

The hospital failed to conduct an investigation as it failed to recognize the incident as possible neglect and failed to initiate the grievance process per their policies and procedures, failed to provide a letter to the patient after it passed the seven day completion time frame as outlined in their policies and procedures, failed to provide a final summary to the patient outlining their grievance process, and failed to implement corrective actions after the incident.

During an interview on 09/13/21 at 1:50 PM Staff A, CEO stated that staff were removed from caring for the patient who complained, but that none of the staff were completely removed from patient care while they conducted their investigations of any of their incident reports.

During an interview on 09/15/21 at 3:15 PM Staff O, Regional Director of Clinical Care acknowledged the findings and acknowledged that she knew that their [the Hospital's] processes had to change in order to protect patients.

Based on interview, policy review, document review, and record review the hospital failed to ensure the patient or the patient's representative received a written notice that included the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion for four of nine grievances reviewed (Patients 10, 11, 12, and 14). These deficient practices have the potential to affect all patients receiving care at this hospital and may lead to harm or other adverse outcomes.

Findings Include:

Document review of the hospital's policy titled "Grievance Resolution Process," revised on 10/09/20, showed grievance was defined as "written or verbal complaint made to the hospital by patient or representative related to . . . abuse or neglect, noncompliance with CoPs [Conditions of Participation] . . . The hospital must attempt to resolve all grievances as soon as possible and must demonstrate the capability to resolve almost all grievances within the 7-day calendar timeframe. If unable to complete the investigation within 7 business days, the hospital will notify the patient in writing of ongoing investigation with completion of investigation and written notification in 30 days . . . provides in writing to the patient who filed the grievance: name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the grievance process."

During an interview on 09/09/21 at 1:50 PM Staff B, Director of Quality Management (DQM) stated that they did not have any abuse or neglect reports since the initial survey (01/11/21 through 01/14/21) and that they did not have any grievances for the months of August (2021) and to date (09/09/21) of September (2021).

Review of the hospital's document titled "Grievance Log," on 09/09/21 at 1:50 PM, showed no recorded grievances for the month of August or September 2021.

Patient 10

Review of the hospital's document titled, "Patient Incident Report," dated 07/19/21 showed that Patient 10 reported that his aide [Staff J, CNA] had left him sitting in his chair for two hours after he had a bowel movement (BM) in his disposable brief. Patient 10 had stated that the aide "isn't very compassionate and wants something addressed." Review of an interview that Staff B, DQM had with Staff J, CNA on 07/20/21 showed that Staff J reported "she remembered taking care of this patient last night and three other times. The patient told her that the patient had to stay up as long as he can. The patient yelled at [Staff J], he went ballistic when she told him he had to stay up after his therapy. [Staff J] then gave the patient 30 minutes after lunch . . . she [Staff J] also asked the RN [unidentified] how to make him feel comfortable . . . She [Staff J] stated the cold food complaint was probably last night 07/19/21 when the dinner came in late at 6:15 pm (sic) when the brother came to feed him his dinner." Review of the resolution letter dated 08/20/21 showed "On the day of your complaint, July 20, 2021, our records indicate that . . . the physical therapist had placed you sitting up in a wheelchair at the end of your session at 10:30 am (sic). The occupational therapist noted that you had increased fatigue due to increased time in chair , and your session ended at 2:00 pm (sic). When you were seen by the rehab (sic) nurse practitioner at 3:00 pm (sic), you complained of fatigue. The occupational therapist that saw you the previous day had noted that she educated you on the importance of staying out of bed. The certified nurse assistant who cared for you stated that the therapists did recommend you to sit up on the chair longer to increase your sitting balance . . . In regard to your food situation, staff members reported that your food comes out warm from the tray lines and they reheated them for you prior to assisting you for meals, per your request."

The letter failed to address the Patient 10's complaint of being left in BM soiled briefs for two hours and complaint of not being laid down upon his request. The letter failed to identify whether or not Patient 10's complaints were substantiated or not. The letter failed to address the cold meal that he may have received on 07/17/21 when the food arrived late, as Staff J indicated. The investigation showed that the unidentified nurse that Staff J referred to in her interview, was not interviewed. The investigation failed to show results of chart reviews for repositioning or toileting assistance.

Patient 11

Review of the hospital's document titled, "Patient Incident Report," dated 08/26/21 showed Patient 11 had reported that Staff L, CNA, had used a tone of voice that made her feel uncomfortable when he stated that she should not put her pants, that were soiled, onto the floor. The report showed that the DQM informed Patient 11 that Staff L would no longer be assigned to her care. During an interview completed by the hospital, it showed that Staff L stated, "I was there to help her, and I was just wanting her to call so I could help her. I didn't mean for it to come out in a mean way." A written statement from Staff N, RN showed, "I talked to [Staff L] about the need to watch how he talks to the patient. He said he would watch how he says things but in no way meant to come across as mad or mean."

During an interview on 09/13/21 at 10:25 AM, Staff B, DQM, stated that the patient was satisfied with removing the staff from her care. If the patients are satisfied with the real time resolution, that the incident is not further investigated.

The hospital failed to complete a thorough investigation by failing to recognize the incident as possible abuse and handling the complaint as a grievance as written in the hospital's policy, failed to provide a letter to the patient after it passed the seven day completion time frame as outlined in their policies and procedures, and failed to provide a final letter to the patient regarding their grievance process.

Patient 12

Review of the hospital's document titled, "Patient Incident Report," dated 08/31/21, showed that Patient 12's son (F2) "reports that [Patient 12] was not sent home with any medications. Son reports that he thinks that [Patient 12] took old medications and that the patient became unresponsive and he had to call 911." Attached to the report was a sign in sheet with the topic, "Process 'Care Coordination Incidents'" that was held on 09/08/21 at 12:00 PM. Meeting minutes showed "Issues: Care coordination incident filed regarding patients not getting their prescription medications when being discharged." Review of documentation showed that the hospital had not provided an initial letter or a follow up letter that the investigation was passing the seven-day allowance per their policies and procedures.

During an interview on 09/13/21 at 10:25 AM Staff B, DQM, stated that she had not sent out a letter to the patient or the patient representative regarding the grievance process, investigation outcome, and corrective actions taken.

Patient 14

Review of the hospital's document titled, "Patient Incident Report," dated 07/20/21 showed that Patient 14's daughter (F4) reported that Patient 14 had to call out three times to get back into bed and that the nurse (unidentified) kept coming in and telling him that she had to finish passing medications. F4 reported that the last time that the nurse had gone in, she took the call light away from Patient 14. Further review showed, "per review, issue has been resolved and addressed." Attached to the incident report provided by the hospital were two documents titled, "In-service Sign-in sheet," dated 06/30/21 to 07/01/21, "Topic: Empathy." Staff that attended signed off. This in-service was completed prior to the incident.

During an interview on 09/13/21 at 10:25 PM, Staff B, DQM stated that F4 was satisfied after speaking to the head nurse about the issue, so it was not investigated.

The hospital failed to provide a final summary to the patient outlining their grievance process, investigation outcome, or corrective actions taken.