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Based on record reviews and interviews, the hospital failed to ensure its grievance policy was implemented as evidenced by failure to have documented evidence by S5DirER/ICU (Director of Emergency Room/Intensive Care Unit) of an investigation of a grievance reported to him on 02/19/15 and interviews with staff members who provided care to the complainant that resulted in the grievance discovery date being 03/13/15 for 1 (#2) of 1 grievance reviewed from a total of 10 grievances reported from January 2015 through 08/03/15.
Findings:

Review of the hospital policy titled "Patient/Resident Complaint/Grievance", revised July 2010 and presented as a current policy by S1CQO (Chief Quality Officer), revealed that the person documenting receipt of the complaint/grievance will describe the complaint in the patient's words and forward it to the Risk Manager. The report form is forwarded to the applicable department Manager immediately for review and action. The Department Manager completes any investigation, identifying if the issue has been resolved or not resolved, corrective actions taken, and any needed notification of other personnel for follow-up.

Review of the documentation regarding the grievance submitted by Patient #2, presented by S1CQO, revealed the "Event Detail Summary" listed the occurrence date as 02/19/15 and the discovery date as 03/13/15. Further review revealed S14RiskMgr (Risk Manager) documented that prior to a meeting on 03/13/15 with S5DirER/ICU, S1CQO, and herself with Patient #2, Patient #2's mother, and Patient #2's godmother, S5DirER/ICU had been conducting an investigation and requested assistance from Risk Management and Quality.

Review of the typed "Patient Complaint", not signed but with a hand-written note that read "From S5DirER/ICU)" revealed a summary of Patient #2's complaints that had been received during a meeting with Patient #2's mother on 02/19/15.

Review of the entire packet of information regarding the investigation of the grievance submitted by Patient #2 presented by S1CQO revealed no documented evidence that S5DirER/ICU interviewed S13RN and S21RN, staff nurses who were named by the complainant in the grievance. Further review revealed no documented evidence that anyone involved in investigating the grievance had interviewed S11RN, the nurse who received Patient #2 on the Med/Surg Unit when she was transferred from ICU.

In an interview on 08/13/15 at 11:35 a.m., S11RN indicated she had received Patient #2 when she was transferred to the Med/Surg Unit from ICU. She further indicated Patient #2 told her (S11) that she (Patient #2) was very upset with the nursing care she received in ICU. She further indicated Patient #2 complained about the delay in the nursing staff's response to her calls for assistance to go to the bathroom. S11 indicated she didn't remember if she reported Patient #2's complaints about ICU to her unit manager, but she should have. She further indicated she didn't know the difference between a complaint and a grievance. S11 indicated no one from management, such as her unit manager, S5DirER/ICU, or S14RiskMgr, spoke with her about a complaint made by Patient #2.

In an interview on 08/13/15 at 2:00 p.m., S14RiskMgr confirmed that she did not speak with S11RN as part of her investigation and thus didn't know that Patient #2 had actually began her grievance on 02/19/15 at 2:35 p.m. when she was transferred to the Med/Surg Unit. She confirmed that the investigation documentation did not occur until she became involved on 03/13/15, 22 days after the grievance was reported.

In an interview on 08/13/15 at 3:00 p.m., S5DirER/ICU indicated he did not have any documentation of his investigation into Patient #2's grievance. He confirmed that he spoke with S13RN and S21RN but did not document the interviews. He further indicated he did not interview S11RN as part of his investigation and was not aware that Patient #2 had complained about her nursing care in ICU.

Based on record reviews and interviews, the hospital failed to ensure its grievance process was implemented in accordance with hospital policy as evidenced by failure to have documented evidence of an investigation of a patient grievance received on 02/19/15 until 03/13/15 and the first resolution letter sent to the patient on 03/17/15 rather than within 7 days as required by policy for 1 (#2) of 1 grievance reviewed from a total of 10 grievances reported from January 2015 through 08/03/15.
Findings:

Review of the hospital policy titled "Patient/Resident Complaint/Grievance", revised July 2010 and presented as a current policy by S1CQO (Chief Quality Officer), revealed that the patient is provided written notice of its receipt, investigation, and outcomes regarding a complaint/grievance within 7 days of the hospital's receipt of the grievance, even though the resolution need not be complete within the 7 day limit. If the grievance is not yet resolved within the initial 7 days, the written response will indicate that the hospital is working towards a resolution and that a follow-up written response will be provided within a specified time period not to exceed 30 days. If the grievance remains unresolved after 30 days, additional written follow-up would be indicated within a specified time period but not to exceed an additional 30 days.

Review of the documentation regarding the grievance submitted by Patient #2, presented by S1CQO, revealed the "Event Detail Summary" listed the occurrence date as 02/19/15 and the discovery date as 03/13/15. Further review revealed S14RiskMgr (Risk Manager) documented that prior to a meeting on 03/13/15 with S5DirER/ICU, S1CQO, and herself with Patient #2, Patient #2's mother, and Patient #2's godmother, S5DirER/ICU had been conducting an investigation and requested assistance from Risk Management and Quality.

Review of the typed "Patient Complaint", not signed but with a hand-written note that read "From S5DirER/ICU)" revealed a summary of Patient #2's complaints that had been received during a meeting with Patient #2's mother on 02/19/15.

Review of the entire packet of information regarding the investigation of the grievance submitted by Patient #2 presented by S1CQO revealed no documented evidence that S5DirER/ICU interviewed S13RN and S21RN, staff nurses who were named by the complainant in the grievance. Further review revealed no documented evidence that anyone involved in investigating the grievance had interviewed S11RN, the nurse who received Patient #2 on the Med/Surg Unit when she was transferred from ICU.

Review of the entire packet of information regarding the investigation of the grievance submitted by Patient #2 presented by S1CQO revealed a hospital response letter was sent to Patient #2 on 03/17/15 (26 days after the grievance was discovered rather than 7 days as required by policy) by S14RiskMgr informing Patient #2 that her concerns continue to be investigated. Further review revealed that S14 documented that "the information we obtain from this analysis will be forwarded to the highest committee levels of our hospital for review and further recommendations. We expect to complete resolution of this issue within 30 days. By then we will have instituted any recommendations made through this process." There was no documented evidence in the letter that Patient #2 was informed that she would receive further information regarding the resolution of the grievance within 30 days. The final resolution letter was sent to Patient #2 by S14 on 04/10/15, 50 days after the grievance was discovered.

In an interview on 08/13/15 at 11:35 a.m., S11RN indicated she had received Patient #2 when she was transferred to the Med/Surg Unit from ICU. She further indicated Patient #2 told her (S11) that she (Patient #2) was very upset with the nursing care she received in ICU. She further indicated Patient #2 complained about the delay in the nursing staff's response to her calls for assistance to go to the bathroom. S11 indicated she didn't remember if she reported Patient #2's complaints about ICU to her unit manager, but she should have. She further indicated she didn't know the difference between a complaint and a grievance. S11 indicated no one from management, such as her unit manager, S5DirER/ICU, or S14RiskMgr, spoke with her about a complaint made by Patient #2.

In an interview on 08/13/15 at 2:00 p.m., S14RiskMgr confirmed that she did not speak with S11RN as part of her investigation and thus didn't know that Patient #2 had actually begun her grievance on 02/19/15 at 2:35 p.m. when she was transferred to the Med/Surg Unit. She confirmed that the investigation documentation did not occur until she became involved on 03/13/15, 22 days after the grievance was reported.

In an interview on 08/13/15 at 3:00 p.m., S5DirER/ICU indicated he did not have any documentation of his investigation into Patient #2's grievance. He confirmed that he spoke with S13RN and S21RN but did not document the interviews. He further indicated he did not interview S11RN as part of his investigation and was not aware that Patient #2 had complained about her nursing care in ICU.

Based on record reviews and interview, the hospital failed to ensure in its resolution of a grievance the patient received written notice of its decision that included the results of the grievance process for 1 (#2) of 1 grievance reviewed from a total of 10 grievances reported from January 2015 through 08/03/15.
Findings:

Review of the hospital policy titled "Patient/Resident Complaint/Grievance", revised July 2010 and presented as a current policy by S1CQO (Chief Quality Officer), revealed that the Risk Manager is responsible for completing and sending a letter to the complainant in response to a complaint/grievance that includes the results of the grievance process.

Review of a letter sent to Patient #2 by S14RiskMgr (Risk Manager) dated 03/17/15 revealed "When asked what you you would like to see happen regarding the situation you gave three requests. You stated you would like the hospital bill resolved by the hospital, you would like a written apology from S13RN (Registered Nurse) and S21RN and you feel some type of compensation should be offered."

Review of the "Claims Manager Report", presented by S1CQO as part of the documentation of the grievance by Patient #2, revealed S14RiskMgr documented on 04/15/15 (after the date of the letter sent to Patient #2 on 04/10/15) that "I received a written response to my letter on 03/31/15 from the pt. (patient). S1CQO, S5DirER/ICU (Director of Emergency Room/Intensive Care Unit), and I met on Monday, 04/16/15 regarding the letter. With the additional comments within the letter it was decided not to address each item due to the feeling that there will be no satisfactory resolution..."

Review of the resolution letter dated 04/10/15 sent to Patient #2 by S14RiskMgr revealed the following:
"In this and any investigation and resolution, it is not for the patient to decide conclusion. We do however take your opinion and our discussion with you into consideration. We as a hospital do and will always follow out processes and protocols, and in concluding will make the final determination of appropriate action to be taken. (ie [that is] Whether a staff member will be terminated or not) Our goal is to always adhere to the Patient Rights and Responsibilities. All of our patients are provided a copy of these rights. We do feel we have been given an opportunity to improve on these Rights and Responsibilities and they have been addressed. Should legal allegations or requested actions occur that are beyond our scope, we will have to defer to our legal team."
There was no documented evidence that the resolution letter included the decision that addressed Patient #2's requests.

In an interview on 08/13/15 at 2:00 p.m., S14RiskMgr indicated she didn't directly put the resolution in the final letter sent to Patient #2. She further indicated the final resolution would have been the hospital's answer to the requests made by Patient #2.

Based on record reviews and interview, the hospital failed to ensure its written policy regarding the visitation rights of patients included the reasons for the clinical restrictions or limitations that the hospital placed on the visitation rights. The deficient practice affected 1 (#2) of 1 closed medical record reviewed and 4 (#1, #3, #4, #5) of 4 current inpatient records reviewed for visitation tights from a total sample of 5 patients and had the potential to affect all future patients admitted to the hospital.
Findings:

Review of the hospital policy titled "Visitation (General Hospital)", revised 06/12/15 and presented as the current policy by S1CQI (Chief Quality Officer), revealed general visitation policies with restrictions and visitation policies for ICU (Intensive Care Unit) and the Mother-Baby Unit with restrictions. Further review revealed no documented evidence that the reason for the restrictions was included in the policy.

In an interview on 08/13/15 at 9:10 a.m., S2CNO (Chief Nursing Officer) confirmed the hospital visitation policy did not include the reason for the restrictions that the hospital placed on the visitation rights.

Based on record reviews and interview, the hospital failed to ensure that each patient was informed of his/her visitation rights including any clinical restriction or limitation on such rights and the reason for the clinical restriction or limitation for 1 (#2) of 1 closed medical record and 4 (#1, #3, #4, #5) of 4 current inpatients from a sample of 5 patients. This deficient practice had the potential to affect all future patients admitted to the hospital.

Review of the hospital policy titled "Visitation (General Hospital)", revised 06/12/15 and presented as the current policy by S1CQI (Chief Quality Officer), revealed general visitation policies with restrictions and visitation policies for ICU (Intensive Care Unit) and the Mother-Baby Unit with restrictions. Further review revealed no documented evidence that the reason for the restrictions was included in the policy and that the hospital was to inform each patient of his/her visitation rights.

Review of the "Notice of Patient Rights and Responsibilities" signed by each patient or their representative upon admission to the hospital revealed that the patient had the right to receive the visitors whom they designate. Further review revealed "to the extent this facility places limitations or restrictions on visitation, you have the right to set any preference of order or priority for your visitors to satisfy those limitations or restrictions." Further review revealed no documented evidence that the limitations or restrictions to visitation with the reason for the limitations or restrictions were included.

Review of Patient #1's medical record revealed he was admitted on 08/11/15. Further review revealed no documented evidence that Patient #1 was informed of the hospital's limitations or restrictions to visitation in ICU and the reasons for the restrictions or limitations.

Review of Patient #2's medical record revealed she was admitted on 02/18/15. Further review revealed no documented evidence that Patient #2 was informed of the hospital's limitations or restrictions to visitation in ICU and the reasons for the restrictions or limitations.

Review of Patient #3's medical record revealed she was admitted on 08/09/15. Further review revealed no documented evidence that Patient #3 was informed of the hospital's limitations or restrictions to general visitation on the Med/Surg (Medical/Surgical) Unit and the reasons for the restrictions or limitations.

Review of Patient #4's medical record revealed she was admitted on 08/12/15. Further review revealed no documented evidence that Patient #4 was informed of the hospital's limitations or restrictions to general visitation on the Med/Surg Unit and the reasons for the restrictions or limitations.

Review of Patient #5's medical record revealed he was admitted on 08/10/15. Further review revealed no documented evidence that Patient #5 was informed of the hospital's limitations or restrictions to general visitation on the Med/Surg Unit and the reasons for the restrictions or limitations.

In an interview on 08/13/15 at 9:10 a.m., S2CNO (Chief Nursing Officer) confirmed the hospital visitation policy did not include the reason for the restrictions that the hospital placed on the visitation rights. She further confirmed that the notification of patient rights that patients are given at admission does not include the specific general visitation limitations and those for specific nursing units, along with the reasons for the limitations or restrictions.

Based on record reviews, observations, and interviews, the hospital failed to ensure the RN (Registered Nurse) supervised and evaluated the nursing care of each patient as evidenced by:

1) Staff failed to follow hospital policy for standing admission orders for ICU (Intensive Care Unit) Isolation Precautions for patients admitted to ICU with isolation precaution orders following a standard admission culture for MRSA (Methicillin-resistant Staphylococcus aureus) as evidenced by 1 of 1 patient (#1) admitted to ICU and staff not following the hospital's policy on standing admission orders for MRSA isolation precautions from a total sample of 5 patients.

2) Failing to develop a policy for the use of the manufacturer's telemetry monitoring settings for patients ordered routine telemetry monitoring when no specific parameters were ordered by the physician as evidenced by 2 (#1, #5) of 3 patient (#1, #3, #5) medical records reviewed for routine telemetry monitoring by the physician with no specific telemetry parameter orders from a total sample of 5 patients.

3) Failing to ensure the RN implemented physician orders for notification of elevated blood glucose levels as ordered for 1 (#2) of 4 (#1, #2, #3, #4) diabetic patient records reviewed from a total sample of 5 patients.
Findings:

1) Staff failed to follow hospital policy for standing admission orders for ICU Isolation Precautions for patients admitted to ICU with isolation precaution orders following a standard admission culture for MRSA:
A review of the hospital policy, titled "Infection Control", as provided by S1CQO (Chief Quality Officer), as the most current, revealed in part: In an effort to identify and prevent the spread of MRSA, admission cultures will be performed on high risk patients admitted to the facility and on all patients admitted to ICU. All patients meeting criteria to have a nasal swab must be placed on Contact Precautions until the results are negative or the patient is discharged. Contact Precautions will include: Before entering the patient's room to perform hand hygiene, put on a gown, and put on gloves.

A review of Patient #1's medical record on 08/12/15 at 1:10 p.m. revealed in part: the patient was admitted to ICU from the Emergency Department on 08/11/15 with a diagnosis of Diabetic Ketoacidosis. A nasal swab was obtained and sent to the lab upon the patient's admit to ICU as per ICU's Infection Control Standard of Care Admission Orders. A review of the ICU's Standard of Care Admission Order interventions revealed in part: initiate Isolation Contact Precautions; Educate and facilitate proper hand hygiene for patient, staff and visitors; Utilize appropriate PPE (personal protective equipment); Isolation Precaution notice on patient's door; Chart flagged; Isolation barrels in patient room. A further review of Patient #1's medical record on 08/12/15 at 1:10 p.m. revealed that no lab results had been reported back on the patient's MRSA nasal swab.

An observation on 08/12/15 at 1:10 p.m. of Patient #1 in ICU revealed the following: S7RN was observed entering Patient #1's ICU room without donning gown and gloves. Patient #1's family member was later observed visiting Patient #1 on 08/12/15. A further observation revealed no signage outside the patient's ICU room regarding contact precautions and the patient's chart was not flagged denoting contact precautions.

In an interview with S7RN on 08/12/15 at 1:15 p.m., she was asked about Patient #1. S7 indicated that she was caring for the patient today and that the patient was admitted on 08/11/15 from the Emergency Department. S7 was asked about ICU's Isolation Precautions for patients admitted to ICU with isolation precaution orders following a standard admission culture for MRSA. S7 indicated that all patients admitted to ICU received a nasal swab to rule out MRSA as per ICU's Infection Control Standard of Care Admission Orders, and the patients were immediately placed on contact precautions pending the MRSA results. S7 was made aware of the above observations on 08/12/15. S7 indicated that she did not gown and glove when she entered the patient's ICU room, because she only went to talk to the patient. S7 was asked about the lack of a contact precaution sign on the patient's door and that the patient's chart was not flagged for contact precautions. S7 indicated that the admitting RN (S19RN) must have forgotten to place a contact precaution sign on the patient's door, and she must have forgotten to flag the chart. S7 indicated that she was caring for the patient today (08/12/15) and had also forgot to assure that the ICU's Isolation Precautions admission policy was followed.

In an interview on 08/12/15 at 1:20 p.m. with Patient #1's family, before she entered the patient's ICU room and after an observation was made of S7RN handing the family member a PPE gown, the family member indicated that she was Patient #1's wife. The wife was asked if she knew why she was handed a PPE gown before entering the patient's room. The wife indicated that she had visited the patient several times in the last 2 days and was never told to wear a PPE gown by a staff member. The wife indicated that she was not aware of Patient #1 being on any precautions and received no education by staff on any precautions of the patient.

An observation on 08/13/15 at 10:00 a.m. was made of S18Physician entering Patient #1's ICU room without donning a gown or gloves.

In an interview on 08/13/15 at 10:15 a.m. with S18Physician, he indicated that he was Patient #1's attending physician. S18 was asked if Patient #1 was on any precautions. S18 indicated that Patient #1 was on contact precautions due to a positive MRSA culture result that was reported to him on 08/12/15 at 7:00 p.m. S18 was asked about the hospital's contact precaution policy. S18 indicated that "theoretically" he should have donned gown and gloves before entering Patient #1's ICU room.

In an interview on 08/13/15 at 4:00 p.m. with S5DirER/ICU (Director Emergency Department/Intensive Care Unit) and S1CQO, they were made aware of the above observations and interviews. S1 and S5 indicated that the staff and the physician did not follow the ICU Isolation Precaution policy for patients admitted to ICU with isolation precaution standing orders following a standard admission culture for MRSA.

2) Failing to develop a policy for the use of the manufacturer's telemetry monitoring settings for patients ordered routine telemetry monitoring when no specific parameters were ordered by the physician:
A review of the hospital policy titled, "Telemetry", provided by S1CQO, as the most current policy, revealed in part: To provide EKG (electrocardiographic) monitoring via telemetry system when ordered by patient's physician and to provide documentation of telemetry and/or arrhythmias. The central telemetry monitor is located in ICU and is monitored by the ICU nurses. A slave telemetry monitor is located at the nurse's station on the medical- surgical unit. Telemetry monitoring will be initiated upon physician order and may be initiated by the charge nurse following a significant clinical patient change with immediate notification of the patient's physician. A nurse will be responsible for applying the telemetry monitoring leads to the patient and notifying ICU to begin monitoring. The nurse will set the high and low alarm limits based upon the individual patient needs.

Patient #1
A review of Patient #1's medical record on 08/12/15 revealed in part: the patient was admitted to ICU from the Emergency Department on 08/11/15 with a diagnosis of Diabetic Ketoacidosis. A review of S18Physician admit orders dated 08/11/15 revealed an order for routine telemetry monitoring. A further review of S18's admit orders revealed no order indicating the parameters for the telemetry monitoring settings.

In an interview on 08/12/15 at 1:30 p.m. with S7RN, she indicated that Patient #1 was ordered routine telemetry monitoring by S18Physician. S7 further indicated that the parameters for the telemetry settings were the default telemetry monitoring settings set up in the telemetry monitor itself and that she had no specific orders from S18 for telemetry monitoring parameter settings.

Patient #5
A review of Patient #5's medical record on 08/13/15 revealed in part: the patient was admitted to the medical-surgical unit from the Emergency Department on 08/10/15 with a diagnosis of Atrial Fibrillation and exacerbation of Congestive Heart Failure and SOB (shortness of breath). A review of S18Physician admit orders dated 08/10/15 revealed an order for routine telemetry monitoring. A further review of S18's admit orders revealed no order indicating the parameters for the telemetry monitoring settings.

In an interview on 08/13/15 at 4:00 p.m. with S5DirER/ICU, he indicated that the ICU nurses were responsible for the telemetry monitoring of all patients in the hospital. S5 indicated that when a physician ordered routine telemetry monitoring for a patient that the staff used the default telemetry monitoring settings established by the manufacturer for the telemetry monitor parameters (for the high and low alarm settings) unless the physician ordered a different setting. S5 indicated that the telemetry monitoring settings for Patient #1 and Patient #5 were the default telemetry monitoring settings established by the manufacturer and that Patient #1 and Patient #5 did not have specific high and low alarm settings ordered by S18Physician.

In an interview on 08/13/15 at 4:30 p.m. with S2CNO (Chief Nursing Officer), the hospital policy on telemetry monitoring was reviewed with S2. S2 was made aware of the staff utilizing the manufacturer's default telemetry monitoring settings on the telemetry monitors for the high and low alarm settings when the physician did not order specific high and low alarm settings for the patient. S2 indicated that the staff followed the manufacturer's default telemetry monitoring settings on the telemetry monitors when a patient's physician did not order specific settings. S2 further indicated that the hospital's policy on telemetry monitoring did not address that the manufacturer's default telemetry monitoring settings could be utilized by the staff. S2 indicated that the manufacturer's default telemetry monitoring settings being utilized by the staff were not approved as a hospital policy and therefore was not approved by the Medical Staff/Governing Body.

3) Failing to ensure the RN implemented physician orders for notification of elevated blood glucose levels as ordered:
Review of Patient #2's medical record revealed she was admitted on 02/18/15 and discharged on 02/20/15. Further review revealed her reason for admission was Tachycardia, Polyuria, Polydipsia, and Lower Abdominal Discomfort. Her discharge diagnoses included Acute Urinary Tract Infection, Morbid Obesity with Basal Metabolic Index of 75, new diagnosis of Diabetes Mellitus Type 2, and Hypertensive Urgency which resolved on medication.

Review of Patient #2's medical record revealed she arrived in ICU on 02/18/15 at 10:30 p.m. and was assessed by S12RN.

Review of Patient #2's physician orders revealed an order on 02/18/15 at 10:50 p.m. to notify the provider of glucose levels higher than the target for 3 hours. Further review revealed the target blood glucose range was 70 to 110.

Review of Patient #2's lab results revealed the following blood glucose results:
02/19/15 at 1:27 a.m. - 306
02/19/15 at 2:37 a.m. - 264
02/19/15 at 4:07 a.m. - 236
02/19/15 at 7:13 a.m. - 258
02/19/15 at 8:32 a.m. - 245
02/19/15 at 9:55 a.m. - 321
02/19/15 at 11:23 a.m. - 326
02/19/15 at 1:27 p.m. - 357.

Review of Patient #2's "Patient Care Notes" revealed the following blood glucose checks and results:
02/19/15 at 12:30 a.m. by S12RN - 345
02/19/15 at 1:30 a.m. by S12RN - 306
02/19/15 at 4:00 a.m. by S12RN - 236
02/19/15 at 6:00 a.m. by S12RN - 246
02/19/15 at 11:07 a.m. by S21RN - 326.

Review of Patient #2's medical record revealed no documented evidence that any RN notified the physician that her blood glucose levels were above the target for 3 hours.

In an interview on 08/13/15 at 11:00 a.m., S2CNO (Chief Nursing Officer), after reviewing Patient #2's medical record, confirmed there was no documentation by any nurse that the physician was notified of the elevated blood glucose levels as ordered.




30172

Based on record reviews and interview, the hospital failed to ensure the nursing staff were educated and evaluated for competency on the hospital's grievance procedure for 3 (S12, S13, S21) of 3 ICU (Intensive care Unit) RN's (Registered Nurse) personnel files reviewed and 1 (S11) of 1 Med/Surg (Medical/Surgical) RN's personnel file reviewed for competency of the grievance procedure from a total of 13 ICU RNs and 18 Med/Surg RNs.
Findings:

Review of the "Clinical Position Description/Evaluation" for S11RN, S12RN, S13, and S21RN revealed they demonstrated "knowledge of patient rights and the reporting procedure for violation, or suspected violation, of patient rights and/or patient abuse, neglect, or exploitation' and completed the required annual educational and compliance training within the past 12 calendar months." There was no documented evidence that S11RN, S12RN, S13, and S21RN had received education and had been evaluated for competency on the hospital's grievance procedure.

In an interview on 08/13/15 at 11:35 a.m., S11RN indicated she didn't know the difference between a complaint and a grievance.

In an interview on 08/13/15 at 1:35 p.m., S2CNO (Chief Nursing Officer) indicated when she reviewed the computerized transcripts of education for S11RN, S12, S13, and S21RN, she didn't see that patient rights and the grievance procedure was listed. She indicated she had no documented evidence to present of S11RN, S12, S13, and S21RN being educated on and being evaluated for competency on the hospital's grievance procedure.