HospitalInspections.org

Based on document review and interview facility failed to document follow-up, investigation and outcome of a complaint/grievance in 1 (one) instance (P2).

Findings include:

1. Facility policy titled Patient/Parent Rights and Responsibilities, Complaints and Grievances, no policy number, Publication Date: 07/05/2023, under IV. Definitions, Patient Grievance: 1. Any patient complaint that cannot be resolved promptly on the spot, by patient care team members after escalating through immediate supervisor, their delegate, or clinical leadership. VI. Procedures, B. Patient Complaint Process, 3. Unresolved complaints may become grievances, and the following procedures may apply if resolution is not achieved. C. Patient Grievance Process, 3. The Patient Relations Consultant will notify the patient that their grievance is being reviewed and confirm the grievance steps. Efforts will be made to resolve grievances within seven business days. 4. The Patient Relations Consultant will contact the appropriate physician, nursing team members, or ancillary department to participate in resolving the grievance. Resolving the grievance may include additional conversations between the patient and clinical leaders or physicians. 5. The Patient Relations Consultant will communicate the results of the investigation and any needed action to the patient. 6. The patient will receive a written response regarding the resolution of the patient grievance.

2. Review of facility Complaint/Grievance log from 12/1/24 through 5/5/25 indicated the following complaint related to allegations involving P2:
a. Encounter Type: Response, Theme: In the moment, Assigned to A20 (Patient Liaison), Resolved: No, Received a Diagnote from Unit Coordinator from 5 East Unit. Family of P2 requested to speak to a patient advocate about the care for P2. A20 spoke with A18 (Nurse Manager 5 East Unit) regarding any issues expressed by P2's family. A18 indicated call light issues were brought up and he/she pulled call light reports and the average time to answer call lights was about 11 minutes. Family had issues with responsiveness, cleanliness and overall communication regarding P2's care. A20 rounded on P2 and spoke with FM1 (P2 family member). P2 was getting ready to eat and was unable to cut a very burnt piece of chicken and a new lunch tray was ordered. FM1 expressed several complaints. Call lights, timely pain medication, care team response to requests made by family were perceived as rude. The family requested for P2 to have a bath prior to discharge. P2 was assisted with a shower prior to discharge. Due to response to call lights family had brought in supplies for the patient. FM1 also indicated Respiratory Therapy had not consistently checked on P2 and did not get P2's CPAP (Continuous Positive Airway Pressure) on until 0100 hours and P2 uses CPAP routinely for sleep. FM1 was pleased that A20 was able to sit and listen. No follow up, no formal grievance entered, or investigation documentation noted on allegations A20 received regarding P2.

3. In phone interview on 5/6/25 at approximately 1611 hours with A20, he/she confirmed there should have been additional documentation regarding complaints made by P2's family. A20 confirmed he/she should have entered a grievance that would have been sent out to each department involved in the complaint to further investigate allegations made to follow-up with staff members.

Based on document review and interview, staff failed to provide a daily bath for 6 of 10 patient medical records reviewed. (P2, P4, P6, P8, P9 and P10)

Findings include:

1. Facility document titled Education Express Patient Care: Daily Hygiene and Urinary Diversion Devices, September 2024, Guidelines for Patient Care: Nursing Teams Must: Provide and document that bathing was provided or refused every 24 hours regardless of patient condition.

2. Review of P2 MR indicated patient admitted to the facility on 3/20/25 through 3/25/25.
a. MR lacked documentation of patient bath or refusal on 3/21/25 and 3/23/25.

3. Review of P4 MR indicated patient admitted to the facility on 1/21/25 through 2/3/25.
a. MR lacked documentation of patient bath or refusal on 1/29/25.

4. Review of P6 MR indicated patient admitted to the facility on 3/25/25 through 3/31/25.
a. MR lacked documentation of patient bath or refusal on 3/26/25.

5. Review of P8 MR indicated patient admitted to the facility on 4/17/25 through 4/21/25.
a. MR lacked documentation of patient bath or refusal on 4/19/25 and 4/20/25.

6. Review of P9 MR indicated patient admitted to the facility on 2/28/25 through 3/7/25.
a. MR lacked documentation of patient bath or refusal on 3/1/25, 3/2/25, 3/3/25 and 3/4/25.

7. Review of P10 MR indicated patient admitted to the facility on 1/16/25 through 1/30/25.
a. MR lacked documentation of patient bath or refusal on 1/17/25, 1/24/25 and 1/27/25.

8. In interview on 5/5/25 at approximately 1610 hours with A11 (Quality), he/she confirmed P2, P4, P6, P8, P9 and P10 MRs lacked documentation of patient bath or refusal of bath.