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Based on clinical record review, document review and staff interview, it was determined the facility failed to ensure all complaints are documented and the patient or representative are informed of the grievance process and how to file a grievance. This deficient practice was identified in one (1) of ten (10) clinical records reviewed in which a complaint was voiced by a family member, and there was no documentation of an investigation (patient #1). Failure to document patient complaints or grievances can result in patient care issues not being recognized and addressed, resulting in possible negative outcomes, with a violation of patient rights.

Findings include:

1. Review of the clinical record for patient #1 revealed the patient was admitted on 6/19/13 with a diagnosis that included degenerative joint disease lumbar spine. On 6/23/13, nursing documented in a note at 0530 the patient fell when going back to bed from the bathroom. Chest X-rays completed after the fall demonstrated the patient had fractures of the right 6th, 7th and 8th ribs.

2. Hospital complaints were reviewed from June 1, 2013 to July 30, 2013. There was no documentation of a complaint or grievance that was received or investigated by the hospital involving patient #1.

The Director of Regulatory Compliance was questioned on 7/30/13 at 1640 about any documented grievances involving patient #1 and she stated there weren't any.

3. The Director of 2 South and the Critical Care Step Down Unit was interviewed on 7/29/13 at 1230. She stated she had spoken with the wife of patient #1 on Monday, June 24, 2013, who was upset over not being notified about a fall her husband had suffered over the weekend. The Director explained she looked into the matter and found the patient was alert and oriented and had told the staff not to call his wife, which was his right. When asked if she documented her investigation and resolution of the complaint she said she had not because she thought the matter was resolved. Additionally, she was questioned if she had explained to the wife the hospital's grievance process and provided her with an opportunity to file a compliant/grievance and she stated she did not.

Based on document review, clinical record review and staff interview, it was determined the facility failed to provide assessments and documentation for patients following falls, per facility policy for three (3) of three (3) patients who suffered falls in the Critical Care Step Down Unit (patients #1, 2 and 3). Failure to immediately assess a patient's condition following a fall, and failure to adequately document the event, has the potential to adversely impact the immediate care, as well as the continuity of care, of all patients who suffer falls in the facility.

Findings include:

1. The policy entitled, "Falls Prevention", last reviewed October 2012, states in part (under the heading, III. Post Fall Action Plan): "The following interventions are taken immediately after a fall to determine the causes of and injuries sustained from the fall. The patient is assessed and findings are documented on the patient Post Fall Assessment Form retained in the medical record." Thirteen (13) interventions are then listed in the policy, including, "B. vital signs" and "H. Description of the fall and injuries noted from the fall".

2. Review of the clinical record for patient #1 revealed the patient was admitted with a diagnosis that included degenerative joint disease lumbar spine. On 6/26/13 at 0513, nursing documented the patient was yelling from the room and staff found him sitting on the floor beside the bed near bathroom. An abrasion noted on his right forearm. The record lacked a Post Fall Assessment Form, which includes a full system assessment that is completed immediately after a fall.

The Director of the Critical Care Step Down Unit reviewed the above record on 7/31/13 at 1100 and agreed the record did not have a Post Fall Assessment, as directed by hospital policy.

3. Review of the clinical record for patient #2 revealed a Risk Management Report, dated 7/13/13, which documents a fall suffered by the patient at 0625 that morning. The first set of vital signs recorded following the fall were documented at 0835. The first assessment of the patient following the fall was documented at 0743 and is identified as a "Standard Shift Assessment". There was no documentation describing either the fall, the assessment findings or the interventions implemented, in the clinical record. There was no Post Fall Assessment Form found in the clinical record.

An interview was conducted with the Director of 2 South/Step Down Unit on 7/30/13 at 1050. She reviewed the above record and agreed with the findings. She was unable to explain the lack of documentation, per policy, in the record. She stated her expectation would be to have a description of the fall, the assessment findings, and the interventions implemented, documented in the clinical record, per policy.

4. Review of the clinical record for patient #3 revealed a Risk Management Report, dated 6/1/13, which documents a fall suffered by the patient at 0200 that morning. The first set of vital signs recorded following the fall were documented at 0416. The first assessment of the patient following the fall was documented at 0445 and is identified as a "Standard Shift Assessment". There was a nursing note at 0223 stating, "Note: re:fall, Lamis and Neuro checks unchanged, staff member at bedside." There was no documentation of assessment findings, or interventions implemented, in the clinical record. Additionally, there was no Post Fall Assessment Form found in the clinical record.

An interview was conducted with the Director of 2 South/Step-Down Unit on 7/31/13 at 1115. She reviewed the above record and agreed with the findings. She was unable to explain the lack of documentation, per policy, in the record. She stated her expectation would be to have the interventions documented in the clincial record, per policy.