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Based on document review and interview, the facility failed to ensure a grievance resolution letter was sent in a timely manner to the patient and/or family for 1 of 10 patient medical records reviewed. (P1)

Findings include:

1. The facility policy titled, "Patient/Family Grievances", PolicyStat ID 13420947, last revised 04/2021, indicated the Patient Advocate/designee responding to the grievance shall inform the patient or family the timeframe within he/she will follow-up. This time frame shall not exceed 7 days unless there are extenuating circumstances, at which point the patient shall be notified of the need for an extended time frame and an agreement is made as to when follow-up will occur. Once the issue has been resolved, the Patient Advocate/designee shall provide a timely written response to the patient/resident and/or family. The response shall include: the name of the contact person, the steps taken to investigate the grievance, and the results of the grievance process.

2. A complaint/grievance was received for P1 on 2/2/24 with concerns of the patient not receiving heart medications and was sent to the emergency room for this reason and sleeping arrangements that would facilitate the use of his/her CPAP (Continuous Positive Air Pressure) machine. No resolution letter had been sent at the time of survey.

3. In interview on 2/29/24 at approximately 2:00 pm with A1 (Director of Performance Improvement & Regulatory) indicated no letters had been issued/sent to P1 or family about the complaint/grievance filed on 2/2/24.

Based on document review and interview, nursing services failed to ensure an MD (Medical Doctor) and/or NP (Nurse Practitioner) was notified of severe range blood pressures in 1 of 10 medical records reviewed (P1); nursing services failed to document home medications and/or medical supplies per policy for 1 of 10 medical records reviewed. (P1)

Findings include:

1. The facility policy titled, "Vital Signs", PolicyStat ID 13467438, last revised 03/2020, indicated the RN (Registered Nurse) will notify the MD/NP if : BP (Blood Pressure) systolic >160 or < 80, BP diastolic >100 or <50

2. The facility policy titled, "Patient's Own Medications (POM)", PolicyStat ID 13480353, last revised 04/2022, indicated the following: Medications brought by the patient to the facility will be logged on the Home Medication/ Medical Supply Inventory form at the time of admission. The following will be documented by the nurse:
a. If medication is sent home at admission, "Y" or "N"
b. If medication will be administered during hospitalization, "Y" or "N"
c. Medication Name
d. Strength of medication
e. Number of Pills at time of admission
2. The patient/guardian or other staff member will sign as a witness to the medications logged on the form.
9. Medications brought from home and stored in the facility are to be returned to the patient or family/guardian upon discharge or destroyed per physician order. Medication not returned to the patient at discharge or not claimed by the patient will be destroyed via Rx Destroyer no sooner than one month after discharge.
a. For each medication kept at the hospital, the discharging nurse will count the number of pills in each vial and document on the Home Medication/Medical Supply Inventory form.
b. The patient/guardian or other staff member will sign as a witness to the stored medications logged on the form.

3. MR for P1 lacked documentation that a physician and/or NP was notified of P1's blood pressure(s) on 1/31/24: 187/11 at 4:03 pm, 187/111 at 6:38 pm; on 2/1/24: 174/95 at 8:16am and 206/111 at 3:24pm.

4. MR for P1 lacked documentation on Home Medication/Medical Supply Inventory form indicating if medication was sent home at admission, strength, number of pills on admission, number of pills at discharge, or medical supplies present on admission or discharge.

5. In interview on 2/29/24 at approximately 11:00 am with A3 (Director of Nursing) confirmed there was no documentation that a provider had been notified of P1 severe range blood pressures and should have been as policy dictates.

6. In interview on 2/29/24 at approximately 11:30 am with RN1 (Registered Nurse) confirmed he/she did not notify a provider about P1 severe range blood pressures.