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Based on record review and interview, the hospital failed to ensure grievances were resolved according to the hospital policies. The deficient practice is evidenced by failure of the hospital to provide a letter describing the steps taken to investigate the patient's claims for 1(#3) of 1 reviewed allegations of sexual assault that occurred in the hospital.
Findings:

Review the provided hospital policy "Grievances: Patient & Family; The Role of the Patient Advocate," revised 10/2023, revealed in part, "For the purposes of this policy, a "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the facility's compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR Section 489. . . . All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purposes of these requirement." Further review revealed, "10. Once the issue has been resolved, the staff person responsible for investigating and resolving the grievance will provide a written response with seven (7) days of the grievance complaint being received."


Review of the Occurrence Log revealed on 04/26/2024 Patient #2 kissed Patient #3 on the cheek. An investigation which included camera review and interviews was performed. The investigation revealed Patient #3 was shocked by the incident and "traumatized" because she was not expecting the kiss.

Review of the binder with the closed grievances failed to reveal a letter was sent to Patient #3 or her parents.

In interview on 06/03/2024 at 10:25 a.m., S5Adv verified the parents of Patient #3 were not sent a letter. S5Adv verified she was given a copy of the investigation and was aware she needed to send a letter, but failed to do so.

Based on record review and interview, the hospital failed to provide care in a safe setting. The deficient practice is evidenced by failure to perform withdrawal assessments as ordered for 1 (#1) of 1 patient with ordered withdrawal assessments.
Findings:

Review of the policies "Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR)" revised 09/2021, and "Clinical Opiate Withdrawal Scale (COWS)" revised 07/2018, revealed neither policy had guidelines for allowance of early or late performance of the assessment.

Review of the medical record for Patient #1 revealed the patient was admitted on 05/07/2024 with a diagnosis of opioid dependence with withdrawal and alcohol abuse.

Review of the physician's orders revealed, "CIWA AR Scale; Every 4 hours for Detox; Notify provider if above 15; Start 05/08/2024 at 2:00 p.m." and "COWS Scale- Opiate Withdrawal Scale; Every 4 hours while awake; Start 05/08/2024 at 5:00 a.m."

Review of the medical records revealed on 05/08/ 2024 the CIWA was performed at 1:22 a.m., 7:01 a.m., 10:17 a.m., 2:08 p.m., 5:37 p.m., and 10:00 p.m. Further review revealed the COWS Scale was performed on 05/09/2024 at 4:08 a.m., 8:35 a.m., 12:05 p.m., 5:22 p.m., and 9:56 p.m.

In interview on 05/30/2024 at 3:00 p.m., S3DON verified the assessments were not every 4 hours. S3DON stated the hospital policy allowed them to be performed within a range before or after the scheduled time for each assessment.

In interview on 06/03/2024 at 10:00 a.m., S2DRM verified the policy did not address guidelines for the allowance of early or late assessments and therefore should have been performed every 4 hours.

Based on observation and interview, the hospital failed to ensure the registered nurse supervised the care of each patient. The deficient practice is evidenced by failure to the nurse review and sign the observation sheet for 1 (#2) of 5 (#1-#5) reviewed medical records.
Findings:

Review of the hospital policy "Observation Rounds," revised 04/2024, revealed in part, "PROCEDURE: Charge Nurse: . . . D. Reviews and signs patient observation forms, at least twice per shift for accuracy (2) two times for eight hour shift and (3) times for twelve hour shifts."

Review of the Patient Observation record for Patient #2 revealed on 04/26/2024 the registered nurse failed to review and sign the record during the 11:00 a.m. - 3:00 p.m. shift and the 3:00 p.m. - 7:00 p.m. shift.

In interview on 5/30/2024 at 1:05 p.m., S2DRM verified the nurse did not supervise the patient's care according to the hospital's policy.