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Based on observation, interview, and document review, the facility failed to promote and protect patient rights for all patients who file a grievance and for 2 of 10 patients (#1 and 2) reviewed for care in a safe setting, resulting in the potential for less than optimal outcomes. Findings include:

See tags:

V-0118 Failure to provide response to a grievance.

V-0144 Failure to provide care in a safe setting.

Based on document review and interview the facility failed to have a process for prompt resolution of patient grievances and failed to respond in writing to 5 of 5 (pt.#1,#2,#11,#12,and #13) grievances received resulting in denying patients and patient representatives the right to have grievances addressed by the facility. Findings include:

On 6/12/2023 at 1450 during the entrance conference a request was made for the facility's complaint and grievance log. On 6/13/2023 at 0850 a complaint and grievance log was provided by the facility. A review of the log failed to have a grievance listed for patient #1 or #2. At the time of review, Staff J, the patient experience advocate was then asked if there were any further complaints/grievances that were not listed. Staff J stated that a "patient experience log" was kept by the facility that were not considered a complaint or grievance. Staff J was asked to provide the patient experience log for review. On 6/14/2023 at 0900 the patient experience log was presented by Staff A, Director Quality Patient Safety Officer. Review of the patient experience log revealed there was contact to Staff J on 2/3/2023 and 5/30/2023 by the son of patient #1 who forwarded his concerns to Staff D, the director of risk. The information in the log stated the complainant had concerns with the "chaos" during the time of patient #1's death and concerns with quality measures taken to investigate the event of patient #1's incident that ended in patient #1's death. Staff J was queried if the concern was considered a grievance. Staff J stated, "the concern was discussed with the complainant and forwarded to staff A, Director Quality Patient Safety Officer and staff D, the Director of Risk Management for follow up. Staff J was asked if a letter was sent to the complainant to acknowledge the grievance for patient #1. Staff J stated, "No." Further review of the patient concern log listed contact by the son of patient #2 on 3/8/2023 and 3/10/2023 concerning patient #2's fall with injury. Staff J was queried if a letter had been sent to acknowledge the complainants grievance. Staff J stated, "No."
On 06/12/2023 at 1500 review of the patient experience log showed no documentation of a response to the complainant regarding patient #2's fall that resulted in a neck fracture. Staff J stated the complainant of the grievance for patient #2 was informed to have his attorney contact the facility attorney. Staff J was queried if she had responded to the complainants any further. Staff J responded, "No" at the time of finding.
On 6/14/2023 at 0925 a selection of three patient grievances from the patient experience log was made for further review (pt.# 11,#12, and #13) and documentation of acknowledgement of the grievance was requested. Patient #11 submitted a grievance on 1/25/2023 and according to the log, "patient's arm fell off of the operating table and no one knew how long it was in that position. Patient now only has 40% usage. The doctor told him someone form the hospital will be contacting him on how he can (afford) therapy w/o cost." Further reference to patient #11 stated, "(staff D) to have them bill "Risk Management" as the guarantor." No further documentation regarding patient #11's complaint response was available.
On 06/14/2023 at 0930 review of the Patient Experience Log revealed that Patient #12 submitted a grievance on 2/6/2023 stating "Mother (name) is worried to bring in her son if he has a seizure. Last time she was here (3/2022) the staff was dismissive and wouldn't treat her non-verbal son well." No documentation was listed for the follow-up for the grievance submitted.
On 06/14/2023 at 0935 review of the Patient Experience Log revealed that Patient #13 submitted a grievance on 3/7/2023 stating, "Patient's hair is matted really bad, it may have to be shaved. The ICU (Intensive Care Unit) took care of her hair and bathing. She wasn't getting any of that on the sixth floor." No documentation was listed for follow-up for the grievance submitted. Additional documentation was requested for the grievances selected for patients #11, #12, and #13 and was not provided for review prior to the end of the survey.

On 6/14/2023 at 0945 an interview occurred with Staff S, the Director of Patient Experience. Staff S was queried about the facility's process of handling complaints/grievances. Staff S stated that if a complaint or grievance was received, investigated, and resolved in a 24-hour period that the facility considered a phone call was sufficient to close the complaint/grievance. Staff S further stated that any complaint/grievance that had a litigious potential was automatically sent to risk management. Staff S was queried if any written acknowledgement of receipt of a complaint/grievance was sent to the person filing the complaint/grievance. Staff S stated not if it is sent to risk. Staff S stated she did not know if risk follows up on complaints/grievances once it was sent from the patient experience department.

On 6/14/2023 at 1250 a review occurred of the policy titled, "Patient Complaints/Grievance and Appeal,100-048," dated 02/2021, policy ID# 9299950. According to the policy it stated, "Level 1: General Patient Complaint...Those post-hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay/visit are categorized as a complaint and not required to be defined as a grievance." The policy further stated, "Level II: Patient Grievance - The patient issue is a grievance when the complaint: * cannot be resolved at the time of the stay by staff present; * requires further investigation; * is received in writing through letter, e-mail, or with a patient satisfaction survey; * is formally lodged with a regulatory agency, insurer, accrediting agency or other third party regarding care or service at (facility); * is telephoned to a hospital representative alleging abuse, neglect or violation of any CMS requirement; * is accompanied by a request for a written response from the hospital; * is received from a patient receiving home care services provided by (health system)."

Further review of the policy stated, "All Level II patient grievances will be referred to the Patient Experience Advisor as soon as possible after receipt. Initial contact to the patient to acknowledge the receipt of the grievance must be made within 5 days of receipt. * The patient experience advisor will telephone the patient. Three (3) attempts will be made by telephone. If the patient experience advisor is unable to contact the patient by phone, the patient experience advisor will contact by e-mail, letter, or fax to notify the patient that the grievance was received and is being investigated. This will occur within the designated five (5) day period. * If limited information regarding the good complaint or grievance is available, the patient experienced advisor will make every effort to identify patients and obtain contact information in order to make contact and facilitate resolution. * The patient experienced advisor will enter the grievance in RL solutions and delegate portions of it to others. * Per recommendation of CMS conditions of participation, 42 CFR 482.13 (a)(ii) and (iii), a written response will be sent to the complainant within seven (7) days of receipt of the grievance. * If an investigation and subsequent resolution letter cannot be completed within seven (7) day time frame, the patient experience advisor will send a follow up letter to the grievance for a specific event type and informing the patient/family an investigation has been initiated in a summary of investigation, findings, and resolution are forthcoming within thirty (30) days. Any and all written responses of the hospital 's decision to the patient or patient representative will be reviewed by the patient experience advisor prior to sending. * If the patient is a Medicare beneficiary, follow the process outlined "An Important Message from Medicare about your rights" which is given on admission and within 2 days of discharge." "All patient complaints and grievances that are not submitted in writing should be documented in RL solutions under provision of care. Select complaint/grievance type."

Based on document review and interview, the facility failed to provide care in a safe setting by 1. Not following the standard of care in a respiratory procedure for 1 (#1) of 10 sampled patients, leading to a less than optimal outcome and 2. Not implementing fall precautions for 1 (patient #2) of 10 sampled patients, resulting in a fall with injury. Findings include:

Document review of patient #1's medical record occurred on 6/13/2023 at 1100. According to the patient's medical record the patient 's chart indicated that on 2/1/2023 at 1629 Staff U, a respiratory therapist documented the following, "Called by nursing to help deep suction patient came to evaluate patient I keep (SIC) oral suctioned patient with the yankauer and remove several thick old bloody clots. I sweeped (SIC) out the patient 's mouth with oral sponge and tried to suction a second time. After second suction I went to get an oxy mask and bubbler. At the time the patients relative stated that her spO2 was decreasing. Arrived back in the room and her SpO2 was registering in the 40s and patients breathing was approximately 6 times a minute. I pressed the staff assistant and nursing called a rapid response. Per (Staff M, physician) we began bagging patient with ambu (bag mask valve) bag and 100% FIO 2 for several minutes. Doctor (Staff M) called the family members, and the decision was made to stop all interventions."

On 6/14/2023 at 1100 an interview occurred with the manager of the respiratory department, Staff O. Staff O was asked to review the documentation by the respiratory therapist (Staff U) that provided care to patient #1 on 2/1/2023 specifically to the deep suctioning of the patient with a yankauer suction. Staff O stated a yankauer suction was not to be used for the deep suctioning of a patient. Staff O stated, "deep suctioning of a patient occurs with a small tube-like catheter not a yankauer device."

On 6/14/2023 at 1120 an interview occurred with the medical director of the respiratory department, Staff N. Staff N was asked to review the documentation by the respiratory therapist Staff U for patient #1 on 2/1/2023. Staff N was queried about the procedure of deep suctioning a patient with yankauer suction. Staff N stated deep suctioning would not occur with a yankauer suction...deep suctioning was to be performed using a small tube-like catheter.


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On 06/13/2023 at 1045 review of Patient #2's history and physical dated 01/22/23 revealed she was an 87-year-old female with minimal past medical history who presented to the emergency room with stroke like symptoms after son found her on the floor at home. She was previously very independent and living with her son. Her medical history included macular degeneration (degenerative eye disease), and no known prescription medications. During her Emergency Department (ED) course Patient #2 experienced a seizure during a CT (radiological examination) scan of her head and required intubation (breathing tube placed to assisted in maintaining airway). She had right sided weakness with CT negative for stroke, and was admitted to ICU (intensive care unit) for continued workup. Per the discharge summary, Patient #2 had a fall with trying to get out of bed on 02/23/2023 at which time a CT head and C-spine did reveal a non-displaced type 2 odontoid fracture (a break that occurs through part of C2, the second bone in the neck), which will require a C-collar (collar worn around the neck to support the spine) for a minimum of 4 weeks with neurosurgical follow-up.

On 06/13/2023 at 1045 review of Patient #2's Daily focused assessment dated 02/22/2023 at 1032 revealed she had a Morse fall score (A fall risk assessment tool) of 70 (high fall risk) with a history of falls, use of anticoagulant (blood thinning medication), weak gait, and bed rest with nurse assist, with interventions listed to include side rails up x2, call system in reach, bed in low position, wheels locked, fall precautions, instructed patient to call for help, bed alarm.

On 06/13/2023 at 1045 review of hospitalist progress note dated 02/24/2023 revealed "Patient had a fall last night" and was unable to determine if she hit her head or not, so a CT was ordered, which revealed a nondisplaced odontoid fracture. She was seen by neurosurgery and placed in a Vista Collar (cervical collar)."

On 06/13/2023 at 1045 review of CT head and neck report dated 02/23/2023 at 1740 revealed acute nondisplaced fracture the dens type II odontoid fracture.

On 06/13/2023 at 1045 review of the entire medical record for Patient #2 with Staff H, did not reveal any nursing documentation of the fall for Patient #2, no nursing assessment of Patient #2 after the fall, no documented post fall huddle.

In an interview on 06/13/2023 at 1410, Staff A, Director of Quality Patient Safety stated the facility did not complete a root cause analysis (RCA) on the fall of Patient #2. Staff A stated the facility does not do RCA's and did not sit down as a team of leaders to discuss the fall of Patient #2.

During an interview on 06/13/2023 at 1145, Staff H reviewed the record of Patient #2 with the surveyor and confirmed there was no documented nursing documentation of Patient #2's fall, no documented assessment of Patient #2 after her fall and no documentation of the family or physician being notified. Staff H stated it was her expectation as the Manager of the ICU (Intensive Care Unit) and facility policy that family and doctor be notified, an assessment be completed and all information should be documented in the patient's medical record. Staff H stated she had provided coaching to Patient #2's nurse (Staff I) at the time of the fall (Staff I) regarding not completing a post fall huddle, documentation, and turning off the patient's bed alarm. Staff H stated Staff I had taken Patient #2 to the bedside commode earlier in the day and turned off the bed alarm at that time. Patient #2 was found on the floor during rounds.

In an interview on 06/13/2023 at 1345 Staff I stated she had assisted Patient #2 to the bedside commode and then back to bed. Staff I stated she didn't remember what time that was because she didn't document that care. The next time she saw Patient #2 was when a co-worker came and reported that the patient had fallen. Staff I said she went to Patient #2's room and observed Patient #2 on the floor by the sink. Staff I stated Patient #2 had no neurological issues so 2 or 3 staff members lifted Patient #2 by her arms and legs and put her back in bed. Staff I said she did reach a provider who ordered imaging. When queried as to any education that was provided to her regarding the fall of Patient #2 Staff I stated she could not remember any specific education and then stated maybe they did discuss some ways to improve documentation, post fall huddle and communication. Staff I stated Staff H did speak to her about making sure the bed alarm was in working condition because when she (Staff I) went to set Patient #2's bed alarm, she suspended it instead of turning it on. Staff I stated she had turned off Patient #2's bed alarm.

On 06/13/2023 at 1450 review of Safety Incident Management report dated 02/23/2023 revealed Patient #2 sustained a fall on 02/23/2023 at 1730 with no known harm. She was found near the sink, patient bed alarm did not go off, it was turned off instead of on. The report indicated a facility post fall huddle was performed within 60 minutes of the fall with charge nurse, other nursing staff and family member attending.

During a telephone interview on 06/08/2023 at 1430, the complainant stated he was the son of the patient. The complainant stated there had been a snowstorm preventing him from visiting that day, so he was not at the facility on the day his mother fell.

On 06/13/2023 at 1400, Review of facility Fall and Injury Prevention Program Policy and Procedure dated 01/2023 revealed, "Patients will be cared for in a safe environment. Fall prevention is based on assessment of the patient, determination of the patient ' s risk for fall, and implementation of interventions that reduce the intrinsic and extrinsic fall risks identified." The policy indicated a Fall Risk Score >13 is High Risk Fall Prevention Interventions which included Implementing Universal and Moderate Fall Preventions PLUS "...Remain with patient at all times when standing, ambulating or up to toilet, implement alarms as appropriate..." The policy indicated, "The following interventions are taken immediately after a fall to determine the causes of, and injuries sustained from the fall. Findings are documented in the patient's medical record. Rapid assessment of patient for injury: Patients mental status, vital signs, including blood pressure, pulse and respirations. If blood pressure is stable and no obvious signs of injury are noted the patient may be moved. If vital signs are unstable or there are obvious signs of injury, the physician is notified immediately. Check blood sugar and pulse oximetry, asses for pain, injuries noted from the fall, description of the fall, determine causes of the fall." The policy indicated the Unit Director, Nursing Supervisor, Family member or next of kin, and physician are notified. Within 15-60 minutes the Clinical Manager will convene all staff present for a brief post fall huddle.

Based on document review and interview the facility failed to follow medical staff bylaws for completing medical records resulting in 38 of 38 records reviewed for completion status being incomplete. Findings include:

On 6/14/2023 at 1015 an interview occurred with the HIM (Health Information Management) Director, Staff R, the HIM manager, Staff Q, and the HIM lead, Staff P. A list of outstanding medical records greater than 30 days was presented for review. According to the document a total of 38 open records greater than 30 days (31-60 days - 32, 61- 90 days - 3, 91-120 days - 0, and more than 120 days - 3) existed for the facility. Staff R was queried about the facility's policy for open records. Staff R stated that records were to be completed within 30 days. Staff R was then queried if notice was provided to physician's who have records open greater than 30 days. Staff R stated report was provided weekly to department chairs of all open records. Staff R was then queried if a policy existed stated for outstanding records. Staff R stated suspension of physician privileges was outlined in the Medical Staff bylaws. Staff R stated the bylaw for outstanding records was never enforced. Staff R provided a copy of the Medical Staff Bylaws for review.

On 6/14/2023 at 1230 a review occurred of "Medical Staff Bylaws," dated 10/21/2021, it states under section 2.15, subtitle, "Completion of Medical Records,...the patients (SIC) medical record shall be complete at the time of discharge, including progress notes and final diagnosis. The written or dictated discharge summary shall be completed within thirty (30) days of discharge." Further review of the "Medical Staff Bylaws" states under section 2.16, subtitle "Delinquent Medical Records,...Patient medical records are required to be completed within thirty (30) days of discharge. The Health Information Management Department will provide each physician with a list of his/her incomplete medical records every seven (7) days. At the twenty-first (21st) day for any incomplete medical records, the letter will include a warning that the record(s) will be delinquent at thirty (30) days and the physician's privileges will be suspended if any records become delinquent."

Based on document review and interview the facility failed to meet the needs of all patients requiring respiratory services in accordance with acceptable standards of practice, resulting in the potential for poor patient outcomes. Findings include:

V-1160 Failure to have policies and procedures for the respiratory department.

Based on document review and interview the facility had zero (0) respiratory therapy policies and/or procedures developed by the medical staff, resulting in the potential for less than optimal outcomes for all patients requiring respiratory services at the facility. Findings include:

On 6/14/2023 at 1100 an interview occurred with the manager of the respiratory department, Staff O. Staff O was asked to provide a policy/procedure for deep suctioning a patient. The documentation provided lacked a date and time of approval by the medical director of the department (Staff N) for the procedure. Staff O was queried if the document had been reviewed and approved by the medical director, the medical staff, and governing body of the facility. Staff O responded she had been in her position for one year and no policies or procedures were available for the respiratory therapy department. Staff O was then queried why the department failed to have policy or procedures. Staff O stated she had run into "roadblocks" obtaining policy and procedures for the respiratory department. She further stated that approval had to be provided at the corporate level in order to obtain policies and procedures from other facilities within the organization. Staff O stated that she had worked there one year, and it had been a struggle to obtain any assistance for policies and procedures."

On 6/14/2023 at 1120 an interview occurred with the medical director of the respiratory department, Staff N. Staff N stated that she was an interim medical director for the department due to no pulmonologist being available to oversee the respiratory department. Staff N stated she was an anesthesiologist. Staff N was queried about the lack of policies and procedures in the respiratory department. Staff N was stated, "(Staff O) has made a diligent effort to try and obtain policies and procedures for the respiratory therapy department but approval from the corporate level was needed in order for policies and procedures to be shared from other facilities." Staff N stated she was aware of the lack of policies for the respiratory department.