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Based on policy and procedure review, grievance log review, and staff interviews, the facility staff failed to identify and follow the grievance process for discharged patients in 1 of 1 sampled grievance (Patient #5).

The findings included:

Review of the grievance log from September 2022 to May 2022 failed to reveal any grievances that had been filed by a patient or someone on their behalf following discharge.




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1. Review of the closed medical record for Patient #5 revealed a 74-year male admitted 09/09/2021 at 1601 for altered mental status (AMS) [confusion - not aware of self, time, or place], delusions (something that is believed to be true or real but that is actually false or unreal) and paranoia (irrational and persistent feeling that people are out to get you), auditory hallucinations (experience hearing something not present) and visual hallucinations (experience seeing something not present), agitation (the act of moving back and forth or with an irregular, rapid, or violent action), and grandiosity (unrealistic sense one considers themselves as superior or unique from others). Review of medical record revealed Patient #5 was discharged home 09/30/2021 at 1230. Review of the medical record revealed, Clinical Care Coordinator #5's note dated 10/05/2021 at 1204 (4 days, 23 hours and 34 minutes after discharge) stated "Discharge planner spoke with (Female Name) regarding (Patient #5's first name) discharge plan. She wanted some clarification sue (sic) to (Patient #5's first name) returning home." Review of the LCSW #6 (Licensed Clinical Social Worker) note dated 10/05/2021 at 1259 revealed "Therapist was informed ... (dtr) [daughter] had called and was not satisfied with (Patient #5's first name) discharge as she identified that she was not informed of the discharge by (Facility initials) or her sister ... Therapist attempted to call (Female name) to discuss this matter in an attempt to provide her with the discharge process. Therapist LM (left message) at 1247 ..." Review of the LCSW #6 note dated 10/05/2021 at 1356 revealed "Therapist received a return call from (Female name). Therapist and (Female name) discussed discharge process ..."

Interview on 05/04/2022 at 1458 with the Director of Quality/Compliance/Risk Manager (DQCRM) revealed it was not the hospitals process to track grievances following a patient's discharge. The DQCR stated if a patient or someone on the patient's behalf called following discharge to file a grievance, the concerns were delegated to whomever could address the concerns. Interview revealed following resolution, no one mailed a resolution letter to the person filing the grievance and the grievance was not tracked. The DQCR stated he only tracked patient complaints and grievances that were submitted while they are an inpatient. The DQCR stated if a patient filed a grievance while an inpatient but discharged prior to resolution, he mailed them a resolution letter.

Based on policy review, medical record review, facility incident report review, and staff and provider interviews facility nursing staff failed to perform assessments and notify a medical provider for 1 of 4 patient (Patient #3) who experienced a fall.

The findings include:

Review of facility policy titled "Risk for Falls" revised 12/2021 revealed, "... IN THE EVENT OF A PATIENT FALL, WITH OR WITHOUT INJURY ... a. A nurse will assess the patient immediately b. The attending physician will be promptly notified to determine the need for further evaluation ..."

Closed medical record review revealed Patient #3 was a 63-year-old female who was admitted to the named facility on 03/04/2022 with a diagnosis of "Paranoid and or Delusional Thoughts or Behaviors r/t [related to] Schizoaffective (bizarre behaviors)." Review of a note written by CNA #1 on 03/15/2022 at 0419 revealed, "Pt [patient] complaint with meds and rules. Pt stayed in her room this evening. She talked to staff when we checked on her. Pt fell out of bed about 2335 with no apparent injuries. V/S [vital signs] were taken and given to the nurse. Pt had a rough time trying to go to sleep, she finally did and appears to be resting well tonight. No issues at this time." Review revealed Registered Nurse [RN] #2 was Patient #3's assigned RN on night shift of 03/14/2022. Review revealed no evidence of nursing assessment or provider notification after Patient #3 fell out of bed. Review of a Psychiatric Progress Note written on 03/15/2022 at 1448 by Medical Doctor [MD] #3 revealed, "[Patient #3 Named] is confused today. She had a witnessed fall this morning. She had a lac [laceration] on her right forehead that was approximately 2 inches. Bleeding was controlled. She also had left hip pain. She remained at her neurological baseline. EMS [Emergency Medical Services] was called immediately and IM [Internal Medicine] was notified. She was taken to the ED [Emergency Department] for evaluation. Multiple calls have been made to request a status update, but no one answered the patient assistance number ..." Patient #3 was evaluated and the laceration was repaired at the ED. Additionally a CT [Computerized Tomography] scan was performed and Patient #3 was cleared from any significant head injury. Patient #3 was returned to the named facility. Once it was discovered the ED had not evaluated Patient #3's hip pain, she was sent back to the ED. The ED diagnosed Patient #3 with a hip fracture and Patient #3 was admitted to the hospital. Patient #3 did not return to the named facility.

Facility incident report review revealed Patient #3 experienced a fall that was captured on video on 03/15/2022 at 0922.

Staff interview conducted on 05/03/2022 at 1248 with the Director of Quality, Compliance, and Risk Management [DQCRM] revealed the video footage was not saved and is unavailable for review.

Repeat interview conducted on 05/04/2022 at 0900 with the DQCRM confirmed record review revealed no evidence of nursing assessment or provider notification after Patient #3's fall from her bed on 03/14/2022 at approximately 2335.

Telephone interview was attempted with RN #2 on 05/04/2022 at 1322, to no avail.

Physician interview was conducted with MD #3 on 05/04/2022 at 1337. Interview revealed MD #3 did not recall being notified of Patient #3's initial fall from her bed on the evening of 03/14/2022. Interview revealed Physician's Assistant [PA] #4 may have received notification of the fall.

Provider interview was conducted with PA #4 on 05/04/2022 at 1409. Interview revealed PA #4 did not recall being notified of Patient #3's initial fall from her bed on the evening of 03/14/2022. During the interview, PA #4 conducted chart review, and reviewed the facility's provider text message system and provider on-call phone memory and could find no evidence a provider was notified of Patient #3's fall.

Telephone interview was attempted with CNA #1 on 05/04/2022 at 1514, to no avail.

NC00186998; NC00181907; NC00187203; NC00185478; NC00186032; NC00185374