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Based on policy review, record review and interview, the hospital failed to ensure patient complaints, requiring further investigation, were recognized as grievances. This deficient practice was evidenced by failing to correctly identify patient grievances for 1 (#2) of 1 patient reviewed for complaints/grievances from a total patient sample of 3. Findings:

Review of the hospital's policy titled, "Complaint Grievance" revealed in part: 1. A grievance is a "written or verbal complaint by a patient or the patient's representative, regarding the patient's care ... Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the hospital or health clinic with a complaint regarding the patient's care ... A grievance may include a situation where the patient or his or her representative phones the hospital or health clinic with a concern that constitutes a grievance (i.e., the care provided to the patient ... All verbal or written complaints regarding discrimination, abuse, neglect, patient harm, or health clinic or hospital compliance with federal regulations, are grievances.

Review of Patient #2's medical record revealed the patient was admitted for obervation on 02/07/2024 and was received on the third floor at 6:00 p.m.

Review of the hospital's Complaint Grievance Logs failed to reveal Patient #2.

In an interview on 02/27/2024 at 2:05 p.m., S3RN stated he received a call from Patient #2's daughter on the morning of 02/08/2024. The patient's daughter complained that her mother had not been seen by the staff, had not her vital signs taken and had not had anything to drink prior to this phone call. This information was received by the daughter from her mother during a telephone conversation and was relayed to S3RN during their telephone conversation. S3RN reported to this surveyor that he did not initiate a grievance report regarding this complaint. S3RN reviewed the hospital's grievance policy and acknowledged a grievance report and investigation should have been initiated following this complaint.

Based on record review and interviews, the hospital failed to ensure the Quality Assurance/Performance Improvement (QAPI) program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of hospital services and operations. This deficient practice was evidenced by failing to ensure operations of the vacuum system in the surgical center was monitored following the equipment failure of the vacuum pumps.
Finding:

Review of the hospital's policy titled, "Medical Air and Vacuum System Failure Policy" revealed in part: ... the following procedure will be followed. Procedure-1.Communication a. In the event of a medical vacuum system failure, notify all affected departments and key personnel immediately. Departments: Respiratory Therapy; Surgery; Labor and Deliver; Recovery; Intensive Care Unit; Emergency Department; Nursing Units; Cath Lab, and One Day Surgery. Key Personnel: Respiratory Therapist; Plant Operations; Administration and Nursing Administration. 2. Response b. Respiratory Therapy in conjunction with Nursing Administration and the effected department directors will evaluate alternative methods to address patient needs including the need for portable compressors, portable suction devices and any other medical gas supplies needed to sustain patient care until services can be restored.

In an interview on 02/26/2024 at 12:15 p.m., S4RN Nursing Director of Surgical Services stated the main vacuum system in the surgical center has been inoperable since October or November of 2023 and that the replacement vacuum pumps have arrived and are awaiting installation. S4 continued to state that the surgical center and its post anesthesia recovery area are currently using the stand-alone Stryker-Neptune suctions systems located in each operating suite and these devices were already in use for intraoperative suctioning of liquids and vapors.

Observations 02/26/2024 at 1:45 p.m. of the Materials Management Warehouse located on the ground floor revealed two large crated boxes containing the Busch replacement vacuum pumps.

In an interview on 02/26/2024 at 3:00 p.m., S2Chief Quality Officer stated she was unaware that the main vacuum system in the surgical center was inoperable.

In an interview on 02/26/2024 at 3:30 p.m., S1CEO stated she was made aware in late December of 2023 that the surgical center's main vacuum system was inoperable but did not forward the information to S2 or the QAPI department. She continued to state the new pumps have arrived and are to be installed this week in the surgery center.