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Based on interview and record review, the facility failed to adhere to its grievance policy for 1 of 4 sampled patients with grievances (Patient # 1). The facility failed to ensure:
· A grievance filed by Patient ID # 1 family was fully investigated in a timely manner.
· A grievance filed by Patient ID #1 family received updated written communication every 30 days during investigation process.

Findings include:

TX #00423650

Record review of facility grievance and complaint log dated January 1, 2022 through January 1, 2023 revealed that Patient ID #1 had a grievance registered June 28, 2022 which was submitted by a family member.

Record review of facility case details/investigation of grievance details with Director of Quality Staff ID #51 on January 12, 2023 at 3:00 p.m. revealed that Patient Services Manager staff ID #61 received a 4 page detailed complaint from patient's family on June 28, 2022 at 1:48 p.m. Staff ID #61 acknowledged re-opening grievance at this time. Records demonstrate letter was sent October 4, 2022 to complainant acknowledging concerns and stating the case "remains under review" and "as soon as the review of your concerns is completed, I will notify you by mail."

Record review of facility clinical policy # 09.03.05, "Patient Rights: Patient Grievance Policy," work flow stated for grievance "Is grievance resolved? No, Within 7 days, send letter to patient on status of grievance and every 30 days until resolved. If not completed within 30 days, send grievance to Administration/Manager to review."

Interview with Patient Services Manager Staff ID #61 on 1/12/2023 at 1:30 p.m. revealed she had extensive recollection and 72 pages of grievance and complaint documentation surrounding the issues brought forward by Patient ID #1 family and the facility's responses. She confirmed that she re-opened grievance on June 28, 2022 based on new email received by family. She stated she had sent an update letter October 4, 2022 however stated that she is "behind" in her caseload. She stated that due to the fact there had been previous grievance completed, she was awaiting feedback on discerning what "new grievances" were raised and the assistance of numerous other departments for closure. She acknowledged failure to follow facility grievance policy regarding timeline of investigation and follow-ups.

Based on record review and interview, the facility's nursing staff failed to perform and document a pain assessment prior to administration of a prn narcotic pain medication per facility policy (Patient ID #1).

Findings Included:

Record review of Patient ID #1 medical record revealed Patient ID #1 had Morphine 4 mg slow IV push ordered prn breakthrough pain 4-10. Staff RN ID # 63 administered Morphine 4 mg IV push on 3/23/2022 at 10:48 am and 3/23/2022 at 4:44 p.m. There was no pain assessment documented prior to administration of IV narcotic pain medication on either dose provided 03/23/2022.

Record review of facility policy "UTMB Nursing Practice Policy #7-2-101 Pain Management" stated "1. Pain assessment shall include at least: location of pain, intensity of pain, quality of pain .... Pain assessment/re-assessment shall be performed ... 3.6 before and after each pain management intervention ...".

Record review of facility policy "UTMB Department of Pharmacy Policy and Procedures Policy #07.56 Administration of Controlled Substances," last reviewed 08/22/2018, stated "The nurse of physician administering the controlled substance is responsible for assuring the patient assessment, patient monitoring, and documentation is completed during the patient's treatment in that area."

Interview with Neuro ICU Nurse Manager Staff ID #55 on 1/12/2023 at 12:45 p.m., she confirmed there was no documented pain assessment for Patient ID#1 prior to administration of narcotic pain medication given on 03/23/2022 at 10:48 a.m. and 03/23/2022 at 4:44 p.m. She confirmed the policy and expected practice would be to perform a nursing assessment and document this assessment associated with prn medication administration.