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Based on record reviews and interviews, the facility failed to provide complainant #1 with the results of her complaint according to the facility policy and procedure on Complaint and Grievance Resolution for Patients and Customers, last revised 10/2016.

Findings included:

Record review of complainant #1's complaint form, dated 04/28/16, written to the state regulatory agency revealed but was not limited to the following: On 09/29/1015, complainant #1 and her brother met with the ICU nurse director to file a complaint against the hospital for what had occurred. Patient #1 (her father) had received CPR for 25-30 minutes after a colonoscopy on 09/23/15. The hospital did not call either herself or her sister-in-law to inform them what had happened. In addition, Patient #1 had an out of hospital DNR which had not been transferred to his inpatient hospitalization. The ICU nurse director listened and took notes. They asked if it was our responsibility to notify the hospital of the DNR or theirs. She said it was part of the admittance procedure. She said that a new DNR had to be signed once the patient was admitted to the hospital. The complainant asked why the hospital did not call the family since they had contact information. She did not have an answer. The complainant asked for a copy of the records that had been sent with her father (patient #1) from the nursing home. The ICU nurse director stated she would investigate the situation and get back with them. The complainant alleged she saw her on three separate occasions in the hospital and again asked for the records that her father was sent with from the nursing home. She never received an update from the ICU nurse director.

Interview on 12/13/16 with Complainant #1 confirmed the previously listed complaints and that she never received a verbal and/or written answer from the hospital regarding her complaint to the ICU nurse director.

Record review of facility Internal Risk Management Verification Report, dated 10/01/15 revealed the following: "It was entered by ICU nurse director as treatment or medical complaint. Corrective action was listed as refer to administrative, refer to hospital department, and facility legal notified. There was no indication that Complainant #1 had been notified of the results of her complaint by the facility.

Interview on 12/06/16 with the facility Chief Nursing Officer (CNO) revealed but was not limited to the following: "This was determined to be an incident report and not a complaint by the facility and thus, the facility would not have sent a letter to complainant #1. She stated the thinking was the "incident" was settled by a change in physicians.

When surveyor asked for further clarification on how the "medical complaint" was handled, the CNO stated that information was considered confidential due to being part of the Patient Safety Work Product and was not disclosable to regulatory agencies.

Record review of Complaint and Grievance Resolution for Patients and Customers, last revised 10/2016, revealed but was not limited to the following: "A grievance was defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, when a patient issue cannot be resolved promptly by staff present. A complaint was defined as an expression of dissatisfaction by a customer, but is interpreted as a lesser dissatisfaction that can be immediately resolved, that is, no later than the same calendar day of the complaint. The Director/Manager handling the complaint completes the investigation, follows up with the patient, and enters the findings and action taken in Meditech, noting whether or not there was a resolution. If the complaint is not promptly resolved, the complaint then becomes a grievance and is notes as such in Meditech. If the grievance can be resolved within seven days, the patient or patient's representative will receive a "Grievance Follow-Up letter," in lieu of the "Notification of Receipt of Grievance" letter. Some grievances may require more extensive investigation and will be resolves as quickly as possible but within 21 days. If the grievance requires more than seven business days to resolve , the complainant will receive a Notification of Receipt of Grievance letter, indicating the hospital is investigating and will send a Grievance Follow-Up letter."

Based on record reviews and interviews, the facility failed to track adverse patient events and analyze their causes. The facility failed to follow its policies and procedures in the review of code blue forms for 1 of 1 patients (#1) reviewed who coded in the facility.

Findings include:

Record review of the Code Blue record for Patient #1 revealed that on 9/23/15@ 1800 the patient went into cardiac arrest and a code blue was initiated by nursing staff.

Record review of the facility policy entitled: Code Blue Resuscitation/ Crash Cart, revised 08/2014 revealed in part the following:

Documentation/ Performance Improvement:

- B.) Code Blue review form:
o The code blue review form is to be completed by the critical care responder upon termination of the resuscitation attempt, regardless of outcome, and routed through the appropriate review process. The form will be submitted to the Quality Management Department who will collect data, analyze, summarize and report findings to the Quality Council and the Organization Performance Improvement Committee (OPIC).

Record review of the facility Performance Improvement Committee records revealed no evidence that the Quality Management Department collected data, analyzed, summarized and reported findings to the Quality Council and the Organization Performance Improvement Committee regarding patient #1's adverse event.

In an interview conducted on 12/20/16 at 1:17 pm, the facility Risk Management Nurse confirmed the above findings and revealed that the Code Blue Review Form had not been completed, nor had a review/ analysis of the adverse event been conducted by the OPIC. She further stated that a review had not been conducted because the original Code Blue Form had been misplaced and was not contained with the patient's permanent medical record.

Based on record review and interview, the facility failed to ensure that inpatient medical records were properly filed, retained, and accessible for 1 of 1 patients (#1) who were admitted to the facility.

Findings include:
Record review of the nurse's notes for Patient #1 revealed the following documentation:
-Registered Nurse (RN)-A
- 9/23/15 @1800: Code Blue initiated by 1:1 bedside sitter stating patient appeared pale, lethargic, and did not look like he was breathing. Per sitter patient did not have food in his mouth at the time of what appeared to be a seizure.
- 9/23/15 @1845: Refer to code blue sheet.
- 9/23/15 @ 1850: Patient transferred to ICU per ER physician.
Further review of the nursing notes revealed no further evidence of nursing documentation to cover the 45 minute gap refelcting the patient's status at the time of the event.
Record review of the Physician's progress notes for Patient #1 revealed the following:
- Physician- A
- 9/24/15 (untimed) Interval History: The patient sustained cardiopulmonary arrest post- code. He received epinephrine and was mechanically ventilated immediately.
- 9/25/15 (untimed) Interval History: The patient sustained a cardiopulmonary arrest after he underwent a colonoscopy. He was successfully resuscitated. At the time that the cardiopulmonary arrest occurred, just prior o the time that he sustained a cardiac arrest, he had a tonic-clonic seizure that caused desaturation of oxygen and lead to the arrest.

Further review of the patient's facility records revealed no evidence of a Code Blue sheet being initiated by nursing staff.

On 12/19/16 @ 4:31 pm, survey staff received a faxed copy of the Code Blue record for Patient #1 from the facility Risk Management Nurse. The record indicated that Patient #1 sustained cardiopulmonary arrest and that CPR was performed on 9/23/15 from 1800- 1842.

Record review of the facility policy entitled: Code Blue Resuscitation/ Crash Cart, revised 08/2014 revealed in part the following:

Documentation/ Performance Improvement:
- A.) Code Blue Record:
The Code Blue record form is utilized for documentation. The Unit Charge nurse is responsible for documentation on the Code Blue record for the sequence of events and medications given..... This form remains as a permanent part of the medical record. Copies of the Code Blue Form are routed to the pharmacy and Quality Management Director.

- B.) Code Blue review form:
The code blue review form is to be completed by the critical care responder upon termination of the resuscitation attempt, regardless of outcome, and routed through the appropriate review process. The form will be submitted to the Quality Management Department who will collect data, analyze, summarize and report findings to the Quality Council and the Organization Performance Improvement Committee (OPIC).

In an interview conducted on 12/20/16 at 1:17 pm, the facility Risk Management Nurse confirmed the above findings and revealed that the Code Blue Review Form had not been completed, nor had a review/ analysis of the adverse event been conducted by the OPIC. She further stated that a review had not been conducted because the original Code Blue Form had been misplaced within the Intensive Care Unit (ICU) records and was not contained with the patient's permanent medical record.