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Based on record review and interview, the hospital failed to ensure an effective grievance process was in place. This deficient practice is evidenced by the facility failing to thoroughly investigate a patient's grievance for 1 of 2 patients with grievances in the past 3 months (Patient #1).
Findings:

Review of the hospital policy titled, Patient Complaint/Grievance Policy, revealed in part that a grievance will require an investigation and requisite action from management level personnel.

Review of the two grievances filed by patients in the past 3 months, provided by S1ADM, revealed one was filed by Patient #1 . Patient #1 mailed a written grievance, dated 07/22/22, to the hospital after discharge which included a complaint about not receiving medications as ordered by the physician. Interview with S1ADM on 08/31/22 at 1:00 p.m. revealed that the grievance committee investigated the patient's grievance and found it not valid.

During the survey process, record review of Patient #1's medical record revealed evidence that the patient's medications were not administered as ordered.

On 09/01/22 at 9:50 a.m., interview with S2DON revealed that she had not investigated any issues regarding the patient's grievance.

On 09/01/22 at 10:00 a.m., S2DON reviewed the patient's electronic medical record with the surveyor and confirmed that the patient's medication was not administered as ordered by the physician.

On 09/01/22 at 11:45 a.m., S1ADM stated that S3Therapy Supervisor was responsible for investingating the issues with the patient's medication. S1ADM stated that he was not aware that the patient did not receive medication as ordered by the physician and further stated the grievance had not been thoroughly investigated.

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered in accordance with orders of the practitioner responsible for the patient's care as evidenced by 1 patient (Patient #1) failing to receive medications as ordered by the physician in a total sample of 5.
Findings:

Review of the physician orders for Patient #1 dated 06/16/22 at 8:50 a.m. revealed they included:
- Clarinex 5mg by mouth daily
- Victoza 6mg subcutaneous every night at bedtime
- Linzess 290mcg by mouth every morning

Review of the patient's June 2022 MAR revealed that the first dose of Clarinex was not administered until 06/19/22 (3 days after being ordered).

Review of the patient's June 2022 MAR revealed that Victoza was not administered until 06/17/22 at 9:00 p.m. (the next day after it was ordered).

Review of the patient's June 2022 MAR revealed that Linzess was administered on 06/17/22, but documentation on the MAR for 06/18/22, 06/19/22, 06/20/22, 06/22/22, 06/23/22 and 06/24/22 revealed the medication was not available. There was no other documented evidence in the record of the reasoning that the medication was not available, attempts to obtain the medication or physician notification.

On 09/01/22 at 10:00 a.m., S2DON reviewed the above information in the patient's electronic medical record with the surveyor. S2DON confirmed that the above patient's medication was not administered as ordered by the physician.