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Based on document review, interview, and policy review the facility failed to provide two of five complainants (pt #33 and #34) with written notice of its investigation of the grievance, its results of the grievance, and the date of completion of the grievance resulting in the denying the patients their rights to the grievance process. Findings include:

On 8/9/2017 at 0830 during document review of the grievance log for the facility two of five grievances selected for review failed to have a final decision and correspondence to the complaint. According to the documentation a grievance was received on 5/15/2017 from patient #33. A letter of acknowledgment of receipt of the complaint was sent on 5/16/2017. The letter states "you will receive the outcome of the investigation that is taking place by the hospital. The outcome will be based on interviews with the individuals involved and your medical record if necessary..." On 6/9/2017 an additional letter was sent to the complainant stating "a letter was mailed on May 16, 2017 with notification an investigation was initiated, however, at this time no final outcome has been reached. I will continue to communicate the continued progress of our investigation and potential outcome." The complainant received communication from the patient experience coordinator on 6/30/2017 and 7/21/2017 stating the investigation continued and no result was available at either time. The letter also failed to have a estimated time of completing the investigation.

On 8/9/2017 at 0830 during document review of the grievance log for the facility two of five grievances selected for review failed to have a final decision and correspondence to the complaint. According to the documentation a grievance was received on 5/10/2017 from patient #34. A letter of acknowledgment of receipt of the complaint was sent on 5/15/2017. The letter states "you will receive the outcome of the investigation that is taking place by the hospital. The outcome will be based on interviews with the individuals involved and your medical record if necessary..." On 6/9/2017 an additional letter was sent to the complainant stating "a letter was mailed on May 15, 2017 with notification an investigation was initiated, however, at this time no final outcome has been reached. I will continue to communicate the continued progress of our investigation and potential outcome." The complainant received communication from the patient experience coordinator on 6/30/2017 and 7/21/2017 stating the investigation continued and no result was available at either time. The letter also failed to have a estimated time of completing the investigation.

On 8/9/2017 at 0930 an interview was conducted with the Patient Experience Coordinator (PEC). The PEC was queried as to the process of when a grievance was received by the facility how the grievance was delegated as to who was responsible for the investigation. The PEC stated "it is dependent on the nature of the grievance. If it is clinical in nature then the department head is responsible for investigating the grievance and returning the results to either myself or the manager of risk management. I am not clinical so I am unable to investigate the grievance if it is in regards to clinical areas." The PEC was then asked if there was a process to track the grievance investigation. She stated "we have a program to track the log of grievances but updates are dependent on department managers inputting information." The PEC was then asked if she was aware of how many grievances were still outstanding. The PEC stated "no, not exactly because I'm not sure of where the department managers are at with closing the investigation process."

On 8/9/2017 at 1100 a review of the policy titled "patient complaint/grievance policy and procedure" dated 10/2005 with a revision date of 06/2012 was conducted. According to the policy "written updates provided at no fewer than twenty-one day intervals by patient rep(resentative), final letter prepared by responsible administrator or designee and sent to corporate compliance for review. Copy to patient rep(resenative) for file." The policy further states that the letter of acknowledgement of the grievance is to include "1. the substance of the grievance, 2. the steps being taken to investigate the grievance, 3. an estimated date of completion, 4. a statement that a follow-up letter will be sent upon completion of the investigation."


On 8/9/2017 at 1330 an interview was conducted with the Risk Manager. The Risk Manager was queried what the process was to ensure grievances were answered in a timely manner. The Risk Manager responded "we respond every 21 days as required by our policy to update the complainant." The Risk Manager was then asked if there was a process that department managers are held to to close the process in order for complainants to have closure to the grievance filed with the facility. The Risk Manager responded "some grievances take longer than others but we are dependent upon department managers reporting findings."

Based on document review, policy review, and interview the facility failed to follow policy in triaging the patient and placing the patient in the appropriate setting for monitoring one of eight patients (pt #28) resulting in the potential for adverse outcomes for all patients presenting to the emergency department (ED). Findings include:

On 8/8/2017 at 1030 an interview occurred with the charge nurse of the ED. The charge nurse of the ED was asked how it was determined to let a patient stay in the waiting area versus placing the patient in an ED bay. The charge nurse replied "well several factors are assessed ...if a patient appears to be stable." The charge nurse was then asked if the patient complained of chest pain would that be a factor in determining if they needed to be in an ED bay. The charge nurse replied "well, it would depend if they were having chest pain related to like a cough or if they were younger ...if they are younger they are probably not having chest pain related to a cardiac event."

On 8/9/2017 at approximately 0830 a review of patient #28 chart was conducted. Patient #28 was seen on 5/29/2017 in the ED at 1458. The patient was a 48 year-old male. The patient's primary complaint was listed as syncope (passing out) and collapse while in the shower approximately 30 minutes prior to presenting to the ED. The patient stated a history of syncopal episodes. The patient stated a complaint of headache. The patient's medical history included MI (myocardial infarction - heart attack), DVT (deep vein thrombosis - blood clot), dyslipidemia (high cholesterol), HTN (hypertension - high blood pressure), and GERD (gastrointestinal reflux disorder). The patient also had a surgical history of pacemaker leads (no date). An EKG (electrocardiogram) was obtained on patient at 1503. The patient's EKG was noted as being normal sinus rhythm with septal infarct - age undetermined. The patient was triaged as "Emergent". The patient was not documented as being seen by a physician and the nursing note on 5/29/2017 at 1727 stated "pt (patient) left without being seen in the er (emergency room)." No further testing or labs were evidenced of being ordered.

On 8/9/2017 at 1345 the policy titled "Triage" dated 1/6/2016 was reviewed. According to the policy "2. Emergent - Major injury or illness but stable ....These patient will not be returned to the waiting room as frequent reassessment is required ...chest pain that is low suspicion for being cardiac in nature (chest pain that is sharp and/or reproducible) ...patients with cardiac history, regardless of complaint...Headache."

On 8/9/2017 at 1355 an interview was conducted with the director of the ED. The director was asked what was the protocol or policy for patients when seen in the ED for the patient to be placed in an ED bay (bed). The ED director was queried if the patient (#28) should have been placed in the waiting area related to his recent syncopal event with collapse and his medical history of an MI. The director stated "No." The director was then asked if a patient's age should be used as criteria for placing the patient in the waiting area. She responded "No."

Based on document review and interview, the facility failed to update the Plan of Care (POC) for 3 (#1, #4, and #20) of 8 patients reviewed for POC, resulting in the potential for less than optimal outcomes. Findings include:

Review of patient #1's medical record with Nurse D, on 8/8/17 at approximately 1030, revealed that this patient was admitted with urinary issues on 8/6/17 and was designated at high risk for skin break down with a Braden Score of 12. The POC documented "Problem: "Skin impairment" and the "Expected Outcome: Absence of skin break down," but there were no documented measures specified. Interview with Nurse D, on 8/8/17 at approximately 1035, revealed that "the measures should be documented in the intervention section on the right hand side of the plan."

Review of patient #4's medical record with Nurse F, on 8/8/17 at approximately 1045, revealed that the patient was admitted on 8/1/17 with respiratory issues and was designated at high risk for skin break down with a Braden Score of 11. This POC also documented "Problem: "Skin impairment" and the "Expected Outcome: Absence of skin break down," but there were no documented measures specified. Interview with Nurse F, on 8/8/17 at approximately 1050, revealed that she stated, "I assessed this patient yesterday but there are no interventions listed." Interview with Nurse H, on 8/8/17 at approximately 1100, revealed "the interventions should be listed on the POC."

Review of patient #20's medical record with Nurse E, on 8/9/17 at approximately 1100, revealed that the patient was admitted to the Intensive Care Unit in critical condition on 4/20/17. The patient developed an at risk Braden Score of 13 on 4/21/17 and remained at high risk with scores of 13 or less throughout the hospitalization, discharged on 5/13/17. The Plan of Care documented "Impaired Skin Integrity POC on 5/3/17, Expected Outcome: Absence of new skin breakdown." The specific measures were not documented in the POC. Further interview with Nurse E on 8/9/17 at approximately 1330, verified that although measures were implemented, these measures were not documented in the POC.

On 8/9/17 at 1500, review of the facility policies and procedures (P&P) related to skin care and nursing documentation on the POC revealed the following:
"Skin Integrity, revised 6/2016, 2.1. ...Patient's with a Braden score of 18 or less are at risk of developing pressure ulcers."
"Nursing Documentation in the Medical Record, revised 5/2016, 8. Plan of Care... c. Interventions/Plan of Care Orders: Qualified actions directed at the patient that are steps to achieve the desired outcome and are individualized."