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Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to provide timely resolution of grievances for one of two grievances reviewed.

Findings include:

Review of facility policy "RESOLUTION OF PATIENT COMPLAINTS/GRIEVANCES", last revised 12/21, revealed: "... 1. Provision of Response... c. ...1) Grievances that require extensive investigation and are not resolved within seven days: Must be discussed with the Quality Performance Resources and complete within 30 days of the grievance. ...".

Review of facility documentation revealed that the mother of MR1 contacted the facility to file a grievance on 12/10/21. Review of a letter from the facility to MR1 and the mother of MR1, dated December 14, 2021 revealed: "... Thank you for the opportunity to respond to your concerns. ...You will receive a written follow-up letter at the completion of the investigation. Such reviews may take several weeks, so we ask for your patience as you await a response. However, you can be assured that we will respond within 30 days. ...".

Further review of facility documentation revealed a second and final letter addressed to MR1, which was dated March 7, 2022 (83 days later), and revealed steps taken to investigate and address the concerns raised by the family.

During an interview with EMP3 on March 16, 2022, at 2:40PM, EMP3 confirmed the above findings.

Based on review of facility materials, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to integrate its emergency services with other departments of the hospital for five out of eleven medical records reviewed (MR1, MR2, MR3, MR4, and MR5).
Findings include:
Policies regarding handling the dietary needs of patients in the emergency department awaiting transfer were requested. Facility does not have any currently.
On March 16, 2022, at 12:00pm review of medical records revealed that the facility failed to place diet orders and failed to document meals eaten for MR1, MR2, MR3, MR4, and MR5 Findings confirmed by EMP3.
On March 16, 2022, at 2:00pm, review of "Late Tray Log" from dietary revealed inconsistencies for meals needed for patients in the emergency department. Log was reviewed for five charts of patients permitted to eat (MR1, MR2, MR3, MR4, and MR5).
MR1 on December 4, 2021, "8:30" " seclusion room P&P "; December 5, 2021, at no specific times "seclusion room finger foods", "seclusion chix sand (lunch)", and "seclusion chix tenders, fries (dinner)"; December 6, 2021, "5:05" " ER sec room P&P" and "4:30" " ER seclusion".
MR2 was in both ER9 and ER1 during their stay. On October 5, 2021, at no specific time "ER #1 cardiac", no documentation for a patient in ER9 that day; October 6, 2021, at no specific time "ER9 finger food".
MR3 was in seclusion, ER3, and ER18 during their stay. On October 5, 2021, there is only documentation for ER18, but the last name on the log was listed and did not match with that of the patient selected for the sample. On October 6, 2021, at no specific time "seclusion tender/FF", "ER3 cardiac" unknown which is for the patient as no last names were listed.
MR4 on November 1, 2021, at no specific time "sec breakfast sandwich" and "6:00" "secl."; November 2, 2021, at no specific time "sec Room ER finger food", "11:30" "seclusion chix tender Ad fries" , and at no specific time "seclusion"; November 3, 2021, at no specific time "sec. Room ER finger food" and "12:00" " ER seclusion finger food"; November 4, 2021, at no specific times "sec house", "seclusion room finger food lunch", "sec ADA"; November 5, 2021, "6:05" " sec regular", "8:32" "sec-P&P" and at no specific time "seclusion xz ham salad sand"; November 6, 2021, at no specific time "seclusion finger food" and "seclusion house".
MR5 on November 27, 2021, at no specific time "sec house"; November 28, 2021, "6:20" "sec" and at no specific time "seclusion chix tenders, fries (lunch)". The last entry was crossed out. Unknown reason for crossed out entry per EMP7.
Late Tray Log findings confirmed by EMP7 on March 16, 2022, at approximately 2:00pm.
Interview with EMP2 and EMP6 was conducted at 10:30am on March 16, 2022. EMP2 was asked about policies and procedures for ordering trays for patients that are held for an extended time in the emergency department. EMP2 reports that there is no policy or procedure for ordering trays for these patients, but that a phone call is usually placed to nutrition services regarding how many trays are needed.

Interview with EMP7 was conducted at 11:00am on March 16, 2022. EMP7 was asked to explain the process of how nutrition services is notified of the emergency department needing trays for patients that are being held for extended periods of time while waiting to be transferred. EMP7 explained the process depends on the staff that are working both in the emergency department as well as the staff that are working in nutrition services. The usual process is that the emergency department will call and tell nutrition services which rooms will need a tray and what type they will need (example: regular, cardiac, seclusion, etc.). This process sometimes happens once in the morning for the whole day or sometimes for each meal. The nutrition department then writes it down on a log titled "Late Tray Log," which has a location for the date at the top of the form and columns that provide a place for the time, initials of nutrition staff, patient name, room number, and tray type. Per EMP7, these forms are not always filled out for each meal, but EMP7 reports that staff will still send trays for all of the rooms they have at the beginning of the day. EMP7 reports they are trying to get the emergency department to place diet orders for patients regularly because it automatically will be put into the nutrition service's system and eliminate phone calls and paper logs. By placing the order, it will discontinue once the patient leaves the facility.