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Based on document review and interview, the facility failed to ensure members of a grievance committee investigated and resolved all allegations of abuse, neglect and patient harm for one occurrence.

Findings include:

1. Review of the policy/procedure Customer Issue Resolution (Patient Grievance) (approved 9-20) indicated the following: "The Board of Directors delegates to the Grievance Committee the responsibility for effective operation of the grievance process including review and resolution of patient/family/visitor grievances... The responsibility for investigation of formal concerns/complaints/grievances is assigned to the grievance committee; the Customer Service Representative/Patient Advocate, the Director of Nursing/VP Patient Services/Chief Nursing Officer, and the Hospital President (or Administrator on Call)."

2. Review of administrative documentation indicated the Patient Advocate A9 returned a call on 1-24-22 at 1634 hours to a representative for Patient #3 (Pt#3) who reported the patient was abused by a [Gender C] staff member during their recent hospital stay. The patient's representative (PR86) indicated Pt#3 told PR86 they (Pt#3) yelled at the staff member and told them to get out of the room when the staff allegedly grabbed and squeezed Pt#3's genitalia. PR86 indicated the patient reported the allegation of abuse to a second nursing staff when the staff came into the patient's room afterwards, and the second nursing staff indicated to Pt#3 the inappropriate contact was probably an accident, and no other administrative documentation indicated an allegation of patient abuse involving Pt#3 was communicated before the call to the Patient Advocate.

3. Review of the event summary for Pt#3 indicated the documentation was forwarded to the 2MS/SURGE 3MS Nursing Manager A8 to investigate the allegations, and staff A8 forwarded the grievance to Flex Team Manager A12 (the supervisor for [Gender C] staff member), and no administrative documentation provided for review indicated the grievance committee convened and/or any other grievance committee members participated in the formal grievance investigation process prior to 2-7-22 at 0915 hours when the federal complaint investigation was initiated at the facility.

4. On 2-8-22 at 0945 hours, the Administrative Director of Nursing A3 confirmed the above.

Based upon document review and interview, the facility failed to ensure all Registered Nurses followed the policies and procedures of the hospital for 1 of 10 medical records (MR) reviewed (Patient #3).

Findings include:

1. Review of the policy/procedure Maltreatment of the Adult (approved 2-20) indicated a failure to address allegations of patient abuse, neglect or harassment that allegedly occurred at the facility by a staff, other patients, or visitors.

2. Review of the policy/procedure Event Reporting (approved 4-21) indicated the following: "All events, regardless of harm level, should be entered in the (event reporting system) as soon as possible... (and)... all harm events should be reported verbally to the unit/department leadership."

3. Review of the policy/procedure Medical Records (approved 1-21) indicated the following: "...documentation created in the normal course of patient/client care... will be sufficiently comprehensive to support the diagnoses and outcomes and justify the course of treatment."

4. Review of 5 events reported around the date of the allegations failed to indicate on 1-18-22 an event involving Patient #3 was reported.

5. Review of the MR for Patient #3 lacked documentation on 1-18-22 indicating the Agency Registered Nurse N32 utilized a condom catheter for management of the patient's urinary incontinence after an indwelling catheter was discontinued and/or indicating an allegation of abuse was reported to staff N32 Patient#3 and the patient's family member FM68.

6. Review of facility administrative documentation indicated a report of abuse involving Patient #3 was received on 1-24-22 by the Patient Advocate A9.

7. During an interview on 2-7-2022 at 1220 hours, the2MS/SURGE 3MS Nursing Manager A8 indicated they spoke to the Agency Registered Nurse N32 assigned to provide care on 1-18-22 to Patient #3 and N32 confirmed they were notified about the allegation of patient abuse by Patient#3 and the patient's family member FM68.

8. On 2-8-22 at 0945 hours, the Administrative Director of Nursing confirmed no documentation indicated an allegation of patient abuse was reported to the facility prior to notice on 1-24-22.

9. On 2-8-22 at 1450 hours, the Quality and Accreditation Specialists A4, A5, A6 and A7 confirmed the MR for Pt#3 lacked the indicated documentation.