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Based on review of policy and interview with staff an initial written response for a grievance to the complainant within seven (7) days was never provided to the complainant. This requirement was not met.

Findings:

a. In review of the facility's policy "Complaint and Grievances" last revision effective date 02/01/12 page 3 of 5 under section III. Policy, Procedure F. states:

" Initial written responses to patient grievances will be provided within (7) days. Most grievances will be investigated and completed within seven (7) days. Some grievances will require detailed investigation and require longer than seven (7) days to complete. The patient or patient's representative will be notified in writing within seven (7) days of filing the grievance of the following: (a) the facility's anticipated date of completion of the grievance investigation and (b) written response of the resolution or plan of resolution. If the facility is unable to meet this date the patient or patient's representative will be contacted with a revised date.

b. In an interview with staff #1, Risk Manager on 10:30am on October 22, 2014 in an office on the 3rd floor of St. Luke's Baptist hospital for complaint survey TX00202187 and at 11:00am on October 23, 2014 in the administration boardroom at St. Luke's Baptist hospital for complaint survey TX00202379. Staff #1, Risk Manager could not show evidence that this regulatory requirement and hospital policy were met in these two complaint surveys.

c. In the policy "Complaints and Grievances" a grievance is defined as
" Any and all verbal or written complaints regarding abuse, neglect, and patient harm or hospital compliance with CMS requirements. " Patient grievance" is a verbal complaint that cannot be resolved at the time of the complaint by the " staff present"..."

Based on review of policy and interview with staff the facility never sent a written response for a grievance to the complainant. This requirement was not met.

Findings:

a. In review of the facility's policy "Complaint and Grievances" last revision effective date 02/01/12 page 4 of 5 under section IV. Procedure A. Complaint/Grievance Process #6 states:

"All patient grievances will receive a written response from Administration, the Risk Manager, or an appropriate designated individual. The Risk Manager will coordinate the response and include: the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

b. In an interview with staff #1, Risk Manager on 10:30am on October 22, 2014 in an office on the 3rd floor of St. Luke's Baptist hospital for complaint survey TX00202187 and at 11:00am on October 23, 2014 in the administration boardroom at St. Luke's Baptist hospital for complaint survey TX00202379. Staff #1, Risk Manager could not show evidence that this regulatory requirement and hospital policy were met in these two complaint survey.

c. In the policy "Complaints and Grievances" a grievance is defined as

" Any and all verbal or written complaints regarding abuse, neglect, and patient harm or hospital compliance with CMS requirements. " Patient grievance" is a verbal complaint that cannot be resolved at the time of the complaint by the " staff present"..."

Based on review of medical record and interview with staff the nursing staff did not adhere to all physician orders. This requirement was not met under this circumstance.

Findings:

a. In review of the medical record of a 65 year old male patient it was observed that the physician orders on July18, 2014 documented an order for the patient to wear a Bi-level positive airway pressure (BiPaP) when sleeping. It was observed through documentation in the medical record that staff # 4, nursing staff had removed the patient BiPaP as per patient's request because he wanted to eat. She replaced the BiPaP with nasal cannula delivering 4 liters per minute (lpm) of oxygen. Before she left the room the patient was alert and oriented talking to family. Upon rounding she stopped in the room and noticed the patient was asleep. But did not replace the BiPaP as per physician orders for the patient to wear the BiPaP while asleep. The patient had a respiratory arrest at 10:30pm on July 18, 2014 it was documented that the patient had a nasal cannula inserted in his nose and was not on a BiPaP. The patient was successfully resuscitated.

b. Interviewed staff # 2, Patient Care Technician at 10:35am on October 23, 2014 via telephone while in the conference room who explained around 10:20 - 10.25pm on July 18, 2014 she went in the patient room to obtain vital signs and the wife was in the room. She said she realized the patient was unresponsive and was not breathing. She immediately turned up the oxygen delivery to the nasal cannula that was in his nose, called a code blue and the respiratory therapist. She said the patient's wife thought the patient was just sleeping.

c. Interviewed staff # 3, Respiratory Therapist at 1:40pm on October 23, 2014 in the administration conference room. Staff #3, respiratory therapist was on the night shift 7pm to 7am on July 18, 2014. He said he was assessing the patient every 4 hours and last did an assessment on the patient around 7:30 - 7:40pm on July 18, 2014. He said when he assessed the patient at that time the patient did have his BiPaP on at that time. He said around 10:25pm on July 18 2014 he was assessing a patient who was having respiratory problems in the room next to patient #1 65 y/o male. He said he heard staff #2 who was in the patient of concerns room yell out for him and the code blue was activated. He said he rushed in the room and the patient had a nasal cannula in his nose and did not have good respiratory response. Critical care team responded shortly after and provided cardio pulmonary resuscitation to the patient. It took about 30 minutes but they were able to successfully resuscitate him. The patient was taken to the ICU and placed on a mechanical ventilator.

d. Interviewed staff # 4, License Vocational Nurse (LVN), attending floor nurse at 2:20pm on October 23, 2014 while in the administration conference room. Staff #4 was on the night shift 7pm to 7 am shift. Staff #4 explained that she was told during turn-over that the patient was on nasal cannula delivering oxygen at 4 liters per minute in the day and BiPaP at night when he was asleep. Staff #4, floor nurse estimated that around 7:45pm to 8:00pm on July 18, 2014 when she went to assess the patient he was awake sitting up in bed and his wife and daughter was in the room. She said he had asked her if she could remove the BiPaP machine because he wanted to eat his food. Staff # 4 said she attempted to remove the mask for the patient but was having difficulty. She then asked for the RN on staff to assist her in removing the mask and both of them were able to assist the patient in his request. Staff #4 explained the patient was laughing and talking and telling jokes and appeared to be doing fine. She stayed there with him for a while talking to him and his family. She said then she left him talking to his family and did her rounds to all her other patients. She said she started to fill out paperwork at the nurse ' s station when the patient's wife came to ask for a blanket because her daughter was cold. Staff #4 was unsure of the time. The wife said she and her daughter were going to get something to eat and would be back soon. Staff #4 said she brought the blanket that the wife requested for the daughter to the patient room. She said the patient was asleep at this time he still had the nasal cannula in his nose. She said the patient in the room next to patient #1 started having some problems she responded to his room and was assessing this patient when she heard the code blue call in patient #1 room next door. She said she made sure the patient she was working with was stabilized and rushed to the room next door. She said when she arrived the respiratory therapist and the patient care technician were present in the room. The patient was unresponsive. Critical care team responded shortly thereafter.

Once the nurse observed the patient asleep in his room she did not place the BiPaP back on the patient as per physician ordered..