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Based on record review and interview, the hospital failed to ensure patient complaints were recognized as grievances. This deficient practice was evidenced by failing to correctly identify patient grievances for 2 (#2, #4) of 2 patients reviewed for complaints/grievances from a total patient sample of 5. Findings:

Review of the hospital policy titled, Grievance, Complaints, and Appeals, revealed in part, a "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issue related to the hospital's compliance with CMS Hospital Condition of Participation, or Medicare beneficiary billing complaint related to rights and limitation provided by 42CFR 48.

An interview was conducted with S3QA on 09/13/2021 at 2:00 p.m. She reported Patient #2 and Patient #4 called in complaints to her after they were discharged from the hospital. S3QA reported the complaints were not formally written complaints so the complaints were not treated as a grievances and letters were not sent to the patients as would be if they were grievances. She went on to report she did investigate the complainant's issues, but she thought grievances were only written complaints.

Based on record review and interview, the registered nurse responsible for supervision of nursing care failed to ensure care was provided in accordance with hospital policy as evidenced by: 1) Failure of the nursing staff to provide a complete nursing assessment per hospital policy in 1 (#3) of 5 (#1-#5) patients sampled; 2) Failure of the nursing staff to perform daily control tests on the glucometer prior to using the instrument on 3(09/08/2021, 09/11/1021, and 09/13/2021) of 13 days in the current month; and 3) Failure of the nursing staff to follow hospital procedure for dietary consultation for 1(#1) of 2(#1 and #3) patients reviewed who required dietary consultations.
Findings:

1. Failure of nursing staff to provide complete nursing assessment per hospital policy in 1(#3) of 5 patients sampled.

Review of hospital policy titled, "Intake Assessment and Treatment," revised 02/04/2019, in part reveals, "The assessment shall include at least the following ... 5. Initiate Medication reconciliation orders per the physician order." "A nursing assessment is completed within 8 hours of admission."

Review of the medical record of Patient #3 reveals the patient was admitted on 09/11/2021 with a diagnosis of psychosis and a past medical history of hypertension, diabetes, deep vein thrombosis and amputation of the left lower extremity.

Review of the Admit Medication Reconciliation Form reveals, "Waiting on fax from Facility A," signed and dated by the nurse on 09/11/2021 at 1:52 p.m.

Further review of the medical record reveals additional attempts to get the list of home medications by S2DON on 09/13/2021 at 8:30 a.m. and 10:00 a.m. The list of home medications received on 09/13/2021 at 1:10 p.m.

In interview on 09/13/2021 at 3:30 p.m., S2DON verified there were no documented attempts to complete the admission medication reconciliation over the weekend and she verified medication reconciliation is part of the required admission assessment. She verified patient #3 did not get his anticoagulant for two days.

2. Failure of the nursing staff to perform daily control tests on the glucometer prior to using the instrument on 3 of 13 days in the current month.

Review of hospital policy titled, "Blood Glucose Monitoring," revised 02/04/2019, in part revealed, "Test checks of the system will be done daily when in use on a patient."

Review of the CBG Control Flow Sheet for September 2021 for Hall B reveals the glucometer was not control tested on 09/02/2012, 09/03/2021, 09/08/2021, 09/11/2021, and 09/13/2021.

Review of "Hall B Glucose Log" reveals patients did receive blood glucose testing on 09/08/2021, 09/11/2021, and 09/13/2021.

In interview on 09/13/2021 at 10:20 a.m., S3QA verified that the glucometer was not tested for accuracy per hospital policy.

3. Failure of the nursing staff to follow hospital procedure for dietary consultation for 1 (#1) of 2(#1 and #3) patients reviewed who required dietary consultations.

Review of hospital policy titled, "Dietary Services," revised 07/07/2020, revealed in part, "A nutritional screening will be conducted by the nurse during the initial nursing assessment. Patients at high risk will be denoted by a higher scoring. If the patient receives a score of 8 or more, the nurse will notify the dietician of the need for a dietary consult."

Review of the medical record of Patient #1 revealed admission on 09/07/2021 and Nutritional Screening was performed on 09/07/2021 at 10:44 p.m. A dietary consult was needed. Further review of the medical record revealed the consult was not performed.

Interview on 09/13/2021 at 3:45 p.m., S5AdmA verified that the consult was not done. She verified hospital policy for dietary consults to be performed within 72 hours of admission.

Based on record review and interview, the hospital failed to ensure that drugs were administered in accordance with physician orders. This deficient practice was evidenced by failing to administered a medication on the day the physician ordered the medication to be administered for 1(#2) of 5 (#1, #2, #3, #4, #5) patients reviewed for medication administration.
Findings:

Review of the physician order dated 07/30/2021 at 8:16 a.m. for Patient #2 revealed an order for Synthroid 150 mcg 1 po daily, start today.

Review of Patient #2's MAR revealed Patient #2 received her first dose of Synthroid on 07/31/2021.

An interview was conducted with S2DON on 09/13/2021 at 2:00 p.m. She reported Company A only dropped off medications once a day so they had to wait until they received the medication the next day.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use. This deficient practice was as evidenced by having expired and/or unusable medications and biologicals available for patient use.
Findings:

An observation was conducted of Medication Room on Hall A on 09/13/2021 at 9:00 a.m. One tube of anti-itch cream was opened and not labeled with a patient's name or the date or time the cream was opened. Orajel tube was opened without a date or time when the tube was opened. 25 vials of 10 cc Normal Saline were expired on 03/2021 and were available for patient use.

An observation was conducted of Medication Room on Hall B on 09/13/2021 at 10:00 a.m. Fluticasone nasal spray was observed opened without a patient name on the bottle and when the spray was opened. In the medicine cart, a medicine cup labeled with Inderal 20 mg on the outside of the cup was open in the drawer of the cart, 3 yellow tablets were in the cup. Two vials of Glucogon 1 mg was observed in the cabinet with an expiration date of 11/2020. Two loose pills were in the cart. A Normal Saline 10cc vial was in the cart with the expiration date of 03/2021.

An interview was conducted with S3QA on 09/13/2021 at 10:30 a.m. She reported the medication nurses should be checking the medication rooms for expired and unusable medications.

Based on observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice. This deficient practice is evidenced by failing to maintain a sanitary environment.

Findings:

An observation was conducted on 09/13/2021 at 9:40 a.m. of the kitchen storage extension area. The floor was sticky and had debris on the floor and there was a cobweb in the corner of the room.

An observation was conducted on 09/13/2021 at 9:45 a.m. of the Medication room on Hall B. The ceiling vent had a thick layer of dust on it with the surrounding ceiling and a wall having a thick layer of dust on it also. An observation was also conducted at this time of a staff member's meal being in the medication room's refrigerator that was utilized for storing water for the patients.

An observation was conducted on 09/13/2021 at 9:50 a.m. of the chairs in dayroom in Hall A having sand leaking from the 3 of the chairs and debris on the floor and edges of the chairs.

The above observations were confirmed by S3QA on 09/13/2021 at 9:45 a.m.

An interview was conducted with S3QA on 09/13/2021 at 10:00 a.m. She confirmed the staff was not to store their meals in the medication room's refrigerator.