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Based on document review and interview, it was determined the hospital failed to resolve complaints/grievances per policy. This has the potential to affect all patients who receive care by the Hospital with a current census of 24 in-patients and approximately 1800 Emergency Department (ED) patients per month.

Findings include:

1. The policy titled "Grievances & Complaints" (revised 05/10/2023) was reviewed on 02/09/2023 at approximately 2:40 PM. The policy noted "B. Patient Complaints 3. Issues not resolved by staff present or by escalating up through the chain of command should be directed to the Patient Relations Specialist. C. Grievances 1, Whether a patient/family Grievance is received by hospital staff in person, by telephone or in writing, a Complaint/Grievance report will be originated by staff receiving the grievance. Grievances are documented using the Patient Relations Remote Data Entry Form: ... 6. All grievances must be reviewed by Medical Affairs, Vice President of Medical Affairs, or Nursing Leadership."

2. Pt #1 Date of Arrival (DOA)- 12/18/2022
Diagnoses: Vomiting and Diarrhea. The record was reviewed on 02/02/2023 at approximately 10:30 AM. The ED Secure Progress Noted dated 12/19/2022 at 3:40 AM noted Pt #1's son/daughter randomly started to yell because Pt #1 did not have a fall risk wrist band on; utilized threatening words and foul language; stated "I will be calling administration in the morning."; and then left the ED to go to the car and staff agreed to not let Pt #1's son/daughter return to the the patients room for staff safety and per guidelines patients with symptoms of COVID (elevated temperature and diarrhea) were not to have visitors. The record noted while Pt #1's son/daughter was in the waiting room he/she stated staff were breaking the law, should be worried about losing their nurse's license; during a phone conversation on 12/19/22 at 7:33 AM, Pt #1's son/daughter continued to converse in an aggressive irritable manner and used profanity; at 11:38 AM, Pt #1's son/daughter requested Pt #1 be transferred to another hospital, had alerted the police, the states attorney and was filing charges. Pt #1 was ultimately discharged/transferred on 12/21/22 to a long term acute care hospital.

3. The complaint and grievance log dated 11/01/2022 through 02/09/2023 was reviewed on 02/09/2023 at approximately 10:30 AM. The log lacked documentation of Pt #1's son/daughter's complaints on 12/19/2022.

4. During an interview on 02/09/2023 at approximately 2:00 PM, E#1 (Chief Nursing Officer) and E#2 (Chief Nursing Service Officer) stated the complaint and grievance log is generated by calls that come into the Patient Relations Specialist. E#1 and E#2 stated complaints and grievances that occurred in-house are not recorded in the log and should have been.

Based on document review, observation and interview, it was determined for 2 of 10 (Pt #6, Pt #7) patients records reviewed and observed, the Hospital failed to ensure fall precautions were implemented per policy. This has the potential to affect all in-patients with a current census of 24 patients.

Findings include:

1. The policy titled "Fall Prevention Adult/Pediatric, Inpatient" (reviewed 02/2022) was reviewed on 02/09/2023. The policy noted "4. High risk interventions for adult patients include: ... g. "Yield" communication paper... will be placed near patient room door with appropriate transfer interventions checked."

2. The following records were reviewed on 02/09/2023 between 10:00 AM and 10:30 AM and were noted to be on high risk fall precautions:
a) Pt #6 DOA: 02/04/2023, Diagnosis: Altered Mental Status (room 316)
b) Pt #7 DOA: 02/06/2023, Diagnosis: Shortness of Breath (room 319)

3. During a tour of the medical-surgical unit on 02/09/2023 at approximately 1:45 PM with E#1 (Chief Nursing Officer) and E#2 (Chief Nursing Service Officer), the following rooms were observed without a "Yield" communication paper near the patient's room door:
a) Room 316 (Pt #6)
b) Room 319 (Pt #7)

4. During an interview on 02/09/2023 at approximately 2:15 PM, E#1 and E#2 verbally agreed Pt #6 and Pt #7 were at high risk for falls and lacked a "Yield" communication paper near the patient's door and should have had the paper posted.