HospitalInspections.org

Based on document review and interview, the facility failed to ensure a patient grievance was investigated in a timely manner in one (1) instance. (Patient # 10)

Findings include:

1. The facility policy titled, "Patient Rights and Responsibilities", PolicyStat ID 10359862, indicated every person who enters the facility for care has rights. The patient has the right to file a grievance in writing and have it addressed in a timely manner, receive a written response within seven (7) days. Have the grievance investigated and efforts toward a resolution within seven (7) days. This policy was last revised in 09/2021.

2. The facility policy titled, "Patient Grievance Procedure", PolicyStat ID 11795393, indicated the facility will provide a system whereby patients can voice a grievance about the quality of care and/or services received, have their concerns investigated, and addressed in a timely manner. This policy was last revised in 01/2020.

3. The Grievance Log dated 01/01/2023 through 03/01/2023 was reviewed and lacked a grievance which would
have been filed/investigated for patient # 10.

4. Review of patient # 10's medical record (MR), indicated a handwritten grievance form dated 01/23/2023, had been completed by patient # 10 and placed in his/her MR by a nurse.

5. In interview on 03/02/2023 at approximately 4:24 pm with administrative staff member A # 2 (Quality Risk), confirmed the nurse should have made administration aware of the grievance. This grievance was not investigated.

Based on document review and interview, the facility failed to follow their core staffing patient to staff matrix ratio guideline for three (3) of three (3) inpatient units reviewed. (Unit 100, Unit 200 & Unit 300)

Findings include:

1. Review of the facility policy, "Nurse Staffing and Assignments", PolicyStat ID 12508509, indicated the DON (Director of Nursing) would be accountable to ensure a sufficient number of qualified staff are on duty at all times to provide patients with quality care. Staffing will be based on a mix of the Core Staffing matrix which indicated one (1) Registered Nurse (RN) and one (1) Aide/Tech (A/T) for one (1) to twelve (12) patients, and one (1) RN plus (+) one (1) Nurse and two (2) Aide/Tech for thirteen (13) to twenty-five (25) patients. This policy was last revised in 02/2022.

2. Review of the "staffing pattern worksheet" provided by the facility, indicated the units (100, 200 and 300) were short staffed on the following days/nights:

a. 100 unit -
1/15/23 - patient census 14 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift. There was one A/T on the day/evening/night shift.
1/16/23 - patient census 14 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day shift, one nurse on the night shift, and one A/T on the day and evening shift.
1/17/23 - patient census 14 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day shift, one nurse on the night shift, and one A/T on the night shift.
1/18/23 - patient census 14 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the night shift and one A/T on the day and night shift.
1/19/23 - patient census 13 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one A/T on the day/evening/night shift.
1/20/23 - patient census 13 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day/night shift, and one A/T on the day, evening and night shift.
1/21/23 - patient census 13 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day/night shift, and one A/T on the day, evening and night shift.
1/22/23 - patient census 13 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day/night shift, and one A/T on the day, evening and night shift.
1/23/23 - patient census 13 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day shift, one nurse on the night shift, and one A/T on the day and night shift.
1/24/23 - patient census 13 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the evening and night shift.

b. 200 unit -
1/15/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day shift, one nurse on the night shift, and one A/T on the day/evening/night shift.
1/16/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the day and night shift.
1/17/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day shift, one RN on the night shift, and on A/T on the day shift.
1/18/23 - patient census 14 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the night shift, and one A/T on the day and evening shift.
1/19/23 - patient census 15 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day shift, one RN on the night shift, and one A/T on the evening shift.
1/20/23 - patient census 13 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day shift, one RN on the night shift, and one A/T on the evening and night shift.
1/21/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day shift, one RN on the night shift, and one A/T on the day and night shift.
1/22/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day shift, one RN on the night shift, and one A/T on the day/evening/night shift.
1/23/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day shift, one RN on the night shift, and one A/T on the day/evening/night shift.
1/24/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day shift, one nurse on the night shift, and one A/T on the evening and night shift.
1/25/23 - patient census 15 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day/night shift.
1/26/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the day/evening/night shift.
1/27/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the night shift.
1/28/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day shift, one nurse on the night shift, and one A/T on the day and night shift.

c. 300 unit -
1/15/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the evening and night shift.
1/16/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the day and night shift.
1/17/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day shift, one RN on the night shift, and one A/T on the night shift.
1/18/23 - patient census 14 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the evening shift.
1/19/23 - patient census 15 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the day and night shift.
1/20/23 - patient census 13 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day shift, one RN on the night shift, and one A/T on the day/evening/night shift.
1/21/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the day/evening/night shift.
1/22/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the day/evening/night shift.
1/23/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the day/evening/night shift.
1/24/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day/night shift, and one A/T on the day/evening/night shift.
1/25/23 - patient census 15 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day/night shift, and one A/T on the evening and night shift.
1/26/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one nurse on the day shift, one RN on the night shift, and one A/T on the evening and night shift.
1/27/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the day and night shift.
1/28/23 - patient census 16 - per policy staffing called for one RN plus one nurse and two A/T's on all shifts. There was one RN on the day/night shift, and one A/T on the day/evening/night shift.

3. In interview on 03/02/2023 at approximately 4:50 pm with administrative staff member A # 2 (Quality Risk), confirmed the facility had been short staffed in January.

Based on document review and interview, the nurse failed to supervise/evaluate the patient care needs by not recording the patient's information on the log upon receiving the patient's hand written grievance form in one (1) instance. (Patient # 10)

Findings include:

1. The facility policy titled, "Patient Grievance Procedure", PolicyStat ID 11795393, indicated upon notification of a grievance, information sufficient to identify the individual registering the concern will be recorded by the staff member. This policy was last revised in 01/2020.

2. The Grievance Log dated 01/01/2023 through 03/01/2023 was reviewed and lacked a grievance which would
have been filed for patient # 10.

3. Review of patient # 10's medical record (MR), indicated a handwritten grievance form dated 01/23/2023, had been completed by patient # 10 and placed in his/her MR by a nurse.

4. In interview on 03/02/2023 at approximately 4:24 pm with administrative staff member A # 2 (Quality Risk), confirmed the nurse should have made administration aware of the grievance and entered it on the log.