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Based on interview and record review the facility failed to follow its grievance procedure when it failed to classify a telephone grievance as a grievance. The family grievance was reported as an incident and was not investigated as reported by the facility policy and procedure.

Findings Included:

Review of the facility provided policy PATIENT COMPLAINT AND GRIEVANCE RESOLUTION PROCESS (effective 7/2022) reflected:

"...Definition: A patient grievance is defined as:
A Patient grievance is a formal or informal written or verbal complaint
When the verbal complaint about patient care is not resolved at the time of the complaint by staff present
By a patient or patient's representative
Regarding the patient's care, abuse, neglect issues related to the hospital's compliance with CMSCoP or a Medicare beneficiary billing complaint related to rights
All complaints not resolved by staff present during the hospital stay or within one business day of receiving a verbal complaint post-discharge if the complaint was not communicated during the hospital visit..."

...PROCEDURE: Grievance Process:
The grievance will be referred to the Risk Department for further investigation and the Risk Department will provide a response for those cases involving risk and/or quality of care issues..."

Review of the facility grievance log reflected no grievance reported related to Patient #2.

During an interview on the morning of 2/14/23 with Staff #3, Director of Risk Management and Patient Safety, he reported that he never received a grievance related to Patient #2. He continued that after this surveyor requested this information he did find an incident report that was written related to this patient rather than a grievance. He continued that this should have been a grievance or at least identified as a grievance when the incident report was reviewed. He reported that he does not know how this was missed. When asked how these reports are reviewed he reported that typically the grievances and incidents are reviewed by a team of 3-5 staff. They are then referred to the appropriate department for review and/or investigation. This incident was not addressed.

Based on interview and record review the facility failed to establish an appropriate plan and discuss the results of the evaluation with the patient (or patient's representative).

Findings include:

Review of Patient #2's medical record reflected that he was admitted on 10/17/2022 following a fall. The patient was transferred from another facility. The patient was discharged on 10/24/22 with the discharge diagnosis of
"R scalp laceration with hematoma (repaired)
L orbital wall fxs (fx fracture) (superior, inferior, and medial) -nonoperative
Anterior maxillary antral wall fx (nonoperative)
C1 anterior arch fx with BL mildly displaced fx of he (sic)posterior C1 arch (s/p fusion)
C2 type II dens fx with 2mm posterior displacement (s/p fusion)
Longitudinal ligament discontinuity (anterior and posterior)
BL tiny plural effusions...
...Discharge Instructions
Additional Discharge Routines: Wound/Dressing Care (staples removal in 7-10 days)
Wound/dressing care: Change dressing daily (scalp staples removal 7-10 days) ...
Follow-up Appointments
Consulting provider 1: Specialty Spine Surgery
Consult follow up timeframe: In 1-2 weeks
Special Instructions:
No bending, lifting >10 lbs., twisting, or driving.
Prevenar placed at the day of DC, continue x1 week, then remove and place silverlon. Change silverlon q5-7 days or sooner if saturated/soiled. Cover with Aquagards for showers. "

During an interview with patient #2's spouse on the morning of 2/14/23 she reported that the patient was sent home in a lyft (car service) wearing a hospital gown, with a machine that kept alarming. When she called the hospital for assistance, they told her that they couldn't help her. She continued that she eventually found the number to the manufacturer and was able to get information on the machine.

During an interview on the morning of 2/15/23 Staff #6, Social Worker, reported that the Prevenar is a new device that the facility is using. This devise is self-contained. When asked if there were any written instructions that are sent home with the patient, she reported that there are not. She continued that when we set up a wound vac, we usually have the company come teach the family how to use the device. This was not done with patient #2.

Review of the Case Management Report reflected "Discharge: Pt returned home today, 10/24/22, at 4:30 pm. Referral to Red River Home Health: Pending approval ... Comments: 10/25/22 03:02 pm Referral for HHA approved Red River HHA SOC (start of service) 10/28/22."

Review of Patient #2's nurse's notes, dated 10/24/22 13:50 pm, reflected that the discharge instructions were given to the patient. There is no documentation of any written instructions. There is no documentation of reviewing the discharge instructions with the patient's wife.

During an interview on the morning of 2/15/23 staff #5, Director of Progressive Patient Unit, reflected "I would expect to see nurse notes related to talking to the patient's wife and reviewing discharge instructions with her."