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Based on interview, document review, email correspondence, and policy review, the facility failed to follow their policy for the provision of a response to a grievance for 1 (Patient 4) of 3 sampled patients reviewed for grievances.

Findings Include:

Review of a facility policy titled, "Patient Grievance and Complaint Management Policy," with an effective date of May 2020, revealed, "2. Upon receipt of a grievance, the Patient Advocate (or designee of the organization) shall confer with the appropriate department manager to review, investigate and resolve with the patient and/or patient representative within seven days of receipt of the grievance with the exception of complaints that endanger the patient. These grievances should be reviewed immediately by Risk Management given the seriousness of the allegations and the potential for harm to the patient. A representative of the administrative staff will oversee and assist with the resolution process as needed. Medical staff leadership may be involved as needed to resolve physician delivery of care issues. 3. Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days."

Review of the hospital grievance log, revealed Patient 4 called on an unknown date to report a grievance that they had obtained a healthcare associated infection, been accosted, and received poor quality care during their stay.

During an interview on 04/10/24 at 2:50 PM, the Vice President of Quality and Risk acknowledged Patient 4 called and spoke with the Manager of Quality on 01/19/24 and sent a letter that was received on 02/07/24. Per the Vice President of Quality and Risk, Patient 4's concerns should have added as a grievance. The Vice President of Quality and Risk confirmed a seven-day, and 30-day response letter was not sent to the patient.

Review of an email correspondence to the surveyor from the Vice President of Quality and Risk dated 04/10/24 at 3:49 PM, revealed on 01/19/24, Patient 4 called to report their grievance and sent a letter the hospital on 02/07/24. The Vice President of Quality and Risk stated she did not find the 7-daty acknowledgment letter and staff missed the 30-day window to submit the resolution letter to the patient.

Based on policy review, record review, and interview, the facility failed to ensure their policy for vital signs was followed for 1 (Patient 1) of 1 sampled patients reviewed for vital signs.

Findings Include:

A review of the facility policy titled, "Provision of Care Evidence Based Clinical Documentation," with a replaced/revised date of September 2023, revealed, "d. Medical Telemetry/4 North Med [medical] Surg [surgical] Tele [telemetry] i) Routine Care: (1) Vital signs (including but not limited to BP [blood pressure], HR [heart rate], O2 [oxygen] Saturation, RR [respiratory rate], Temperature and pain) unless otherwise ordered by physician, or patient's condition warrants more frequent assessment (a) On admission within 15 minutes (b) Level of Care: Medical or Surgical, every 8 hours."

Review of Patient 1's clinical record documentation, with an admission date of 01/30/24 for abdominal pain and surgical intervention for multiple anterior abdominal wall hernias, revealed that, on 02/11/24 at 7:58 AM, a complete set of vital signs were recorded for Patient 1.

Review of Vital Signs dated 02/11/24 at 6:28 AM showed, Temperature (T) 37.7 (normal 37), HR 101 (normal 60-100), RR 18 (normal 12-20), Oxygen Saturation (SP02) 86% (normal 95-100 %) on room air.

Documentation dated 02/11/24 at 8:18 AM, revealed, "Other notification comments: BP this moring is 77/49. Patient denies paine. Not Symptomatic. Alert and oriented. Rest of vitals are within normal limits. Notified [Nurse Practioner 1]. Order for 500 NS bolus given. After completion of bous. BP is 94/57 with MAP of 69. Patient is stable."

Documentation dated 02/11/24 at 7:58 AM showed, T 37.0, BP 94/57, HR 64, RR 18, SPO2 76% on room air.

Documentation dated 02/11/24 at 12:30 PM, showed, Patient 1's BP was 95/67.

Further review of the medical record showed that on 02/11/24 at 5:05 PM, a "Code Blue" (need for CPR) was responded to and Patient 1 was found sitting in the recliner, unresponsive, with emesis (vomit) coming out of his mouth. The emesis had the appearance and smell of stool. Patient 1 was coded for about 30 minutes. CPR was stopped at 7:45 PM and Patient 1 was deceased.

There was no evidence in the medical record to indicate staff obtained another complete set of vital signs for Patient 1 after 7:58 AM on 02/11/24.

During an interview on 04/10/24 at 2:34 PM, the Director of Clinical Operations confirmed Patient 1's vital signs were not checked every eight hours on 02/11/24.

Based on email correspondence and policy review, the facility failed to ensure there was evidence to indicate 1 (Medical Doctor 3) of 1 physician reviewed had training on restraints.

Findings Include:

Review of the facility policy titled, "Patient Restraint/Seclusion," with an effective date of 02/20/20, revealed, "Physicians and other LIPs [licensed independent practitioner] authorized to order restraint will have a working knowledge of this policy on the use of restraint and seclusion."

Review of email correspondence to the surveyor from the Vice President of Quality and Risk dated 04/10/24 at 11:28 AM, revealed facility staff had been unable to locate Medical Doctor 3's training on restraints.