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Based on observation, medical record review, staff interview, review of the facility complaint/grievance log, and review of facility policy and procedures, it was determined the facility failed to ensure the patients right to a safe environment related to access to patient bathrooms in the Critical Airway unit. (A123). The facility failed to ensure a grievance recorded in the facility's complaint/grievance log was investigated (A144). The cumulative effect of these systemic practices resulted in the facility's inability to ensure patient rights were met.

Based on review of the facility complaint/grievance log, facility policy review, and staff interview, the facility failed to investigate a grievance recorded in the facility's complaint/grievance log.

Findings include:

The facility's complaint/grievance log from 12/15/15 through 02/21/16 was reviewed on 02/22/16 at 11:45 AM. A complaint categorized as a grievance was noted on 01/08/16. The description of the grievance reported that an email regarding a concern with employees posting information on social media regarding an event at the hospital was received by the Family Relations department. An email generated by a patient advocate was sent to the complainant on 01/11/16 that instructed him/her to feel free to contact the Integrity Helpline. There was no evidence that the facility investigated the grievance.
The facility policy for complaints and grievances was reviewed on 02/22/16. According to the policy all grievances will be investigated.
Staff A was interviewed on 02/23/16 at 2:30 PM. It was confirmed that the complaint categorized as a grievance was not investigated by the facility.

Based on observation, medical record review, and staff interview, the facility failed to ensure the patient's right to care in a safe setting related to the lack of access to patient bathrooms. This had the potential to affect all patients on this unit.

Findings include:

The 11 bed (B509-B519) Critical Airway unit was toured on 02/24/16 at approximately 11:00 AM. The census on the unit at the time of the tour was 6 patients. Room B511, a vacant room, was toured. A lock was observed on the inside of the bathroom door. The lock was turned and bathroom door closed. An unsuccessful attempt was made to enter the locked bathroom door.
Staff C, the Director of the Critical Airway unit, was interviewed how staff unlock the bathroom doors. Staff C reported there was a key for the door on the "charge nurse keys." Staff D, the charge nurse, was asked to retrieve the key to unlock the bathroom door. Staff D presented a key ring with approximately 20 keys on it. Staff D stated: "I don't think there is a specific key." Staff D isolated a small silver key and attempted to unlock the door unsuccessfully. Staff D then inserted the nail of his/her right thumb in the lock of the door and attempted to unlock the door unsuccessfully. Staff D then attempted to use the edge of his/her badge to unlock the door. This attempt was also unsuccessful. Staff C was asked how to unlock the bathroom door. Staff C reported that a coin could be used to unlock the door. Staff C was able to retrieve a coin and the door was successfully unlocked.
Staff B was interviewed after the tour at approximately 11:45 AM. Staff B revealed there was a penny taped to the desk of the nurse's station to be used to unlock the bathroom door. Staff B was asked to provide orientation information that revealed staff was trained about the use of a coin to unlock the bathroom door. The orientation packet lacked evidence regarding how to unlock the bathroom door in the event that a patient was locked inside.