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Based on record review and interview, the hospital failed to ensure that in its resolution of a grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 2 grievances reviewed (Patient #1).
Findings:

Review of the policy and procedure titled, Grievance/Complaint, revealed in part that each issue defined as a grievance will be followed up with a written notice of decision from the administrative designee. The written response will contain the following elements: date of receipt of grievance, name of hospital contact person for patient follow up if needed, steps taken to investigate and dates completed, results of investigation and dates completed and completion date.

Review of the Patient Grievance/Complaint Report Form dated 05/05/22 revealed that a family member of Patient #1 called S1DON after the patient's discharge. The family member complained of issues regarding nursing care, physical therapy and radiology issues. Further review of the form revealed that the issues were investigated by S1DON and the box indicating issue resolved was checked. There was no check in the box indicating communication sent.

On 06/13/22 at 1:00 p.m., interview with S1DON confirmed that after resolution of the above grievance, there was no communication or written notice sent Patient #1's family member regarding the grievance, which included date of receipt of grievance, name of hospital contact person for patient follow up if needed, steps taken to investigate and dates completed, results of investigation and dates completed and completion date. Further interview with S1SON confirmed that the hospital did not follow its grievance procedures.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing to weigh a patient daily who was on diuretics and failing to assess a 37 pound weight gain over a two week period for 1 sampled patient (Patient #1) in a total sample of 5.
Findings:

Review of the policy titled, Procedure for Weights/Admission and Daily, revealed in part that patients who are receiving IV or PO Lasix should be weighed daily.

Review of the electronic medical record for Patient #1 revealed the patient was admitted on 04/18/22 with a diagnosis of stroke and an admit weight of 125.

Review of the patient's physican orders revealed the physician ordered IV Lasix to be administered to the patient on the following dates: 04/21/22, 04/29/22, 04/30/22 and 05/01/22.

Review of the only weights documented in the medical record revealed:
04/18/22 (admit), 125 pounds
04/30/22, 162 pounds
05/01/22, 157 pounds

On 06/13/22 at 2:20 p.m., interview with S1DON revealed that the nurses should have reassessed the patient's weights due to the large weight gains that were documented. Further interview with S1DON confirmed that the patient was not weighed daily after beginning IV Lasix, as hospital policy indicated. S1DON confirmed the patient's weights were not accurately assessed.