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Based on review of complaints/grievances, Baptist Health Customer Grievance Policy and interview, it was determined the facility failed to provide the Complainant with a written notice of the steps taken to investigate the complaint, the results of the investigation, the completion date of the investigation and the name of a hospital contact person for two (#2 and #15) of two (#2 and #15) reported complaints. Without a written response, it could not be assured the patient and/or the patient's representative were made aware of the steps taken on their behalf and the results of the grievance. The failed practice had the potential to affect all patients on census and all patients admitted to the facility. Findings follow:

A. Review of the Patient's complaints/grievances documentation revealed there was no evidence of written notification of the hospital's determination regarding the grievance for two (#2 and #15) of two (#2 and #15) Complainants.
B. Review of the Baptist Health Customer Grievance Policy #513 on 11/09/11 at 1400 revealed the hospital must respond to all grievances within seven days, including written notification.
C. Findings were verified with the Chief Nursing Officer at 1030 on 11/10/11.

Based on clinical record review, policy and procedure review and interview, it was determined of seven (#1, #4, #7, #10 #11, #12 and #13) patients selected for review of weights, five ( #4, #7, #10, #11 and #13) patients daily weights were greater than five pounds of the previous weight without a reweigh to determine the accuracy of the weight. The inaccurate weights did not allow for identification of true weight loss so that nutrition intervention could be implemented. The failed practice had the potential to affect 23 patients on current census. The findings were:

A. Review of the policy for using the bed scales reflected the following must be performed:
1) The following linens were to be in the bed bottom sheet, top sheet, two pillows, 2 pillow cases, draw sheet, 2 blue chux and gown.
2) The bed was to be zeroed out before weighing the patient.
3) "When the patient is weighed, if there is a difference more than 5 # (pounds) from previous, nurse must be notified."

B. Patient #4 was admitted on 10/28/11 with an order for daily weights via the bed scales.

Review of the graphic record from 10/28/11 to 11/08/11 revealed weights that varied five pounds or greater as follows: 10/31/11 178.5 to 10/31/11 183.9 which was a 5.4 pound difference; 11/04/11 192.7 to 11/05/11 185.9 which was a 6.8 pound difference; 11/05/11 185.9 to 11/06/11 180.3 which was a 5.6 pound difference; and 11/07/11 181.2 to 11/08/11 174.2 which was a 7 pound difference. There was no evidence the nursing staff was aware of the weight discrepancy and a re-weigh obtained. Interview on 11/09/11 at 1100, the CNO accepted the findings as presented for Patient #4.

C. Patient #7 was admitted on 09/19/11 with an order for daily weights via the bed scales.

Review of the Graphic Record from 09/19/11 to 11/09/11 revealed weights that varied five pounds or greater as follows: 09/20/11 382 to 09/21/11 391.4 which was a 7.4 pound difference; 09/22/11 391.2 to 09/23/11 378.7 which was a 12.5 pound difference; 09/23/11 378.7 to 09/24/11 388.2 which was a 9.5 pound difference; 10/08/11 171.9 to 10/09/11 368.2 which was 196.3 pound difference; 10/12/11 369.5 to 10/13/11 374.7 which was 5.2 pound difference; 10/17/11 377.1 to 10/18/11 371.7 which was a 6.6 pound difference; 10/19/11 371 to 10/20/11 390.5 which was a 19.5 pound difference; 10/22/11 393.3 to 10/23/11 360 which was a 33.3 pound difference; 10/23/11 360 to 10/24/11 404.4 which was a 44.4 pound difference; 10/27/11 405.7 to 10/28/11 388 which was a 17.7 pound difference; 10/28/11 388 to 10/29/11 371.7 which was 16.3 pound difference; 10/29/11 371.7 to 10/30/11 316 which was 55.7 pound difference; 10/31/11 314.1 to 11/01/11 305.7 which was a 8.4 pound difference; 11/03/11 302.5 to 11/04/11 374.4-repeat 381.4 which was a 71.9-78.9 pound difference; 11/04/11 374.4-repeat 381.4 to 11/05/11 307.6 which was a 66.8-73.4 pound difference; 11/05/11 307.6 to 11/06/11 377.4 which was a 69.8 pound difference; 11/07/11 380.7 to 11/08/11 386.6 which was a 5.9 difference; and 11/08/11 386.6 to 11/09/11 367.6 which was 19 pound difference. There was no evidence the nursing staff was aware of the weight discrepancy and a re-weighs obtained. Interview on 11/09/11 at 1300, the CNO confirmed the clinical record findings for Patient #7.

D. Patient #10 was admitted on 11/01/11 with an order for daily weights via bed scales.
Review of the Graphic Record from 11/01/11 to 11/05/11 revealed weights that varied five pounds or greater as follows: 11/02/11 157.9 to 11/03/11 150.5 which was 7.4 pound difference; and 11/07/11 144.9 to 11/08/11 154.1 which was a 9.2 pound difference. There was no evidence the nursing staff was aware of the weight discrepancy and a re-weighs obtained. Interview on 11/10/11 at 1300, the CNO accepted findings as presented for Patient #10.

E. Patient #11 was admitted on 11/01/11 with an order for daily weights via bed scales.

Review of the Graphic Record from 11/01/11 to 11/08/11 revealed weights that varied five pounds or greater as follows: 11/02/11 310.4 to 11/03/11 246.3 which was 64.1 pound difference; 11/04/11 247.0 to 11/05/11 253.7 which was a 6.7 pound difference; 11/05/11 253.7 to 11/06/11 244.9 which was a 8.8 pound difference and 11/06/11 244.9 to 11/09/11 233.6 which was a 11.3 pound difference. Interview on 11/09/11 at 1500, the CNO accepted the findings as presented for Patient #11.

F. Patient #13 was admitted on 10/03/11 with an order for daily weights via bed scales.

Review of the Graphic Record from 10/03/11 to 11/09/11 revealed weights that varied five pounds or greater as follows: 10/07/11 218.7 to 10/08/11 177.2 which was a 41.5 pound difference; 10/14/11 166.3 to 10/15/11 157.7 which was a 8.6 pound difference; 10/15/11 157.7 to 10/16/11 163.4 which was a 5.7 pound difference; 10/22/11 172.5 to 10/24/11 164.6 which was a 7.9 pound difference; 10/24/11 164.6 to 10/25/11 175.8 which was a 11.2 pound difference; and 10/25/11 175.8 to 10/26/11 164 which was a 11.8 pound difference. There was no evidence the nursing staff was aware of the weight discrepancy and a re-weighs were not obtained. Interview on 11/10/11 at 1300, the CNO accepted the findings as presented.



Based on clinical record review and staff interview, it was determined of seven (#1, #4, #7, #10, #11, #12 and #13) patients selected for review of intake and output, three ( #1, #4, and #12) patients had their output greater than the intake without evidence it was addressed by the nursing staff. The failed practice did not assure the patient was assessed for their hydration status to implement interventions to prevent dehydration. The failed practice had the potential to affect all 23 patients on census. The findings were:

A. Patient #1 was admitted on 11/04/11. Review of the Graphic Record from 11/04/11 to 11/09/11 revealed there were four (11/4, 5, 7 and 8) of six days the output exceeded their oral intake without evidence it was addressed by the nursing staff to determine if the patient had any hydration concerns. Interview on 11/09/11 at 1310, Registered Nurse/Case Manager confirmed findings regarding the output.

B. Patient #4: Review of the Graphic Record from 10/28/11 to 11/08/11 revealed there were 6 (11/3-8) of 12 days in which the output exceeded the oral intake without evidence it was addressed by the nursing staff to determine if the patient had any hydration concerns. Interview on 11/10/11 at 1302, Registered Nurse/Case Manager confirmed the Graphic Record for output. Interview on 11/09/11 at 1100, the CNO accepted findings as presented for Patient #4.

C. Patient #12 was admitted on 11/08/11. Review of the Graphic Record from 11/08/11 revealed there were two of two (11/8-9/11) days in which the output exceeded the oral intake without evidence it was addressed by the nursing staff to determine if the patient had any hydration concerns. Interview on 11/10/11 at 1300, the CNO accepted findings as presented for Patient #12.