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Based on record review and interviews, the hospital's governing body failed to ensure the prompt resolution of patient grievances and effective operation of the grievance process. This deficient practice was evidenced by failing to ensure a patient's allegation of lack of quality of care was promptly investigated and written notice provided to the complainant for 1 (#3) of 2 (#2 and #3) patients reviewed for grievances.

Findings:

A review of the hospitals policy titled Family Grievances revealed in part:
3. The patient/ family/representative will be kept informed of all efforts made to resolve their grievance and will receive a written acknowledgment within 7 days of receipt from the hospital administrator (designee).

On 03/31/2021 at 8:30 a.m. a review of the Grievance Log revealed Patient #3 occurrence was documented on 01/30/2021 by an anonymous creator.

In an interview on 03/31/2021 at 10:39 a.m. S1Adm stated Patient#3's family complained the staff failed to ensure Patient #3 was wearing underwear. She also stated the family complained the patient used the bathroom and the staff did not change him.

Reviewed the Grievance letters sent to Patient #3's daughter and noted, the first letter was dated 02/11/2021 and the follow up letter was dated 02/12/2021.

In an interview on 03/31/2021 at 1:54 p.m. S2CCO verified the hospital's policy 7-day time line for initiating the letter to the complainant. She also reviewed the Grievance Log and verified the date of the occurrence as 01/30/2021 and the initial letter was dated 02/11/2021.

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Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure to ensure a patient's nutritional consult was completed within 72 hours per hospital policy for 1 (#2) out of 5 (#1-5) sampled patients reviewed for nutritional consults
2) failure to ensure all patient admission consult orders were followed for 1 (#3) of 5 (#1, #2, #3, #4, #5) sampled patients; and
3) failure to notify the physician and or dietician of a patient's poor intake during his admission for 1 (#3) of 2 (#2, #3) patients reviewed for dietary intake.

Findings:


A review of the hospital policy for Nutritional Screening revealed in part:
1. An initial screening or assessment of each patient nutritional status is conducted during the nursing admitting process.
3. The contracted dietician will perform an assessment within 72 hours or as the patient's need warrants.

1) failure to ensure a patient's nutritional consult was completed within 72 hours per hospital policy

Review of Patient's #2 admission orders, dated 10/27/2020 and timed 6:40 p.m., revealed an order for a full liquid diet and dietary assessment and recommendations.

Review of the Initial Nutritional Assessment revealed the consult was completed by S4Dietician on 11/02/2020 at 9:40 a.m. (5 days after the consult was ordered).

An interview was conducted on 04/01/2021 at 11:30 a.m. with S4Dietician. She reported she does nutritional consults on Tuesdays and Thursdays at the hospital. She reported she was not sure why the consult was not completed the previous Thursday (October 29, 2020) for Patient #2. S4Dietician further stated the hospital had discussed with her about implementing a better process to notify her of pending nutritional consults.


2) failure to ensure all patient admission consult orders were followed

A review of the medical record revealed an order for a Dietary Consult on 1/25/2021. Further review failed to reveal the Dietary Consult was completed.

In an interview on 03/31/2021 at 11:57 a.m. S2CCO reviewed Patient #3's medical record and stated she did not see the completed Dietary Consult in the medical record.

On 03/ 31/2021 at 12:20 p.m. S3ACCO reviewed Patient #3's medical record and stated he could not find the results of the Dietary Consult.

3) Failure to notify the physician and or dietician of a patient's poor intake

A review of Patient #3's Vitals/ Graphics sheet for meals and intake revealed:
1/25/2021: 240 cc,
1/26/2021: 780 cc Breakfast 15%, Lunch0% and Dinner 0%,
1/27/2021: 820 cc, breakfast 0%, Lunch 5%, Dinner blank,
1/28/2021: 1200 cc, Breakfast 0%, Lunch 0% and Dinner 0%,
1/29/2021: 960 cc, Breakfast 0%, Lunch 0% and Dinner 0%, Supplement 480 cc
1/30/2021: 800 cc, Breakfast 0%, Lunch 0%, Dinner 0%, Supplement 360 cc

A review of the Medication Administration Record revealed documentation for Strawberry Ensure consumed on 01/27/2021 at 9:40 a.m. no amount, 50% at 11:30 a.m. and 100% at 4:30 p.m.

In an interview on 03/31/2021 at 10:00 a.m. 2CCO reviewed Patient #3's medical record and confirmed the above findings.

In an interview on 03/31/2021 at 12:30 p.m. 3ACCO reviewed the medical record and verified Patient #3 was not eating nor was the physician or dietician notified. He further stated there should have been documentation addressing Patient #3 not eating, notifying the physician and or dietician.