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Based on interview and record review, the facility failed to ensure there was a process to resolve complaints and grievances timely and notify complainants. The facility failed to ensure there was a process in place to:

A. Identify complaints from grievances.
B. Document complete investigations and timely resolutions.
C. Notify complainants of results per their policy.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:



Review of the facility's Complaint Log 2022 revealed only complaints logged for the timeframe of January 6-31, 2022. There were no complaints logged for the rest of the year.

Review of the log revealed some of the following complaints:

"Pt. daughter sent message to (Staff #1) stating that she was told that mom did not hurt herself but her arms are bruised (R ac and L outer arm) and she didn't have any depends on upon arrival to cascades of Port Arthur. That's humiliating and dehumanizing for the family. I'm not ok with manner of her transfer at all. It doesn't look like the bruise was treated at all. Daughter also states that she had the same socks and yellow socks on the entire stay.."

"..pt. daughter, called (Staff #1) with the following complaints.1. Bug bite to herself,concerned that room needs exterminator.2.Upon arrival on 01/22/2021 on the 7A shift she found her mother with supplies utilized the night before to insert a foley catheter underneath the patient in the bed."


Another complaint revealed that patient's daughter was "pissed off" as witnessed by a respiratory therapist "because she was asking for her moms pain medicine" but the nurse "was busy giving evening medication to her 4 other patients, CN took the medication and gave it." The daughter expressed that she did not want the nurse as her moms nurse anymore.

There was no documentation as to if these were complaints or grievances. There was no thorough investigations, no date of resolution or when complainant notification was made.


During an interview on 08/16/2022 after 1:43 p.m., with Staff #1 (Administrator) revealed they did not have anymore complaints or grievances after January 2022. If they got anything it would have been resolved and not logged. Staff #1 (Administrator) confirmed there were no dates of resolution, there was no additional investigation documentation nor complainant notifications.

Review of the "Nutrition Services Complaint Log- April-August 2022" revealed some of the following:

04/13/2022 "Desserts last night were sent uncovered."
07/09/2022 "NSG complained that Linda took 2 hours to bring a sandwich that a pt requested and left it at the nurses station, does not restock snacks when asked"
08/01/2022 "Food is sometimes too "spicy"
08/16/2022 "Did not receive what was ordered"

Review of the log revealed there were no dates of resolution and there was no thorough investigation.

During an interview on 08/17/2022 after 9:24 a.m., Staff #'s 5 and 6 (Dietitians) confirmed there were no dates of resolution or thorough investigations on the complaints.
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Review of the facility's policy named "COMPLAINT/GRIEVANCE PROCESS" dated 09/01/2011 revealed the following:

..Any difference of opinion, concern, complaint or grievance between a patient or his/her representative and Mid-Jefferson Extended Care Hospital's quality or appropriateness of patient care will be investigated and resolution will occur in a timely manner..
..Each staff member is empowered to manage patient complaint within 24 hours and to use good judgment regarding the reporting of such to their Department Manager/Supervisor.
Complaints are documented on an Occurrence Report and follow occurrence management process..
Grievances are documented on a Grievance Report by the employee as soon as the grievance is received, and the report is immediately forwarded to the Department Manager/Supervisor. At minimum, this must be completed by the end of the working shift ...
..A "Follow-Up" response is provided to the patient within five (5) working days of the event ..."

Based on observation, interview and record review, the facility failed to provide patients with a nutritional intake that met their needs on 1 of 1 Medical floor unit. The facility failed to ensure:

A. Patient meals were served at the correct temperature, portion size and as ordered by the physician.

B. Patient preferences were honored and menus were followed by their contracted service.

C. Patient meals were served timely.

This deficient practice had the likelihood to affect all patients who received meals at the facility.



Findings included

On 8/16/2022 confidential interviews with patients were conducted regarding meal satisfaction.

One patient confirmed he was a diabetic with a foot wound. He verbalized his concern that he was not receiving a diabetic diet. He further explained he received a cinnamon roll for breakfast that was very sweet. During this interview he revealed the meals were not always warm, and at times were cold. The portion sizes were small one day and very large the next day. He was concerned no one understood what a diabetic diet was supposed to be.

Another patient confirmed his meals were at times cold. Sometimes he got a lot to eat and sometimes he got a much smaller portion.

On the morning of 8/17/2022, the patient with a diagnosis of diabetes was revisited and interviewed. He reported his evening meal was pork with a very sweet, "log cabin syrup" sweet glaze. He also reported that yesterday he got a small portion of scrambled eggs and one small sausage for breakfast. Today he got a very large portion of scrambled eggs and two sausages for breakfast. He further reported he had completed his diabetic nutritional education at the previous facility and he understood what he could and could not eat.



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During confidential patient interviews on 08/16/2022 the following was stated about the food:

"Some is good and some is not. Got roast beef that was so soggy. Got a grilled cheese sandwich that was hard, dry and cold. The food is being brought from a place across the street"

"Sometimes it's cold"

"You can ask for what you want, but they don't bring it. The food is not too hot." Grits are cold"


During an observation on 08/16/2022 at 12:27 p.m., Staff #'s 7 and 8 (dietary aides) were observed preparing lunch trays and placing them on a heated cart. The staff revealed that the contracted service delivered the food about 11:40 a.m..

At 12:31 p.m., a test tray was placed on the heated cart and it was taken to the Medical unit for lunch meal service. The first patient tray was served at 12:37 p.m. and the last one was at 12:49 p.m.

At 12:50 p.m., the surveyor's test tray was found with the following meal items: carrots, mashed potatoes and roasted pork. The tray was removed from the heated cart. Staff #6 (Dietitian) tasted the food at the same time as the surveyor and confirmed the pork tasted sweet.

Review of the lunch menu dated 08/16/2022 revealed the following was supposed to be served:
Spaghetti, meat sauce, garlic breadstick and Italian vegetables.

The facility failed to ensure the menu was followed.

During an interview on 08/17/2022 after 9:18 a.m., Staff #1 (Administrator) confirmed there were problems with the contracted services. The problems she said they were having was a lot of staff turnover, quality of food, consistency and variety of menus.

During an interview on 08/17/2022 after 9:24 a.m., Staff #'s 5 and 6 (Dietitians) revealed the contracted service was having problems with a lot of staff turnover. They were having problems with the contracted service preparing food on time and following the menu.

Review of the facility's policy named "SPECIAL DIETS AND ALTERED DIET SCHEDULES" dated 05/2019 revealed the following:

"..Nutrition Services will provide a comprehensive nutrition care program including nutrition and food therapy in an efficient, effective, and timely manner ....
1. Meals will be served:
a. Breakfast 7:00 -8:30 am
b. Lunch 11:00-12:30 p.m.
c. Dinner 4:30 p.m.- 6:00 p.m ...

..5. Nutrition Services will not serve food prepared outside of department or contract facility ...
..6. Patient personal preferences will be reasonably accommodated ..."