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Based on document review, and staff interviews, the facility failed to follow their Patient Complaint/Grievance policies and procedures for one (1) out of ten (10) patients. This failure has the potential to negatively impact all Patients receiving care at the facility.

Findings as follow:

A policy titled, "Patient Complaint/Grievance," last revised on 11/21/2023 was reviewed. The policy defined grievance as, "Grievance: A patient grievance is a written, e-mailed, faxed, telephone or verbal complaint ... by an in-patient, out-patient, release/discharged patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospitals compliance with CMS Hospital Conditions of Participation (CoP). These grievances may be received in writing, letter, e-mail, fax, phone or through an interview. These grievances will attempt to be resolved within seven (7) business days. ..." This policy stated the Grievance procedure as, "... f. The Senior Director, Risk Manager, Department Manager or Hospital Designee receiving the grievance shall record the appropriate patient information, complaint and its resolution (if concluded) on the Complaint Form and/or electronic incident reporting system and forward the original of the same to Administration/Hospital Designee for entry into the log with one (1) business day after receipt of the grievance. Senior Director, Risk Manager, Department Manager or Hospital Designee may retain a working copy of the complaint/grievance which will be forwarded to Administration/Hospital Designee once the same is resolved. ..."

The complaint/grievance log for the past six months were reviewed. Patient #1's HCS call was not recorded on the complaint/grievance log.

An interview was conducted with employee (Emp) #5 on 06/11/24 at 9:56 a.m. To the question if Emp #5 considered the phone call as a complaint/grievance, Emp #5 answered, "I think it was more of an inquiry, just asking questions."

An interview was conducted with Emp #1 on 06/11/2024 at 12:13 p.m. When asked about how the facility determined what would be considered as complaint/grievance and if patient #1's HCS's call should have been considered as a grievance, Emp #1 answered, "If the complainant doesn't verbally say that they want to make it a complaint/grievance, it is not a complaint/grievance. They (complainants) have to verbally say it."

An interview was conducted with Emp #11 on 06/11/2024 at 3:02 p.m. Emp #11 explained the difference between a complaint and grievance as, "Something that does not require further investigation would be a complaint. But if we [facility] can't resolve it immediately, it would be a grievance. I don ' t know how anyone else does it, but I can tell you what I do. When I receive a call, I ask them if they (callers) want to file a formal complaint/grievance." When asked if patient #1's HCS call should have been considered as a grievance since it required Emp #5's further investigation and was not resolved immediately, Emp #11 answered, "I don't know, I wasn't there when the phone call took place. I don't know what the conversation was. If Emp #5 felt like it was a complaint/grievance, it would have been entered into the system." Emp #11 disclosed that Emp #11 did the complaint/grievance training for new hires.

An interview was conducted with Emp #9 on 06/12/2024 at 9:41 a.m. When asked about the difference between complaint and grievance, Emp #9 explained, "If there is some resolution, follow-up, and depending on the severity will determine if it is a complaint or grievance. This call was probably a complaint." When asked if the HCS's call should have been on the complaint/grievance log, Emp #9 stated, "This was a call for awareness." After the definition of grievance was read from the ' Patient Complaint/Grievance, ' Emp #9 commented, "None of us have the first-hand knowledge. You have to be part of the conversation. Unless it was written, I cannot determine whether the call was a grievance or not. I am not willing to make that call."

Based on document review, medical record review, and staff interviews, the facility failed to follow their Pressure Ulcer Prevention and Management (Wound Treatment) policies and procedures for one (1) patient out of ten (10) patients, patient #1. This failure has the potential to negatively impact all Patients receiving care at the facility.

Findings are as follows: Acute Care Wound Care

A policy titled, "Pressure Ulcer Prevention and Management (Wound Treatment)," last revised on 07/15/2022 was reviewed. This policy stated in part, "... Purpose ... To establish a consistent method of documentation that includes skin assessment, description of skin breakdown, pressure ulcer staging, plan of care, treatment and interventions, patient's response to treatment, patient education and discharge plan relating to skin care and prevention of pressure ulcers. ... Policy: 1. Inpatients are assessed by the Registered nurses [RN] for skin integrity and risk of skin breakdown as part of the systems exam and assessment. Two RN's will assess the condition and integrity of each patient's skin upon admission to the facility. An RN or Licensed Practical Nurse [LPN] assesses the patient ' s skin every shift throughout the hospital stay. ... 2. ...Patients identified with skin impairment or pressure ulcers have a nursing care plan and medical intervention to promote healing of the wound. Skin breakdown occurring during hospitalization is reported to the physician, documented in the medical record, and reported in the occurrence reported system. Staging of pressure ulcers is performed by a nurse with documented competency in staging of the pressure ulcer as part of a nursing assessment, however, staging the pressure ulcer as a diagnosis is the role of the physician. Documentation of the diagnostic staging is recorded by the physician in the H&P (Health and Physical), progress notes, procedure notes or discharge not as part of the physician's documentation." This policy stated skin inspection as, "... B. Skin inspection includes visual and palpated assessment for localized heat, edema or induration, especially in individuals with darkly pigmented skin. ..." This policy also stated the documentation of the pressure ulcer as, "Documentation of the pressure ulcer includes stage if the base of the wound is visible, and the wound is stageable. Other documentation requirements include: location, stage, size (length, width and depth); undermining/tunneling; wound bed tissue types; drainage/exudate; peri wound condition including color, temperature, bogginess, and fluctuation; wound edges; sinus tracts; necrotic tissue; odor and presence or absence of granulation tissue. Pressure ulcers that develop during a hospitalization are reported to the attending physician entered into the occurrence reporting system." Per this policy, the measure of the wound and photography of wounds is described as, "... Measurements of wounds are performed upon admission or initial assessment of the wound and once a week thereafter. ; Photography of wounds is conducted with the patient ' s consent ... maintained in the medical record. ... Photographs are taken on admission or upon initial assessment of the wound and once a week thereafter. ... A skin assessment prior to discharge is completed on any patient that has a pressure ulcer ..."

A document titled, "Mepilex Border Flex/Time to change" undated was reviewed. This document stated in part, " ... Mepilex Border Flex may be left in place for seven (7) days ..."

Per Patient #1's acute care admission medical record entered by employee (Emp) #8 on 03/31/2024 at 3:22 a.m. recorded in part, "... Skin Alternation Assessment Skin Temperature: Warm; Type of Alteration: Lesion; Location: Buttock Right. ..." The color, skin Turgor, appearance, drainage, amount, dressing type, dressing condition, dressing change, date, odor, sutures intact, and edges approximated were not recorded.

A medical record titled, "List patient Notes" entry made by Emp #8 on 03/30/2024 at 3:57 a.m. for an occurrence on 03/30/2024 at 10:30 p.m. stated in part, "... Scabbed lesion noted to right buttock. ..."

A medical record titled, "The "List patient Notes" entered by Emp #8 on 04/03/2024 at 6:48 a.m. for an occurrence on 04/03/2024 at 6:40 a.m. stated in part, "Chux changed... Mepilex applied to Coccyx, serosanguinous drainage noted on chux, but no visible open spot or lesion on sacrum/coccyx..."

An interview was conducted with Emp #1 on 06/11/2024 at 12:13 p.m. Emp #1 answered, "The skin assessment should be done at the time of admission along with a picture and two nurses should do the skin assessment. The wound should be described. The wound measurements, location of the wound, the color, odor, etc." to the facility's skin assessment process. Emp #1 confirmed that there should be more pictures and documentation regarding Patient #1's wound.

An interview was conducted with emp #8 on 06/12/2024 at 3:17 a.m. Emp #8 explained the encounter with Patient #1 as, "I admitted [Patient #1] to acute care. [Patient #1] didn't have any wound when admitted [Patient #1]. But a few days later when I was bathing [Patient #1], I noticed a drainage. So, I applied Mepilex and put a bandage on it. But there was no open wound." When asked if Emp #8 reported Patient #1's change of condition to anyone, Emp #8 stated negatively. To the question of Emp #8 was aware if there was any policy that required employees to report patient's change of condition to the providers, Emp #8 responded, "I don't know. I didn't think it was anything serious. But I documented it." For the photograph not taken, Emp #8 answered, "Because I didn't think it was anything serious."

An interview was conducted with Emp #4 on 06/12/2024 at 8:30 a.m. Emp #4 also confirmed that there was not a second nurse for the skin assessment since there were no anatomical man filled out. Emp #4 explained the skin assessment process as, "One nurse would do the skin assessment and the other nurse would fill out the anatomical man. But there is no anatomical man filled out and there are no other nurses listed in the system. So, I don't think there was a second nurse for the skin assessment."

Findings as follow: Swing Bed Wound Care

A policy titled, "Pressure Ulcer Prevention and Management (Wound Treatment)," last revised on 07/15/2022 was reviewed. This policy stated in part, "... Purpose ... To establish a consistent method of documentation that includes skin assessment, description of skin breakdown, pressure ulcer staging, plan of care, treatment and interventions, patient's response to treatment, patient education and discharge plan relating to skin care and prevention of pressure ulcers. ... Policy: 1. Inpatients are assessed by the Registered nurses [RN] for skin integrity and risk of skin breakdown as part of the systems exam and assessment. Two RN's will assess the condition and integrity of each patient's skin upon admission to the facility. An RN or Licensed Practical Nurse [LPN] assesses the patient's skin every shift throughout the hospital stay. ... 2. ...Patients identified with skin impairment or pressure ulcers have a nursing care plan and medical intervention to promote healing of the wound. Skin breakdown occurring during hospitalization is reported to the physician, documented in the medical record, and reported in the occurrence reported system. Staging of pressure ulcers is performed by a nurse with documented competency in staging of the pressure ulcer as part of a nursing assessment, however, staging the pressure ulcer as a diagnosis is the role of the physician. Documentation of the diagnostic staging is recorded by the physician in the H&P (Health and Physical), progress notes, procedure notes or discharge not as part of the physician's documentation." This policy stated skin inspection as, "... B. Skin inspection includes visual and palpated assessment for localized heat, edema or induration, especially in individuals with darkly pigmented skin. ..." This policy also stated the documentation of the pressure ulcer as, "Documentation of the pressure ulcer includes stage if the base of the wound is visible, and the wound is stageable. Other documentation requirements include: location, stage, size (length, width and depth); undermining/tunneling; wound bed tissue types; drainage/exudate; peri wound condition including color, temperature, bogginess, and fluctuation; wound edges; sinus tracts; necrotic tissue; odor and presence or absence of granulation tissue. Pressure ulcers that develop during a hospitalization are reported to the attending physician entered into the occurrence reporting system." Per this policy, the measure of the wound and photography of wounds is described as, "... Measurements of wounds are performed upon admission or initial assessment of the wound and once a week thereafter. ; Photography of wounds is conducted with the patient ' s consent ... maintained in the medical record. ... Photographs are taken on admission or upon initial assessment of the wound and once a week thereafter. ... A skin assessment prior to discharge is completed on any patient that has a pressure ulcer ..."

A document titled, "Mepilex Border Flex/Time to change" undated was reviewed. This document stated in part, " ... Mepilex Border Flex may be left in place for seven (7) days ..."

A medical record titled; "Photo Mount Sheet" dated 04/04/2024 shows the lesion of Patient #1 with measurements. May it be noted that the Photo Mount Sheet form was not completed; the picture quality was poor and employee (Emp) #4 stated on 06/12/2024 at 2:13 p.m. that the measurements could not be determined; and Emp #4 confirmed that the photo was taken for the swing bed admission.

A medical record titled, "Admit: Assessment/Adult" entered by Emp #10 on 04/05/24 at 11:38 p.m. recorded the wound under the Skin Alteration Assessment section as, "... Type of Alteration: Lesion, Location: buttock..." The color, skin Turgor, appearance, drainage, amount, dressing type, dressing condition, dressing change, date, odor, sutures intact, and edges approximated were not recorded.

A medical record titled; "Photo Mount Sheet" dated 04/17/2024 shows the lesion of Patient #1's wound with a ruler placed under the wound. May it be noted that the Photo Mount Sheet form was not completed. Emp #4 stated on 06/12/2024 at 2:13 p.m. that the wound length seemed to be 12 cm and the height seemed to be 6.5 cm based on the photo. Emp #4 further stated that the wound seemed to be unstageable DTI (Deep Tissue Injury).

The dietitian notes entered on 04/05/24 at 3:07 p.m. for an occurrence on 04/05/2024 at 2:37 p.m. stated in part, "... Nursing also reports lesion to right buttock with would care ongoing. Per Braden scale, patient is high risk for pressure ulcers..."

The dietitian notes entered on 04/08/2024 at 1:49 p.m. for an occurrence on 04/08/2024 at 1:27 p.m. stated in part, "... Nursing reports lesion to r(right)-buttock... Skin failure ..."

There were no nursing notes documenting Patient #1's wound.

An interview was conducted with Emp #1 on 06/11/2024 at 12:13 p.m. Emp #1 answered, "The skin assessment should be done at the time of admission along with a picture and two nurses should do the skin assessment. The wound should be described. The wound measurements, location of the wound, the color, odor, etc." to the facility ' s skin assessment process. Emp #1 confirmed that there should be more pictures and documentation regarding Patient #1's wound.

An interview was conducted with Emp #4 on 06/12/2024 at 8:30 a.m. Emp #4 explained the skin assessment process as, "One nurse would do the skin assessment and the other nurse would fill out the anatomical man. But there is no anatomical man filled out and there are no other nurses listed in the system. So, I don't think there was a second nurse for the skin assessment."

An interview was conducted with Emp #7 on 06/11/2024 at 3:55 p.m. Regarding Patient #1's wound not being reported to Emp #7, Emp #7 further stated, "Maybe it was a minor wound and they didn't feel like they had to report it." However, Emp #7 stated the expectation was even minor changes would be reported to the providers.

Based on medical record reviews, document reviews and staff interviews, it was determined the facility failed to follow policies and procedures for one (1) patient out of ten (10) patients, Patient #1 and failed to follow procedures for Discharge Planning and Referral of Patients to Post Discharge Providers. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings are as follows: Acute Care Discharge

A policy titled, "Discharge Planning and Referrals of Patients to Post Discharge Providers," approved on 6/6/2023 was reviewed. This policy stated in part, "Purpose: ... To ensure a discharge planning process that focuses on the patient ' s goals and treatment preferences and includes the patient and his or her caregiver/support person (s) as active participants in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient's goals for care and his or her treatment preferences, ensure an effective transition of the patient from the hospital to post-discharge care, and reduce factors leading to preventable hospital readmissions. ..."

Per Patient #1's acute care discharge summary entered by Emp #10 on 04/05/2024 at 10:47 p.m., the wound care, wound status, and discharge wound assessment sections were not recorded.

An interview was conducted with Emp #1 on 06/11/2024 at 12:13 p.m. Emp #1 stated that the wound care treatment should have been on Patient #1's discharge paperwork.

An interview was conducted with Emp #6 on 06/11/2024 at 12:13 p.m. When asked if Emp #6 disclosed Patient #1's wound and care for the wound, Emp #6 answered negatively and Emp #6 did not record about Patient #1's wound care since Emp #6 was not aware of Patient #1's wound.

Based on document review, and staff interviews, the facility failed to follow their Discharge Planning and Referrals of Patients to Post Discharge Providers policies and procedures for one (1) out of ten (10) patients. This failure has the potential to negatively impact all Patients receiving care at the facility.

Findings as follow: Swing Bed Discharge Planning

A policy titled, "Discharge Planning and Referrals of Patients to Post Discharge Providers," approved on 6/6/2023 was reviewed. This policy stated in part, "Purpose: ... To ensure a discharge planning process that focuses on the patient's goals and treatment preferences and includes the patient and his or her caregiver/support person (s) as active participants in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient s goals for care and his or her treatment preferences, ensure an effective transition of the patient from the hospital to post-discharge care, and reduce factors leading to preventable hospital readmissions. ..."

A medical record titled, "Discharge Summary" dated 04/19/24 for Patient #1 recorded, "Wound Status: Granulate ... Discharge Wound Assessment: Healing ... "There were no other documentation regarding the wound.

In the medical record titled, "Patient Discharge General Information," it was documented, "Wound Care: Wound Status: Granulate Caregiver D/C (Discharge) Instructions: N Discharge Care Plan was education/live instruction provided to lay caregiver prior to discharge Pneumococcal/Influenza Immunization Form ..."

An interview was conducted with Emp #1 on 06/11/2024 at 12:13 p.m. Emp #1 stated that the wound care treatment should have been on Patient #1's discharge paperwork.

An interview was conducted with Emp #7 on 06/11/2024 at 3:55 p.m. Emp #7 used the computer in the interview room and verified that there was no mention of the wound care on the 04/19/2024 discharge summary.