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Based on interview and record review, the facility failed to protect and promote the rights of 2 (P-1, P-7) of 10 reviewed patients requiring a safe environment, resulting in the potential for unsatisfactory outcomes. Findings include:

See tag:
A-0123 Notice of Grievance Decision
A-0144 Care in a Safe Setting

Based on document review and interview, the facility failed to provide the complainant with a written response following the facility's investigation regarding a grievance for 2 (P-1, P-7) of 2 patient representatives filing a grievance with the facility, resulting in the potential for less-than-optimal outcomes. Findings include:

On 9/10/2025 at 1105 review of the Complaint and Grievance log was conducted with the facility's Patient Advocate (Staff Q). Staff Q reported she received a grievance for P-1 on 4/7/2025 by phone from his daughter. Staff Q reported she forwarded the grievance to the ED Manger, LTC Manager and alerted Risk Management on 4/7/2025 about the complaint. Staff Q explained the case was reviewed by the ED Medical Director on 4/7/2025 and interviews were completed with facility staff on 4/10/2025. Staff Q added that she called P-1's daughter on 4/14/2025 and was met with voicemail and message was left requesting a return call. Staff Q explained P-1's daughter called on 4/16/2025 asking why she had not gotten an update about the investigation and was given an update about the status of the investigation. On 4/21/2025 Staff Q called P-1's daughter and wife and provided an update about the investigation findings and she revealed they were both expressing frustration about the opportunities for improvement/staff education and wanted more specific information about how the injury occurred and if the staff member was fired. Staff Q revealed when she attempted to explain that she was unable to provide that information, they notified her they would be contacting their lawyer and suing the facility and requested no further contact and "did not need" a letter.

On 9/10/2025 at 1115 review of grievance #38494 for P-7 was conducted with Staff Q. Staff Q explained the facility received the complaint on 5/9/2025 from a primary care physician by phone that a pediatric patient he sent to the ED was required to wait in the lobby rather than being treated immediately for shortness of breath and that a staff member was rude. Staff Q stated she forwarded the complaint to the ED manager and ED assistant clinical manager. Staff Q revealed the employee involved with the complaint was forwarded to Talent Management for review and the ED leadership spoke with the employee. When queried if the complainant received a follow-up letter, Staff Q responded she did not send a letter because they did not file a complaint. When queried what her policy states about follow-up letters, Staff Q was uncertain that a follow-up letter was required and thought a follow-up by phone was permissible.

Review of facility policy titled 'Patient Complaint and Grievance", policy #860.01D, date effective 1/1/2022, section #3 reveals "F. A written response to the patient/representative will be provided within seven (7) business days of receipt of the concern...NOTE: A written response is required even if the hospital has utilized other means, such meetings [sic] with the patient and/or representative, to resolve the grievance."

Based on interview and record review, the facility failed to provide a safe transfer from wheelchair to stretcher for 1 (P-1) of 10 patients reviewed resulting in injury, unmet patient needs and poor patient outcomes. Findings include:

Review of record on 9/9/2025 at 1045 reveals P-1 was taken to the facilities ED on 3/31/2025 at 0539 for evaluation after an episode of seizure-like activity. Review of the Emergency Department Note reveals a chest x-ray was ordered by the ED provider and revealed P-1 had an "acute-subacute appearing mildly displaced right humeral head/neck fracture". P-1 has been admitted to the facility Long-Term Care floor 4th floor since 4/30/2024.

On 9/9/2025 at 1235 an interview with the ED physician (Staff L) was conducted and revealed he remembered P-1 and was not the primary ED provider but took over care from another provider when he started his shift. Staff L added he remembered that P-1's wife was at the bedside while he was in the ED. Staff L explained that P-1 had an episode of seizure-like activity and was brought down to the ED from the LTC unit on the 4th floor, and a chest x-ray was ordered which found he had a humerus fracture. When queried if they were aware that P-1 had a humerus fracture prior to the x-ray, Staff L revealed they did not, and it was an incidental finding. Staff L explained the x-ray findings said "acute-subacute", and it was unclear when or how the fracture occurred, but this type of fracture of the humerus typically occurs after a fall. Staff L explained the standard course of treatment for these injuries (humerus fractures) is pain management and 4mg Morphine was ordered and application of a sling. Staff L revealed he recommended follow-up with an orthopedic surgeon in one week at discharge and P-1 was taken back up to the LTC unit. When queried if any falls or injuries occurred while P-1 was in the ED, Staff L revealed he was not aware of any.

During an interview with the Long-Term Care (LTC) technician (Staff M) on 9/10/2025 at 0910 it was revealed she remembered P-1 and that she was the one who transported him to the ED the on 3/31/2025 by wheelchair. Staff M recalled that a male staff member in the ED went to lift P-1 up from the wheelchair to the stretcher and she reminded him he was unable to bear weight and offered to help with the transfer, but Staff T declined and picked P-1 up himself and transferred him. Staff M explained she felt the ED nurse could have done a better job and should have had assistance with a Hoyer lift or other staff and reported her concerns to the nurse when returning to the LTC Unit. When queried if anyone from the facility has instructed her to do anything different next time, she transfers a patient to the ED, Staff M revealed, "no nothing has changed".

Review of the High-Quality Review meetings which the facility conducted on 4/7/2025 and 4/23/2025 with the ED Director, LTC Director, ED Manager, Quality Director, Chief Nursing Officer, LTC Administrator following P-1's the fractured humerus. The High- Quality Review revealed the facility identified the following opportunities for improvement and findings:

1. PCT (patient care technician) transferred patient from LTC to ED. Ideally, patient should have been transferred to a stretcher to LTC prior to going to ED. - ACTION: LTC staff will be instructed to request stretcher from RN supervisors prior to transfer to ED. If RN supervisor is unavailable, then an ED staff member will assist with transfer.

2. Request that CMO review Chest Xray with Radiology group to determine if we can gain better understanding of the age of the fracture - ACTION: CMO reviewed with Radiology. It was determined that the fracture was likely recent but there is no way to determine when this happened (LTC vs. ED).

During an interview on 9/10/2025 at 1134 with the former ED Manager (Staff R), who was involved in the High-Quality Review Meetings about P-1's injury, it was revealed that following the meetings he followed up with the ED RN (Staff T) about transferring P-1 to the stretcher from the wheelchair. Staff R explained that he told Staff T that he should not transfer a patient by himself from a wheelchair to a stretcher and directed him to have additional staff help for safety. When queried when the conversation occurred, Staff R was unsure of the date. When queried if education was provided to ED staff about the changes in process for patients being transferred from the LTC Unit to the ED, Staff R revealed he discussed it at employee huddles, and sent and email out to staff, but was unable to provide which employees received the education or the dates of completion.

On 9/10/2025 at 1347 an interview with the House Supervisor Manager (Staff U) was conducted. Staff U revealed she is no longer responsible for managing the house supervisors but did recall the incident involving P-1. When queried if she was responsible for updating/educating the House Supervisors at the facility about the change in process for transfers from the LTC Unit to the ED, Staff U revealed she was and that she sent an email out to the supervisors and spoke about it at daily huddles. When queried if she could provide a list of employees and the dates/times they were educated about the change in process, Staff U revealed she was unable to provide that information.

On 9/10/2025 at 1400 an interview with the Chief Nursing Officer (Staff B) was conducted and when queried if the facility had additional education about safe patient transfers or updated facility policies, Staff B revealed they had not.

The facility did not provide a policy regarding Abuse and Neglect when requested.