HospitalInspections.org

Based on interview, record review, and observation, the facility failed to ensure that written complaints were identified as "grievances." Failure to do so resulted in 4 of 25 patients (Patients #12, 13, 14, and 15) did not receive a written notice from the hospital of the results of the grievance process.

Findings included:

Patient #12.
Record review of the Complaint/Grievance Investigation Form, dated 8/18/2020 at 6:15pm showed that Patient #12's sister complained about the administration of medications to her brother, lack of updates from nurses and physicians, and rudeness from an administrative staff member. Staff A (CEO) documented a phone call phone to the complainant on 8/19/2020 at 10:00am. There was no written notice to the complainant of the steps taken on behalf of the patient to investigate the grievance or of the results of the grievance process.

Patient #13.
Record review of the Complaint/Grievance 2020 log, dated 1/25/2020 showed that Patient #13's daughter complained that she was unhappy with care, adding that the tube feeding was infusing on the floor when she arrived. She also stated that the family "was promised that would care would put a wound vacuum on the patient upon arrival." It was noted that the complaint was resolved on 1/25/2020 and that the issuance of a written response was "not applicable." There was no written notice to the complainant of the steps taken on behalf of the patient to investigate the grievance or of the results of the grievance process.

Patient #14.
Record review of the Complaint/Grievance 2020 log, dated 2/17/2020 showed that Patient #14's brother alleged the patient had been sexually assaulted by one of the hospital personnel. An investigation of the allegation was completed by 2/18/2020. The allegation was not substantiated. It was noted that the complaint was resolved on 2/18/2020 and that the issuance of a written response was "not applicable." There was no written notice to the complainant of the steps taken on behalf of the patient to investigate the grievance or of the results of the grievance process.

Patient #15.
Record review of the Complaint/Grievance 2020 log, dated 3/5/2020 showed that Patient #15 and his wife complained that the nurse took too long to provide colostomy care and the wife had to silence the IV alarms. The wife further stated she was uncomfortable leaving to return to work "due to poor performance and responsiveness." It was noted that the complaint was resolved on 3/5/2020 and that the issuance of a written response was "not applicable." There was no written notice to the complainant of the steps taken on behalf of the patient to investigate the grievance or of the results of the grievance process.

In an interview with the Patient Advocate, Staff B, on 9/3/2020 at 3:00pm, he stated that the process for documenting responses to patient grievances needed to be improved.

Record review of the policy, "Complaint and Grievance Process," revised December 2015 showed: "Patient complaints that become grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding his or her patient care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or come CoPs [Conditions of Participation], or other CMS requirements ... All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements are to be considered grievances for the purposes of these requirements ... The party filing the grievance will be provided written notification of the outcome of the grievance review and investigation, including:
(a) The name of the hospital contact person,
(b) The steps taken on behalf of the patient to investigate the grievance,
(c) The results of the grievance process, and
(d) The date of completion.

Based on interview, record review, and observation, the facility failed to ensure that staff members followed current standards of practice for infection control as evidenced by 2 of 5 staff members (Staff V and Staff W) did not have their mouth and nose covered with a mask. These actions placed patients and other staff members at a potential risk for COVID-19.

Findings included:

During observation of the dining area on 9/3/2020 at 12:10pm, two staff members were observed not wearing their masks properly. Staff V, a dietary cook, was behind the serving station, serving food to staff members. He had his mask below his chin. Staff W, a physical therapy assistant, was in the serving line with three other staff members. She had her mask below her nose. The four staff members were not practicing social distancing. They were standing beside each other in the serving line with no more than a foot between each other.

In an interview with Staff A (CEO) on 9/3/2020 at 2:30pm, she stated a surgical mask has been required for staff "almost since the pandemic began" and a staff member's mask should cover the nose and mouth and be secured under the chin.

Record review of the policy, "Guide for Handling Covid-19 Positive Patients and Suspected Covid-19 Patients." dated 7/9/2020, showed: "General Staff Guidelines: [Staff] must wear surgical mask or N-95 at all times during shift, except in break room for meals or beverages ... ALL staff should avoid taking their mask on and off during shift-only to eat or drink ... Staff should wash their hands immediately after removing their mask ... [Staff] must adhere to social distancing as much as possible both on shift and off shift."

Record review of the Coronovirus Disease 2019 (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-to-wear-cloth-face-coverings.html titled "How to Wear Masks," updated August 7, 2020, showed: "Masks are an additional step to help slow the spread of COVID-19 when combined with every day preventive actions and social distancing in public settings. CDC recommends that people wear masks in public and when around people who don't like in their household ... Wear a mask to protect others. Wear a mask that covers your nose and mouth to help protect others in case you're infected with COVID-19 but don't have symptoms. Wear a mask in public settings when around people who don't live in your household, especially when it may be difficult for you to stay six feet apart. Wear a mask correctly for maximum protection. Don't put the mask around your neck ..."

Based on interview, record review, and observation, the facility failed to ensure that staff members followed current standards of practice for infection control as evidenced by 2 of 5 staff members (Staff V and Staff W) did not have their mouth and nose covered with a mask. These actions placed patients and other staff members at a potential risk for COVID-19.

Findings included:

During observation of the dining area on 9/3/2020 at 12:10pm, two staff members were observed not wearing their masks properly. Staff V, a dietary cook, was behind the serving station, serving food to staff members. He had his mask below his chin. Staff W, a physical therapy assistant, was in the serving line with three other staff members. She had her mask below her nose. The four staff members were not practicing social distancing. They were standing beside each other in the serving line with no more than a foot between each other.

In an interview with Staff A (CEO) on 9/3/2020 at 2:30pm, she stated a surgical mask has been required for staff "almost since the pandemic began" and a staff member's mask should cover the nose and mouth and be secured under the chin.

Record review of the policy, "Guide for Handling Covid-19 Positive Patients and Suspected Covid-19 Patients." dated 7/9/2020, showed: "General Staff Guidelines: [Staff] must wear surgical mask or N-95 at all times during shift, except in break room for meals or beverages ... ALL staff should avoid taking their mask on and off during shift-only to eat or drink ... Staff should wash their hands immediately after removing their mask ... [Staff] must adhere to social distancing as much as possible both on shift and off shift."

Record review of the Coronovirus Disease 2019 (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-to-wear-cloth-face-coverings.html titled "How to Wear Masks," updated August 7, 2020, showed: "Masks are an additional step to help slow the spread of COVID-19 when combined with every day preventive actions and social distancing in public settings. CDC recommends that people wear masks in public and when around people who don't like in their household ... Wear a mask to protect others. Wear a mask that covers your nose and mouth to help protect others in case you're infected with COVID-19 but don't have symptoms. Wear a mask in public settings when around people who don't live in your household, especially when it may be difficult for you to stay six feet apart. Wear a mask correctly for maximum protection. Don't put the mask around your neck ..."