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Based on review of the grievance log, policy titled "Complaint and Grievance Process" (reference #964A, effective 8/09) and staff interview, the hospital failed to follow its grievance policy by not providing documented evidence that a thorough investigation of allegations was performed for 3 of 4 complainants who filed a grievance with the hospital. Findings:

1. Review of the 12/22/2010 written grievance filed by patient #9's daughter revealed that while a patient in the hospital, her mother sustained a skin tear to the right leg, the patient's tube feeding was labeled incorrectly, and her mother's Clinitron bed (a pressure relieving bed) was turned off by staff for an unknown length of time. The complainant also alleged that her mother's dentures were missing. Further review revealed the QA/PI (Quality Assurance/Performance Improvement) coordinator discussed the grievance with staff and in-serviced them on Incident Reporting and equipment safety. Further review revealed the QA/PI coordinator failed to have documented evidence that the grievance was thoroughly investigated and the steps taken to resolve the grievance.

An interview was held with S1 Administrator on 5/09/2011 at 10:00 AM who stated he called and spoke with the complainant regarding her grievance but failed to document the conversation. He stated the nurse administered the wrong tube feeding to patient #9 but he could not find the form that addressed the disciplinary action taken. In an interview on 5/09/2011 at 2:30 PM S3 QA/PI coordinator stated that she received a copy of all variances but she could not find the report that addressed patient #9 receiving the wrong tube feeding. Further interview with S3 confirmed that the nurse administered the wrong tube feeding to patient #9.

2. Review of the 3/03/2010 grievance filed by patient #12's daughter revealed her mother specifically asked the nurse for pain medication to be given IV (intravenous), but the nurse administered an analgesic by mouth. Review of the grievance log revealed the investigation was conducted by S2 Chief Nursing Officer. Further review revealed the hospital reassured patient #12 and her daughter that the grievance would be investigated according to hospital policy and disciplinary action would be taken if necessary. There failed to be documented evidence that the hospital followed their policy to thoroughly investigate the grievance.

3. Review of the 3/24/2011 grievance filed by patient #10 revealed a CNA (certified nursing assistant) on nights unplugged his IV to remove his gown during his care. He said it took 6 hours to get ice from this CNA and she refused to draw his privacy curtain when asked. The CNA told him if he needed anything to ask her "while she was in the room". Further review revealed the investigation of the grievance was performed by S2 Chief Nursing Officer but there failed to be documentation of a thorough investigation of the allegations.

Review of the hospital's grievance policy revealed the Chief Nursing Officer, Quality Assurance/Performance Improvement Coordinator or the Chief Executive Officer (CEO) would "Investigate the circumstances surrounding the concern or complaint and review the issues with the Hospital's Chief Executive Officer (CEO). This policy also indicated that the QA/PI Coordinator would "assist with investigation as needed and ensure the investigative procedure has been completed and corrective action taken".

In an interview on 5/09/2011 at 2:30 PM S3 QA/PI Coordinator stated she was also the risk manager and was responsible for investigating complaints and grievances. She confirmed that the hospital failed to ensure a complete and through investigation was documented for the above grievances.

Based on review of the grievances log provided by the hospital, policy titled "Complaint and Grievance Process" (reference #964A, effective 8/2009) and interviews, the hospital failed to ensure written responses were provided to 2 of 4 complainants informing them of steps taken on their behalf to resolve their grievances. Findings:

1. Review of the 12/22/2010 grievance log revealed patient #9's daughter alleged that her mother specifically requested "IV (intravenous) pain medication for her discomfort and the nurse administered a pain medication by mouth".

2. Review of the 3/24/2011 grievance filed by patient #10 revealed the CNA (certified nursing assistant) on nights unplugged his IV to remove his gown during his care. He said it took 6 hours to get ice from this CNA and she refused to draw his privacy curtain when asked. The CNA told him if he needed anything to ask her "while she was in the room". Documentation of the grievance log revealed S2 Chief Nursing Officer conducted the investigation.

Review of the grievance policy revealed the Director of Quality Management and the Chief Executive Officer were responsible for providing "Written responses to the patient's grievance. The written response is required whether or not a meeting was held to discuss the investigation". Review of the grievance log revealed no documented evidence that the hospital provided written responses to the complainants regarding their grievances.

In an interview on 5/09/2011 at 2:30 PM S3 QA/PI Coordinator stated she was also the risk manager and was responsible for investigating complaints and grievances. She stated that when grievances are handled in house a written response is not sent to the complainant.

Based on record review and staff interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient by not: 1) ensuring wound care was provided according to physician orders for 1 of 2 patients with wounds (#8) and 2) providing ongoing comprehensive skin assessments for 1 of 1 patients (patient #1) at high risk for pressure ulcer development in a total sample of 12. Finding:

1. Review of the closed medical record revealed patient #8 was a 54 year-old male admitted on 1/27/2011 at 1:15 PM for mechanical complications of a skin flap from a previous surgery and a non-healing post surgical wound. Review of physician orders dated 1/27/2011 revealed an order to clean the abdominal wound with "wound cleanser" and dry the area on Monday (Mon), Wednesday (Wed), Friday (Fri) and PRN (as needed). Review of the wound care charting form failed to reveal documentation that the nurse provided wound care on 2/07/2011 (Mon) 2/14/2011 (Mon), 2/16/2011 (Wed), 2/21/2011 (Mon), 2/23/2011 (Wed), 2/25/2011 (Fri), 3/02/2011 (Wed), 3/04/2011 (Fri), 3/07/2011 (Mon), or 3/14/2011 (Mon). In an interview on 5/09/2011 at 2:00 PM S16 LPN wound care nurse was asked by the survey team to review the medical record for patient #8. After reviewing the record S16 confirmed that documentation failed to indicate that wound care was provided for patient #8 on the above dates.

2. Review of the physician History and Physical in the closed medical record for patient #1 revealed she was admitted on 3/14/2011 with diagnoses that included compression fracture of the C-Spine, exacerbation of severe chronic obstructive pulmonary disease, diabetes mellitus, end stage renal disease requiring hemodialysis three times weekly, cardiomyopathy, congestive heart failure with diastolic function, obesity and osteoporosis. Review of the Braden scale form dated 3/14/2011 revealed patient #1 was at risk for pressure ulcer development. The only skin breakdown noted for patient #1 on admit to the hospital was an area under the abdominal fold.

Review of the Wound Care Charting Record revealed patient #1 received treatment to the abdominal fold with EPC (extra protective cream) beginning on 3/15/2011 and it was discontinued on 3/21/2011 when documentation revealed the skin issue was "resolved" (healed). Further review failed to reveal the patient's skin was assessed by a wound care nurse from 3/21/2011 until 3/25/2011.

Review of the Wound Assessment Records revealed documentation on 3/15/2011 that the skin under the abdominal fold on patient #1 was described as a "partial thickness" wound which was treated with EPC. There were daily assessments and treatments documented on the 16th, 17th, 18th, 19th, and 20th. On 3/25/2011 the wound had extended to "full thickness" under the abdominal fold and the EPC treatment was continued.

Review of nursing documentation on 3/22/2011 failed to reveal patient #1 was turned from 6AM until 8PM. On 3/23/2011 the 6AM-6PM RN documented the patient did not have any wounds. There failed to be documentation that the patient was turned from 1:40 PM when she returned from her hemodialysis treatment until 8:00 PM. Review of the 3/25/2011 Wound Care Charting Record revealed patient #1 had developed 2 wounds under the abdominal fold, a new breakdown under each breast and an open wound to the sacrum. The record indicated the breast and abdominal fold wounds were treated with EPC and a 3 x 3 Algisite (medicated dressing) was applied to the sacral wound.

On 3/31/2011 the Wound Assessment Record indicated there was no improvement in the abdominal fold wounds and the treatment changed to Algisite (medicated wound dressing). On 3/31/2011 documentation indicated there were multiple "denuded" areas and the Algisite dressing size was increased to 5 x 5 to cover the area. No other skin breakdown was identified.

On 5/10/2011 at 8:05 AM an interview was held with S10 RN and S11 LPN wound care nurses who stated when they receive a wound consult, they assess the patient from head-to-toe and photograph any skin breakdown. During the interview, S11 LPN reported on 3/15/2011 (day after admit) she assessed patient #1's sacral area and determined that the skin over the coccyx was "denuded" which she described as the surface of the skin was gone indicating an old healed wound. S11 continued to say this area was clean, dry and intact and that she photographed the findings. The survey team asked S11 to provide the photographs and she stated that she could not find them.

Continued interview with S10 RN, wound care coordinator revealed on 3/25/2011 the CNAs were bathing patient #1 and asked her to check the patient's coccyx wound which was now open and draining. S10 said there was a small area on the coccyx which broke open and that she assessed the area and ordered a 3 x 3 Algisite (absorbent dressing) to the wound and contacted the attending physician. S10 continued to say that on 3/31/2011 there were multiple small broken areas on the coccyx and that she ordered a 5 x 5 Algisite to cover the wounds. S10 reported she photographed the area, contacted the physician and documented the wounds as Stage II (topmost layers of skin is broken). S10 further stated when patient #1 was transferred to Hospital A, the coccyx wounds were Stage ll.

On 5/10/2011 at 7:30 AM an interview was held with S9 RN Charge Nurse who stated he performs a complete assessment (head to toe) on all patients admitted on his shift. He further stated if the patient is bed bound or obese, he always consulted wound care to validate his assessment. S9 further stated he assessed patient #1 on admission to the hospital, but did not recall patient #1 having a skin breakdown.
Interview with S4 CNA on 5/11/2011 at 1:30 PM revealed she shared responsibility for the care of patient #1. S4 recalled patient #1 had areas of breakdown ( like yeast) on her bottom and on the inside of the thigh area. S4 indicated all the areas not covered with a bandage (Algisite) were treated with EPC. S4 also indicated she was not aware if any other staff had noted the compromised skin integrity on patient #1's inner thigh area.

Further review of the medical record revealed patient #1 was transferred on 4/05/2011 to acute care Hospital A for a neurological consult. Review of the initial nursing assessment from Hospital A revealed documentation on 4/05/2011 that patient #1 had a reddened abrasion on the left medial thigh area that progressed to a Stage III by 4/07/2011. There failed to be documentation that this skin breakdown was identified at Cornerstone Hospital.