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Based on record review and interview, the hospital's governing body failed to be responsible for effective operation of the grievance process, in 4 of 5 patient complaint/grievances (Patient #'s 1, 2, 3 and 4) reviewed.

Findings include:

The 7/2/15 record review of "Policy Number C06A: Complaint and Grievance Process, revised date:10/1/13" states under "Policy: The hospital has established a mechanism for receiving, acting upon, and responding to patients, families, and visitors expressing concern for patient treatment and all areas of quality of care (the "Grievance Process"). But it is a policy of the hospital to respond to such complaints promptly. It is also the policy of the hospital to establish a process to respond to concerns and complaints and to assure (sic) patients, families, the patient's representative and visitors are aware of this process and their rights to access it...
5. The hospital staff member of receiving the complaint will address the concerns that are appropriate to that individual's area of responsibility, expertise, state practice guidelines, experience, and knowledge and can be addressed immediately (i.e., modification of treatment plan, room temperature, environmental noise, etc.),
6. If a complaint cannot be resolved timely by hospital staff member, the staff member shall notify his/her supervisor and complete the complaint and grievance form. The form is then forwarded to the hospital's director of quality management for chief nursing officer. The DQM shall enter the information on to Lotus Notes grievance software. The DQM shall notify the CEO when a grievance has been received and logged in the Lotus Notes grievance database.
7. The DQM and/or CNO will investigate the circumstances surrounding the concern or complaint and review the issues with the hospital's CEO. The investigation procedure shall be completed, corrective action taken and a written response sent within seven days of receipt of complaint. If a grievance will not be resolved or the investigation completed within seven days, the hospital shall inform the patient or the patient's family member/ representative, that the hospital is still working to resolve the grievance and will follow up with a written response in a stated number of days...
13. Grievances and the grievance resolution are reported to the hospital governing board by the CEO.
14. Patient complaints must be made part of of QAPI process."

1) The 7/2/15 record review of the "Patient/Family Report" reveals that on 6/16/15, Patient #1 reported to RN D that last night the patient call light was turned on and that patient received an intercom response at approximately 7 p.m.. Patient #1 stated that no one came into patient's room until 8:30 p.m., and that when Patient #1 questioned the delay, patient was told by RN D that D never got the message. Patient #1 reported "this is not the first time this has happened, and it occurs almost every night". On 6/16/15, RN D documented under "corrective action taken to resolved the complaint" that information would be passed to the night charge to mention in the huddle (care staff information exchange at shift change). On 6/23/15, the "Patient/Family Report" was reviewed by CNO B , who documented "No further complaints from this patient".

There was no documented evidence that CNO B conducted an investigation into Patient #1's grievance about staff call light response times or quality of care provided by staff. There is no documented evidence that Patient #1's concerns were resolved just because there were "no further complaints", or that patient was offered a written response to grievance concerns per hospital policy.

During interview with CNO B on 7/2/15 at 3 p.m., B stated that there was no documented evidence that their grievance process was followed.

2) The 7/2/15 record review of the "Patient/Family Report" reveals that on 4/28/15, Patient #2's daughter reported to RN D that RN E "did not answer questions" about Patient #2, "seemed disinterested" and was spoken to by RN E in an "abrupt manner". On 4/28/15, Staff D documented under "corrective action taken to resolved the complaint" that an apology was made to Patient #2's daughter, and that RN E would not be assigned to care for Patient #2. The DQM C was notified on 5/7/15 at 5 p.m. On 5/8/15, CEO A documented "I spoke with Patient #2's daughter on 4/29/15, daughter felt like RN D did a great job resolving the concern."

There was no documented evidence that hospital staff conducted an investigation to determine if RN E's behavior rose to the level of abuse/neglect. There was no evidence that administrative staff talked to RN E about this alleged behavior in an attempt to determine investigation details. There was no documented evidence that Patient #2's daughter was provided the opportunity to have a written complaint /grievance resolution letter per hospital policy.

During interview with CEO A on 7/2/15 at 3 p.m., A stated that there was no investigation done into RN E's behavior, or written evidence that Patient #2's daughter did not request a written grievance resolution response.

3) The 7/2/15 record review of the "Patient/ Family Report" reveals that on 5/11/15, Patient #3's sister reported to RN F that RT G, over the weekend, was "rude and insensitive" and "made comments that made Patient #3 anxious and afraid to have G in the room". RN F documented "notified lead RT and CNO about not having employee care for patient." On 5/12/15, CEO A documented "spoke with Patient #3's sister on 5/12/15. Patient #3's sister satisfied with above mentioned resolution. No further follow-up needed."

There was no documented evidence that the hospital conducted an investigation to determine if RT G's behavior rose to the level of patient abuse. There was no documented evidence that the hospital talked to RT G about the reported alleged behavior. There was no documented evidence that Patient #3's sister was provided the opportunity to have a written complaint /grievance resolution letter per hospital policy.

During interview with CEO A on 7/2/15 at 3 p.m., A stated that there was no investigation done into RT G's behavior, or written evidence that Patient #3's sister did not request a written grievance resolution response.

4) The 7/2/15 record review of the "Patient/Family Report" reveals that on 6/23/15, Patient #4's son reported to CEO A that: 1) Staff dropped wipe and then picked it up and then used it. 2) Call light response to toileting needs is slow. 3) Staff need to be more careful when turning due to surgical site on back.

On 6/23/15 (no time documented), CEO A documented "I called Patient #4's son. I told Patient #4's son I would notify staff of concerns and that we would improve. Patient #4's son is OK with this."

There was no documented evidence that CEO A or other hospital staff conducted an investigation into Patient #4's son's care complaints to ensure quality of care provided by staff. There is no documented evidence that Patient #4's son's care complaints were resolved just because son "was OK with this", or that Patient #4's son was offered a written response to grievance concerns per hospital policy.

During interview with CEO A on 7/2/15 at 3 p.m., A stated that there was no investigation done into the complaint concerns or written evidence that complainant did not want written grievance response.

Based on record review and interview, the facility failed to ensure the patient or patient's legal guardian has the right to be informed about the patient's health status in order to have involvement with treatment and care planning decisions, in 1 of 6 patients (Patient #6) reviewed.

Findings include:

The 7/1/15 review of the Patient Rights and Responsibilities information given to patients/ patient representatives on admission reveals that patients have to right to participate in care planning.

On 6/3/15, Patient #6's legal guardian/ health care representative J filed a complaint with the state survey agency alleging inadequate medical and nursing care of Patient #6's wounds causing further infection and subsequent death.

The 7/1/15 and 7/2/15 closed record review of Patient #6 reveals admission on 4/15/15 for the purpose of IV antibiotic therapy and wound care. On 5/2/15, Patient #6 developed fevers that were thought to arise from pneumonia and/ or infected hip wounds. On 5/11/15, the physician "progress notes" reveal an entry by ID physician assistant documenting displacement fracture of the hip and GI infection (C. Diff.). On 5/12/15, and the infectious disease physician discontinued IV antibiotics for the hip wound infection due to "structural defects in the hip". The 5/15/15 "Internal Medicine Daily Progress notes" reveal that Patient #6 remains to have a left lobe pneumonia and was taken off all antibiotics by the ID physicians.

The 7/1/15 closed record review of Patient #6's medical record reveals that health status changes that occurred during the patient's hospital stay were not told or discussed with Patient#6's legal guardian. There is no documented evidence that medical decision-making was conducted with the participation of the legal guardian. There is no documented evidence that medical staff told Patient #6's legal guardian about the changing diagnoses or prognosis to ensure that the legal guardian could effectively exercise the right to make informed decisions.

During interview with primary care physician K on 7/2/15 at 2 p.m., K stated that K does not remember if there is documentation regarding medical decision-making with Patient #6's legal guardian J, in the medical record. K stated that K has a "good relationship" with J, and that J could call K at anytime, and has" about Patient #6.

During interview with Patient #6's legal guardian J on 7/14/15 at 2:30 p.m., J stated that J was told Patient #6 would receive IV antibiotics for wound care. J stated there was no information given about the pneumonia, the hip displacement due to infection, the development of fevers or that Patient #6 was taken off all antibiotics while hospitalized. J stated "if told these things, I would have made different decisions about taking Patient #6 home".

Based on record review and interview, the hospital failed to ensure that all patient complaints of abuse are thoroughly investigated in a timely manner to protect patients from all forms of abuse in 1 of 3 patient complaints (Patient #3) about staff behavior, in a total review of 5 patient complaints.

Findings include:

The 7/2/15 review of "Policy #A02-A: Abuse, Neglect, revised 7/1/12" states under "6. Investigation: As above, all investigations will be prompt and through...7. All incidents will be thoroughly analyzed and reported to applicable agencies as well as the Hospital Governing Board...". .

The 7/2/15 record review of the "Patient/Family Report" filed for patient grievance documentation reveals that on 5/11/15, Patient #3's sister reported to RN F that RT G, over the weekend, was "rude and insensitive" and "made comments that made Patient #3 anxious and afraid to have G in the room". RN F documented "notified lead RT and CNO about not having employee care for patient." On 5/12/15, CEO A documented "spoke with Patient #3's sister on 5/12/15. Patient #3's sister satisfied with above mentioned resolution. No further follow-up needed."

There was no documented evidence that the hospital conducted an investigation to determine if RT G's behavior rose to the level of patient abuse. There was no documented evidence that the hospital talked to Patient #3 or Patient #3's sister to define allegations, so investigation could be conducted. There was no documented evidence that RT G was interviewed about the allegations or that actions were taken to protect other patients from RT G until an investigation was completed.

During interview with CEO A on 7/2/15 at 3 p.m., A stated that there was no investigation done into RT G's behavior.

Based on observation and interview, the infection control officer failed to ensure that aseptic technique was used when providing wound care, in 2 of 2 patients observed (Patient #'s 8 and 9), in a wound care sample of 5 patients.

Findings include:

The 7/15/15 review of policy "Aseptic Technique, (no issue/ revision date) shows no documented evidence that it has been approved by the hospital's governing body. This policy states "2. Medical Asepsis is essentially the measures that control the number of microbes but do not aim for sterility throughout the procedure; while surgical asepsis creates and preserves sterility throughout the procedure. If you know what is clean, what is a dirty, what is sterile and remedy contamination immediately, you will have the basic understanding of aseptic principles...4. In the care of the wounds, remember:... Clean technique for dressing and cleaning is generally appropriate.".

1) Observations of RN wound care staff H and I, on 7/1/15 at 1:50 p.m., providing care to Patient #8 reveals that clean dressing supplies (three strips of transparent wound and scissors used to cut these dressings) were laid on the patient's bed linens before being applied to the wound. The patient's bed linens are potentially contaminated surfaces.

The scissors is to cut Patient #8's "clean" dressings were disinfected with a sanitary wipe while in the patient's room, and then laid on the top shelf of the wound care cart tat was situated outside the room in the hallway, while Patient #8's dressing was changed. The cart's surfaces were not disinfected before the "clean" scissors were placed on it.

2) Observations of RN wound care team staff H and I, on 7/1/15 at 2:25 p.m., providing wound care to Patient #9 reveals that clean dressing supplies were set up on the patient's over bed table, which was not observed to be disinfected before use. This patient's over bed table is a potentially contaminated surface.

The scissors used to cut Patient #9's "clean" wound dressings were taken from the top shelf of the wound care cart (reference example #1), a surface that was not disinfected before the scissors were placed on it. These scissors were not observed to be disinfected before being used to cut Patient #9's wound care dressing.

During interview on 7/1/15 at 3:10 p.m. with RN wound care staff H and I, I stated that "they have one pair of scissors" to use with wound care patients. When told but the contaminated surfaces (patient bed linens and the wound care cart shelf) they stated "OK".