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Based on interview and record review, the hospital failed to follow their complaint and grievance policy when a patient grievance was not investigated or resolved for one of three patients (Patient 5). This failure resulted in an unresolved patient grievance and had the potential to result in unaddressed quality issues.

Findings:

Review of Patient 5's ED (Emergency Department) Nurse Documentation, dated 2/28/25 indicated the patient was seen in the ED after seizure on 2/28/25.

Review of the hospital's grievance log indicated Patient 5 filed a grievance on 3/24/25 regarding staff not allowing her to make medical decisions.

Review of a letter, "Follow-Up on Emergency Department Visit - February 28, 2025," dated 4/3/25, indicated the letter was addressed to Patient 5. It indicated, "Please know your feedback is being taken seriously and has been shared with the appropriate leadership for further review and follow-up."

During an interview on 5/29/25 at 11:40 a.m., the Director of Quality and Risk (DQR) stated that once the hospital receives an incident report (grievance), there should be an investigation completed within 72 hours. The DQR stated there was no investigation into Patient 5's grievance and there was no resolution.

Review of the hospital's policy, "Patient Complaints and Grievances," revised 12/13/2021, indicated, "After talking with the patient, an investigation shall be conducted appropriate to the nature of the grievance... If the grievance cannot be resolved or the investigation cannot be completed within 7 days, the patient will be informed that a follow-up response will be sent within 30 days... The final response to the patient will include the name of hospital contact person, steps taken to investigate, completion date, and results of the grievance process."

Based on interview and record review, the hospital failed to obtain an order for the use of restraints (any manual method or device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) for one of two patients (Patient 3) when Patient 3 was placed in bilateral (both sides) wrist restraints without a physician order. This failure had the potential to result in an inappropriate and prolonged use of restraints.

Findings:

Review of Patient 3's History and Physical, dated 5/16/25, indicated the patient was admitted to the hospital with alcohol withdrawal.

Review of Patient 3's Nursing Restraint Documentation from 5/18/25 to 5/29/25 indicated the patient was in bilateral soft wrist restraints from 5/18/25 to 5/29/25 due to confusion/disorientation, removing medical device, unable to follow direction, and attempting to get up/unsafe ambulation.

Review of Patient 3's Restraint Orders from 5/18/25 to 5/29/25 indicated the patient did not have a restraint order on 5/23/25.

During an interview on 5/29/25 at 2:23 p.m., the Director of Quality and Risk (DQR) confirmed the physician's order for Patient 3's restraint order on 5/23/25 was not documented.

Review of the hospital's policy, "Restraint and Seclusion," dated 7/28/22, indicated, "Each order for restraint to ensure the physical safety of non-violent or non-self-destructive patient must be renewed... once every calendar day."

Based on interview and record review, the hospital failed to follow their pressure injury (pressure-related damage to the skin and/or underlying tissue) prevention/management policy when the admission skin assessment did not include all the wounds present, and wound care was not documented for one of two patients (Patient 1). These failures had the potential to result in patients' needs not being met and worsening pressure injuries.

Findings:

Review of Patient 1's Discharge Summary, dated 4/3/25, indicated the patient was admitted with dysphagia (difficulty swallowing) and severe protein-calorie malnutrition (an imbalance between the nutrients that a body requires to function and the nutrients it receives) on 3/30/25, and was discharged on 4/3/25.

Review of Patient 1's Wound Assessment and Treatment Note, dated 3/31/25, indicated the patient had wounds on his right thigh, coccyx (tailbone, bottom of spine), left hip, left buttock, right hip, right buttock, right flank (side of body between the ribs and hip), bilateral (both sides) posterior heels (back part of heel), and right plantar heel (bottom of heel).

Review of Patient 1's ED (Emergency Department) - Physician Note, dated 4/3/25, indicated, "Patient discharged from our hospital at approximately 7:00 p.m. He arrived back to the emergency department via ambulance at approximately 9:30 p.m."

Review of Patient 1's Nursing - Skin and Wound Assessment, dated 4/4/25, indicated the patient had wounds on his right buttocks, left hip, bilateral lower extremities, and right heel.

Review of Patient 1's Wound Assessment and Photography, dated 4/4/25, indicated there were four pictures of Patient 1's wounds taken. Three of photos indicated Patient 1's wounds were located on the left hip, left lower extremity, and left thigh. One photo did not indicated the location of Patient 1's wound.

Review of Patient 1's physician orders, indicated he had an order, dated 4/7/25, for wound care - change dressing every day, paint all open wounds with betadine (solution that prevents infection) daily, cover open wounds with foam dressings after application of betadine.

Review of Patient 1's Shift Activity Report, from 4/3/25 to 4/14/25, indicated, "Wound Care - Change Dressing" was performed on 4/7/25 and refused on 4/12/25. There was no documentation on other dates that indicated Patient 1's wound dressings were performed or refused.

Review of the report sent to the California Department of Public Health (CDPH), dated 4/9/25, indicated Patient 1 was discharged on 4/3/25 and admitted on 4/4/25. It also indicated a skin assessment of Patient 1 was performed and, "documentation of existing wounds was general and failed to capture all of the wounds that were present on admission."

During an interview on 5/30/25 at 10:05 a.m., the Program Director of Quality and Compliance (PDQC) stated when Patient 1 was readmitted, some of the wounds were not documented on initial assessment.

During an interview and concurrent record review on 5/30/25 at 11 a.m., the Clinical Informaticist (CI) confirmed there was documentation on 4/7/25 that Patient 1's wound care was performed; and on 4/12/25, that Patient 1's wound care was refused. The CI stated there was no other documentation besides the above dates that indicated Patient 1's assigned nurse performed Patient 1's daily wound care treatment

Review of the hospital's policy, "Pressure Injury Prevention/Management (Wound Risk Assessment)," revised 1/2023 indicated, "Thorough documentation of the pressure injury assessment shall include photography of any abnormality... as part of documentation of clinical condition on admission or separately." The policy also indicated documentation requirements included, "Skin assessment - on admission, upon transfers... Wound assessment and photograph... will be completed for any wounds present and placed in the patient's chart. Document all dressing changes in nursing notes."