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Based on facility policy review, medical record review, review of an e-mail and interview, the facility failed to protect patient rights by not investigating grievances for one (#3) of five patients reviewed.

The findings included:

Review of the facility policy entitled Patient Complaint/Grievance Policy, revealed "...It is the supervisor's responsibility to handle unresolved complaints immediately. The supervisor must initiate an initial investigation, including interviews of all involved. Notify the Director of Quality Management. The Director of Quality Management will assign the most appropriate investigator. The Department Head will conduct investigations into complaints assigned by the Director of Quality Management. These investigations include interviews, document review, and scene re-enactment if necessary.

Patient #3 was admitted to the facility on November 8, 2012, with diagnoses including Acute Respiratory Failure, Diabetes Mellitus, Hypertension, Ventilator Acquired Pneumonia, Peripheral Arterial Disease, Severe Chronic Obstructive Pulmonary Disease, Gastroesophageal Reflux Disease, Non-severe Protein Calorie Malnutrition, Dysphagia, and Abnormal EKG with Stent Placement.

Medical record review revealed the patient had been in another acute care hospital and received a tracheostomy and percutaneous endoscopic gastrostomy tube (PEG) since the patient had swallowing difficulties.

Medical record review revealed the patient developed rectal bleeding and was transferred to hospital #2 for evaluation on November 17, 2012.

Interview with the Quality Assurance Director on August 5, 2013, at 2:40 p.m., in the conference room, revealed the Director had received an email from patient #3's family member after the patient had been discharged. Review of the email revealed the family member expressed issues with only male nurses in the ICU; wires pulled patient's gown down and exposed the patient; staff gave the patient Ativan which they shouldn't have; did not give patient pain pills; patient was not on IV fluids; left several messages for the physician to call and none were returned; patient had a hematoma and was not acknowledged how that occurred. Continued interview with the Director reveled the Chief Executive Officer of the facility wrote a letter to the complainant stating "...The Nurse Manager has taken your concerns very seriously and the concerns with the employees have been addressed appropriately. Your concerns with the physician not calling you have been forwarded to the physician..."

Interview with the Nurse Manager on August 5, 2013, at 3:30 p.m., in the conference room, revealed the Nurse Manager had tried to contact the complainant on two occasions but there was no response. Continued interview with the Nurse Manager revealed "...if someone doesn't want male nurses caring for a patient then I will try to get a female tech for bathing. We will also supply a sitter if needed..." Further interview with the Nurse Manager confirmed a specific investigation of the complaints related to the family member's e-mail had not been undertaken. Continued interview with the Nurse Manager revealed "...I like to get as specific as possible so I can go to certain individuals. I can't recall any counseling or write-ups over this patient. I may have made generalized comments in a staff meeting. I did not know who to single out. I did not talk to any staff. I don't know how that got missed..."

C/O #31905