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Based on document review and interview, the hospital failed to provide written notice of decisions and steps taken on behalf of the patient to investigate complaints/grievances not resolved at the time of the complaint by staff present with later resolution/investigation as per CFR 482.13(a)(2) and facility policy/definition from 5/1/22 through 7/6/22.

Findings include:

1. Review of the policy titled Complaint and Grievance Process, review date 2/22, indicated the following:
All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with regulatory requirements are considered grievances.
Most grievances should be resolved in seven days. A written response is sent to the complainant upon resolution of the grievance. For complex grievances that require deeper investigation or resolution of systemic problems, a longer timeframe may be necessary as determined by hospital administration, usually no longer than 30 days. In this instance, the complainant is notified that administration is still working on the resolution and will follow-up with a written response within a stated number of days.
Grievances are considered resolved when the complainant is satisfied with the actions taken. This will be documented as past of the follow up with the complainant.
If complaint is designated as unresolved, or qualifies as a grievance, implement actions and interventions to investigate and seek prompt resolution of complaint. Initiate Grievance Investigation and Resolution form and follow the Grievance process.
Definitions: Patient complaint: Concern/Dissatisfaction - A verbal expression of concern of dissatisfaction with a service or department, that is more substantive than a minor request, and is resolved by the staff present, to the satisfaction of the complainant, on the departmental level at the point of the complaint. Patient complaint: Grievance - Any expression of dissatisfaction (written or verbal) related to an occurrence, which is of such severity that it is not able to be resolved to the satisfaction of the complainant at a departmental level by the staff present. Complaints that require further investigation, further actions for resolution, or are postponed for later resolution are considered grievances.

2. Review of facility complaints/grievances for 5/1/22 through 7/6/22, indicated 11 complaints/grievances were entered. Eight of the eleven (8/11) lacked evidence of patient satisfaction at the time of the complaint by staff present at a departmental level and were indicated to require further investigation and/or action. The reports lacked evidence of complainant notification of resolutions and/or satisfaction or dissatisfaction of actions taken. The hospital lacked evidence a written response upon resolution having been provided to complainants.

3. On 7/7/22, beginning at approximately 5:30 PM, A4, Director of Quality, indicated the hospital did not have any grievances 5/1/22 through 7/6/22, all entries on the log were verbal complaints and therefore no written follow up/resolution information was sent/provided to complainants. A4 verified lack of documentation of complainant satisfaction or dissatisfaction of resolutions.

Based on observation and interview, the hospital failed to ensure the patient's right to the confidentiality of his/her clinical records in one (1) instance for one (1) facility.

Findings include:

1. The following was observed on 7/7/22, beginning at approximately 12:45 PM. On the inpatient unit, in an unattended hall was a portable nursing documentation system [COW (computer on wheels)]. Upon approach of the COW it was noted that at least 5 patient's were listed with PHI visible and a laboratory type tube of dark red substance was sitting unattended on top of the surface. After approximately 30-60 seconds a nurse appeared and verified the COW should not have been left unlocked and unattended with patient information viewable.

2. On 7/7/22, beginning at approximately 12:45 PM, Nurse N6 verified the COW should not have been left unlocked and unattended with patient information viewable.

Based on document review and interview, the hospital failed to ensure for adequate numbers of licensed registered nurses (RN), licensed vocational nurses/licensed practical nurses (LVN/LPN), and other personnel to provide nursing care to all patients as needed between the dates of 5/23/22 and 5/29/22.

Findings include:

1.a. Review of the policy titled Nurse Staffing Plan - non-California, review date 1/22, indicated the following:
The nursing service must have adequate numbers of licensed RNs, LVNs, and other personnel to provide nursing care to all patients as needed.
The licensed nurse-to-patient ratios would be in accordance with acuity of the patient.
b. Review of the Rehab Sample Matrix for Staffing indicated the following:
Census 36 - 37: Day shift and Night shift staff 4 RNs, 2 LPNs and 3 NAs (Nurse' Aides)
Census 35: Day shift staff 4 RNs, 2 LPNs and 3 NAs. Night shift staff 3.5 RNs, 2 LPNs and 3 NAs
Census 34: Day shift staff 4 RNs, 2 LPNs and 3 NAs. Night shift staff 3 RNs, 2 LPNs and 3 NAs
Census 30: Day shift staff 3 RNs, 2 LPNs and 3 NAs. Night shift staff 3 RNs, 2 LPNs and 2 NAs
Census 26: Day shift staff 3 RNs, 2 LPNs and 2 NAs. Night shift staff 3 RNs, 1 LPNs and 2 NAs
Census 25: Day shift staff 3 RNs, 1.5 LPNs and 2 NAs. Night shift staff 3 RNs, 1 LPNs and 2 NAs
Census 23: Day shift staff 3 RNs, 1 LPNs and 2 NAs. Night shift staff 2.5 RNs, 1 LPNs and 2 NAs

2. Review of the One Week Staffing Pattern Worksheet completed for the week of 5/23/22 through 5/29/22 indicated the following:
On 5/23/22, with a census of 23 Night shift staffed 2 RNs, 4 LPNs and 2 NAs
On 5/24/22, with a census of 23, Day shift staffed 2 RNs, 2 LPNs and 3 NAs. Night shift, with a census of 26, staffed 1 RN, 5 LPNs and 3 NAs
On 5/25/22, with a census of 26, Day shift staffed 2 RNs, 2 LPNs and 4 NAs. Night shift, with a census of 30, staffed 2 RNs, 3 LPNs and 2 NAs
On 5/26/22, with a census of 30, Day shift staffed 2 RNs, 2 LPNs and 3 NAs
On 5/27/22, with a census of 34, Day shift staffed 3 RNs, 2 LPNs and 4 NAs
On 5/28/22, with a census of 35, Day shift staffed 1 RNs, 4 LPNs and 4 NAs. Night shift, with a census of 37, staffed 3 RNs, 2 LPNs and 3 NAs
On 5/29/22, with a census of 36, Day shift staffed 2 RNs, 3 LPNs and 4 NAs.

3. On 7/7/22, beginning at approximately 6:45 PM, A2, Chief Nursing Officer, verified staffing worksheet entries, lack of acuity scores and staffing deficits.

Based on document review and interview, the hospital failed to ensure nursing care was provided in accordance with hospital policies/procedures/protocol and/or professional standards for 9 of 10 patients (P1, P2, P3, P4, P6, P8, P9 and P10) for transfers and 1 of 10 patients (P6) for 1. informing family/Power of Attorney (POA) of patient changes, 2. hygiene, 3. medication order entry/administration, and 4. physician orders

Findings include:

1. a. Review of the policy titled Patient Transfer/Transport, review date 2/21, indicated the following:
Upon receipt of a physician's order for transfer to an acute facility the supervisor or designee will notify the Ambulance Company to arrange for emergent transport. The Supervisor or designee will notify the patient's family/significant other of the need for transfer.
The Transfer Packet will be completed by the nurse assigned to the patient.
The Supervisor or designee contacts the acute care emergency room and provides hand off communication via SBAR (an electronic medical record [eMR] entry).
The Medical Record (MR) will include, at a minimum: a. The physician's order for transfer. b. Physician's transfer note (if available). c. Nursing progress notes documenting the events leading to the transfer, actions taken, time of transfer, method of transport, condition of the patient, and the name of the staff person to whom the status report was called.

b. Review of the policy titled Plan for Provision of Care, review date 2/21, indicated the following:
Patient Rights and Organizational Ethics: Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes.

2. MR review:
a. The MR of patient P1 indicated that on 5/23/22 the patient was transferred out to an acute hospital after sustaining injury from a fall. The MR lacked documentation of nursing having called report to the hospital and/or documentation of a transfer packet having been sent with the patient.

b. The MR of patient P2 indicated that on 5/26/22 the patient experienced a fall, hit head and right side of back. MR documentation indicated the patient was to be sent out by EMS (Emergency Medical Services). The MR lacked documentation of the name of the person at the hospital to whom report was called and lacked documentation of the transfer packet having been sent with the patient.

c. The MR of patient P3 indicated that on 5/27/22 the patient was emergently transferred out to an acute hospital due to code activity. The MR lacked documentation of nursing having entered a verbal order for the transfer, lacked documentation of nursing having called report to hospital staff, lacked documentation of the time of transfer and lacked documentation of the transfer packet having been sent with the patient.

d. The MR of patient P4 indicated that on 5/28/22, date of admission, the patient was found down, later developed a change in status and was transferred to an acute hospital emergency department (ED). The MR lacked documentation the transfer packet having been sent with the patient.

e. The MR of patient P6, admitted 5/27/22 and discharged as an acute transfer out on 6/10/22, indicated family member F1 was the patient's legal Power of Attorney (POA) and emergency contact. The MR lacked documentation of notification to POA for changes in medication(s) and/or condition. Medications for pain, upon admission, included Oxycodone 15 mg one or two tablets q (every) 4 h (hour[s]) prn (as needed). On 5/27/22 at 1836 hours a physician order was placed via "Communication to Nurse"" for the order to begin 5/27/22 at 0800 hours with a "Q SHIFT" (every shift) frequency as follows: 3 JP drains Q8 hours (every 8 hours) strip/milk lines keep incisions C/D/I (clean/dry/intact). The MR lacked documentation of the 3 (three) JP drains having been stripped/milked. The nursing admission assessment, completed on 5/27/22 at 1630 hours indicated the degree of physical activity and Mobility-Ability were severely limited or non-existent. The MR lacked evidence of the patient having shaved and/or having been assisted with shaving as part of hygiene. MR documentation in system 2 indicated the following medications were ordered (not all inclusive):
1. On 6/6/22 Oxycodone HCL (oxyCODONE HCL) 15 mg, give 15 MG (1 tablet) by mouth every four hours (q4h) PRN moderate pain (4-10); start date: 6/6/22 at 2231 hours. This order was discontinued (DC'd) on 6/8/22 at 1126 hours.
2. On 6/6/22, start date 6/6/22 at 2232 hours, Oxycodone HCL (oxyCODONE HCL) 15 mg, give 30 mg (2 tablets) by mouth q4hr PRN severe pain (7-10). This order was DC'd on 6/8/22 at 1127 hours.
3. On 6/8/22, start date 6/8/22 at 1129 hours, Oxycodone HCL (oxyCODONE HCL) 15 mg, give 30 mg (2 tablets) by mouth q4hr PRN in the evening while sleeping - medication is prn at night indication: pain. This order was DC'd on 6/10/22 at 1122 hours.
4. *On 6/9/22, start date 6/8/22 at 2203 hours Oxycodone HCL (oxyContin) 15 mg, give 30 mg (2 tablets) by mouth q4hr while awake "HIGH ALERT MEDICATION!!!!". This order was DC'd on 6/9/22 at 2027 hours. Medication Administration Records (MAR) indicated oxyCODONE HCL and oxyCONTIN HCL were administered as follows (not all inclusive):
6/8/22 at 5:33 PM oxyCODONE HCL - 30 mg was given prn
6/8/22, at 6:14 PM oxy CODONE HCL - 30 mg was given per the q4hr PRN in the evening while sleeping order
6/8/22 at 6:18 PM oxyCODONE HCL - 30 mg was given per q4hr scheduled order.
6/8/22 at 10:31 PM oxyCONTIN - 30 mg was given per q4hr while awake order.
6/9/22 at 2:38 AM oxyCODONE HCL - 30 mg was given PRN
6/9/22 at 2:47 AM oxyCONTIN - 30 mg was given per q4hr scheduled order

f. The MR of patient P7 indicated that on 6/13/22 the patient was emergently transferred out to an acute hospital. The MR lacked documentation of the transfer packet having been completed and/or sent with the patient.

g. The MR of patient P8 indicated that on 6/2/22 the patient was transferred out to an acute hospital. The MR lacked documentation of nursing having called report to hospital staff and lacked documentation of the transfer packet having been completed and/or sent with the patient.

h. The MR of patient P9 indicated that on 6/2/22 the patient was transferred out to an acute hospital. The MR lacked documentation of the transfer packet having been sent with the patient.

i. The MR of patient P10 indicated that on 6/15/22 the patient was transferred out to an acute hospital. The MR lacked documentation of nursing having called report to hospital staff and lacked documentation of the transfer packet having been completed and/or sent with the patient.

3. Review of package insert information of OxyContin from https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020553s060lbl.pdf, indicated the following:
OXYCONTIN® (OXYCODONE HCl CONTROLLED-RELEASE) TABLETS
OxyContin 60 mg, 80 mg, and 160 mg Tablets, or a single dose greater than 40 mg,
ARE FOR USE IN OPIOID-TOLERANT PATIENTS ONLY. A single dose greater
than 40 mg, or total daily doses greater than 80 mg, may cause fatal respiratory
depression when administered to patients who are not tolerant to the respiratory depressant
effects of opioids.

4. Review of facility incident reports indicated an event related to a medication error for patient P6 was entered 6/10/22 with the following information: On 6/8/22 at 2200 hours an order was placed for oxycodone HCL (Oxycontin) 15 mg to give 2 pills q4hrs while patient was awake. Patient received four doses of this before being checked the order was verified by RN N4 and Pharmacist C2 the pharmacy approved order that evening (sentence format as written in report). Follow up 6/10/22: Discussed medication variance transcription error with N4.

5. The following was indicated in interview on 7/7/22:
Beginning at approximately 3:15 PM, A2, Chief Nursing Officer, verified MR documentation for P6 did not specify that the patient shaved.
Beginning at approximately 4:00 PM, A2 and A3, HIM (Health Information Management) Director, verified MR findings.