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Based on record review and interview, the facility staff failed to ensure that grievances were fully investigated and the results of the investigation were addressed in the response letter, per facility policy, in 1 of 6 patient grievance files (Patient #1) out of a total of 6 grievance files reviewed.

Findings include:

A review of the facility's policy #6794238 titled, "Patient Complaints and Grievances, AW [Ascension Wisconsin]," last revised 08/12/2019 revealed, " ...Procedure ...1. Filing a Patient Grievance ...If the complaint is reported after the patient has been discharged, an associate may refer it directly to the unit/department leader or designee to follow up on and manage ...2. Response of Grievance Process ...Investigation should include review of medical records as well as interviews with associates, providers, and other department associates as appropriate that were involved or can offer input into the concern ...During the review process the department leader or designee may request consultation with other Department leaders ...Once the grievance has been resolved, the department leader will provide a written notice of the resolution to the patient/guardian who filed the grievance. This notice will be provided in clear language and will include the following information ...Explanations of steps taken on behalf of patient to investigate the Grievance (sic) ...Results of the grievance investigation process ..."

A review of the grievance file #GWP2667223 revealed Patient #1's grievance was entered on 01/05/2022 following a telephone call from Patient #1. A review of the file revealed Patient #1 alleged concerns including that doctors and nurses did not address or treat his/her back pain, the alternating pressure mattress made his/her back pain worse, and that s/he did not receive the results of a CT scan of the spine prior to discharge.

Further review of the grievance file revealed the grievance was assigned to the lead hospitalist for investigation and follow up.

A review of the response letter dated 01/10/2022 revealed, " ...I spoke with the hospitalist physician involved in your care and [s/he] did not recall that you had back pain nor the exact details of the CT scan of your spine. On the day you left the hospital, the hospitalist intended to review all of the studies and follow-up needed after your hospital discharge, but you had left prior to the hospitalist informing you of the discharge plan. We regret that we did not inform you of the CT scan results, even after you left the hospital. As we discussed over the telephone, it is our process to review all imaging with our patients ..."

There was no evidence that the other allegations, including the allegation that Patient #1 was not treated for back pain during the hospitalization, were investigated or addressed.

During a telephone interview with Risk Manager L on 04/07/2022 at 10:30 AM, when asked about Patient #1's grievance, Risk Manager L stated, "I did not speak with the patient directly. I met with the Director of Hospitalists to go over the response letter. S/He talked to the patient. The grievance came in as a phone call from the patient to our feedback management team." When asked if there was any additional investigation into Patient #1's allegation that his/her back pain was not addressed, Risk Manager L stated, "The initial complaint was that no one addressed his/her back pain. There was no investigation into the nursing side of things because the complaint was all against the provider. The Director of Hospitalists spoke to the Hospitalist involved and s/he did not recall the patient having pain or ordering a CT." When asked again if there had been an investigation done regarding Patient #1's allegation that nursing staff did not address his/her pain, Risk Manager L stated, "You're right. There were nursing allegations. I don't know why it wasn't assigned to a nurse leader for investigation. I would need to follow up with our patient safety manager." When asked if there had been any additional communication with Patient #1 or his/her spouse, Risk Manager L stated, "No."

Based on record review and interview the facility staff failed to document pain assessments per facility policy in 4 of 10 patients (Patients #1, 2, 6 and 9) and failed to reassess pain levels following interventions per facility policy for 9 of 9 Patients (Patient #1, 2, 3, 4, 6, 7, 8, 9 and 10) with documented medication interventions for pain relief in a total universe of 10 medical records reviewed.

Findings include:

A review of the facility's policy #8071040 titled, "Pain Management Policy, AW (Ascension Wisconsin)," last revised 05/15/2020 revealed, " ...Patients will be assessed for pain at a minimum of once per shift (0700-1500 [7:00 AM to 3:00 PM], 1500-2300 [3:00 PM to 11:00 PM], and 2300-0700 [11:00 PM to 7:00 AM]) ...Pain and the effectiveness of pain management interventions are reassessed and documented ...Pain is reassessed at a suitable interval following pain interventions. For pharmacologic interventions, the timing of reassessment should consider: drug, route, and dose. For non-pharmocologic interventions, reassessment is ongoing and documented at a minimum once per shift ..."

A review of the facility's policy #10705392 titled, "Pain Management Resource, AW (Ascension Wisconsin)," last revised 11/09/2021 revealed, " ...Reassess once a sufficient time has elapsed for the treatment to be effective. For pharmacologic interventions, timing of reassessment should consider drug, dose, and route. Suggested reassessment is 15-30 minutes after IV (intravenous) administration and 60-120 minutes after oral administration. Reassess more frequently for patients experiencing severe, rapidly changing pain and patients exhibiting excess sedation. Reassess with any new patient report of pain or following a pain-producing event ..."

Examples of Pain Assessments Not Documented At Least Once per Shift:

Patient #1's medical record was reviewed on 04/04/2022 at 2:30 PM with Quality Coordinators C and E who confirmed the following per interview:

Patient #1 was admitted to the facility from 12/10/2021 through 12/13/2021 for new onset seizure and altered mental status.

A review of the nursing flowsheets titled, "Pain Assessment" revealed no documented pain assessments from 12/12/2021 at 8:00 AM through discharge on 12/13/2021 at 4:14 PM. There was no documented evidence found that nursing staff documented Patient #1's pain assessments at least once per shift for over 32 hours.

Patient #2's medical record was reviewed on 04/07/2022 at 9:21 AM with Quality Coordinators I and J who confirmed the following per interview:

Patient #2 was admitted to the facility from 12/07/2021 through 12/14/2021 for ataxia (impaired coordination) due to cancer of the brain.

A review of the nursing flowsheets titled, "Pain Assessment" revealed no documented pain assessments from 12/08/2021 at 11:19 AM through 12/09/2021 at 2:10 PM. There was no documented evidence found that nursing staff documented Patient #2's pain assessments at least once per shift for nearly 27 hours.

Patient #6's medical record was reviewed on 04/07/2022 at 11:10 AM with Quality Coordinators I and J who confirmed the following per interview:

Patient #6 was admitted to the facility from 03/02/2022 through 03/07/2022 for altered mental status.

A review of the nursing flowsheets titled, "Pain Assessment" revealed no documented pain assessments from 03/04/2022 at 8:08 PM through 03/05/2022 at 10:50 PM. There was no documented evidence found that nursing staff documented Patient #6's pain assessments at least once per shift for nearly 27 hours.

Patient #9's medical record was reviewed on 04/07/2022 at 12:06 PM with Quality Coordinators I and J who confirmed the following per interview:

Patient #9 was admitted to the facility on 03/24/2022 for back pain, flank pain, and blood in the urine. Patient #9 was currently still hospitalized at the time of the survey.

A review of the nursing flowsheets titled, "Pain Assessment" revealed no documented pain assessments from 03/30/2022 at 9:01 AM through 03/31/2022 at 8:00 AM. There was no documented evidence found that nursing staff documented Patient #9's pain assessments at least once per shift for 23 hours. There were no documented pain assessments from 04/06/2022 at 8:30 AM through 04/07/2022 at 8:41 AM. There was no documented evidence found that nursing staff documented Patient #9's pain assessments at least once per shift for over 24 hours.

During an interview on 04/07/2022 at 12:13 PM, Quality Coordinator I stated pain assessments were expected to be documented, "At least once a shift."

Examples of Pain Reassessments Not Documented per Policy:

Patient #1's medical record was reviewed on 04/04/2022 at 2:30 PM with Quality Coordinators C and E who confirmed the following per interview:

Patient #1 was admitted to the facility from 12/10/2021 through 12/13/2021 for new onset seizure and altered mental status.

A review of the medical record revealed Patient #1 received Tylenol 650 mg (milligrams) orally for pain on 12/11/2021 at 12:17 PM. There was no pain reassessment documented within 120 minutes per facility policy.

Patient #2's medical record was reviewed on 04/07/2022 at 9:21 AM with Quality Coordinators I and J who confirmed the following per interview:

Patient #2 was admitted to the facility from 12/07/2021 through 12/14/2021 for ataxia (impaired coordination) due to cancer of the brain.

A review of the medical record revealed Patient #2 received Dilaudid (a narcotic pain medication) 0.2 mg IV on 12/07/2021 at 2:44 PM for pain. There was no pain reassessment documented within 30 minutes following the administration of the IV medication per facility policy.

Patient #2 received Morphine (a narcotic pain medication) 2 mg IV on 12/07/2021 at 6:40 PM and at 10:39 PM for pain. There were no pain reassessments documented within 30 minutes following the administrations of the IV medications per facility policy.

Patient #2 received Percocet (a narcotic pain medication) 5-325 mg tablet orally for pain on 12/07/2021 at 11:26 PM; on 12/08/2021 at 4:10 AM and 4:06 PM; on 12/09/2021 at 1:29 AM; on 12/10/2021 at 12:23 PM; on 12/11/2021 at 8:03 AM; on 12/12/2021 at 12:02 AM, 6:15 AM, 11:39 AM, and 5:00 PM; and on 12/13/2021 at 4:03 AM, 10:02 AM, and 6:21 PM. There were no pain reassessments documented within 120 minutes following the administrations of the oral medications per facility policy.

Patient #3's medical record was reviewed on 04/07/2022 at 9:46 AM with Quality Coordinators I and J who confirmed the following per interview:

Patient #3 was admitted to the facility from 12/09/2021 through 12/11/2021 after a fall while intoxicated.

A review of the medical record revealed Patient #3 received Tramadol (a narcotic pain medication) 50 mg tablet orally on 12/11/2021 at 8:41 AM and 2:36 PM for moderate pain. There were no pain reassessments documented within 120 minutes following the administrations of the oral medications per facility policy.

Patient #4's medical record was reviewed on 04/07/2022 at 10:02 AM with Quality Coordinators I and J who confirmed the following per interview:

Patient #4 was admitted to the facility from 11/26/2021 through 12/15/2021 for seizures and brain cancer.

A review of the medical record revealed Patient #4 received Tylenol 650 mg tablet orally on 12/11/2021 at 4:45 AM for pain. There was no pain reassessment documented within 120 minutes following the administration of the medication per facility policy.

Patient #6's medical record was reviewed on 04/07/2022 at 11:10 AM with Quality Coordinators I and J who confirmed the following per interview:

Patient #6 was admitted to the facility from 03/02/2022 through 03/07/2022 for altered mental status.

A review of the medical revealed Patient #6 received Morphine 4 mg IV on 03/02/2022 at 1:01 PM for pain. There was no pain reassessment documented within 30 minutes following the administration of the medication per facility policy.

Patient #6 received Hydrocodone (a narcotic pain medication) 5-325 mg tablet orally for pain on 03/03/2022 at 12:53 PM and 03/04/2022 at 2:33 PM. There were no pain reassessments documented within 120 minutes following the administrations of the oral medications per facility policy.

On 03/05/2022 at 11:40 AM and 10:57 PM, Patient #6 received Fioricet (a pain medication) tablet orally for headache. There were no pain reassessments documented within 120 minutes following the administrations of the oral medications per facility policy.

Patient #7's medical record was reviewed on 04/07/2022 at 11:30 AM with Quality Coordinators I and J who confirmed the following per interview:

Patient #7 was admitted to the facility from 02/26/2022 through 03/13/2022 for severe back pain.

A review of the medical record revealed Patient #7 received Dilaudid 0.5 mg IV on 03/04/2022 at 10:33 AM for pain. There was no pain reassessment documented within 30 minutes following the administration of the medication per facility policy.

Patient #7 received Oxycodone (a narcotic pain medication) 10 mg tablet orally for pain on 03/04/2022 at 5:23 PM; on 03/06/2022 at 4:57 PM; on 03/08/2022 at 9:59 PM; on 03/12/2022 at 5:35 PM; and on 03/13/2022 at 4:13 AM, 8:33 AM, and 2:10 PM. There were no pain reassessments documented within 120 minutes following the administrations of the oral medications per facility policy.

Patient #8's medical record was reviewed on 04/07/2022 at 12:01 PM with Quality Coordinators I and J who confirmed the following per interview:

Patient #8 was admitted to the facility from 03/25/2022 through 04/04/2022 for an infection of the right foot.

A review of the medical record revealed Patient #8 received Oxycodone 5 mg tablet orally for pain on 03/26/2022 at 11:30 AM and 3:57 PM; on 03/27/2022 at 12:28 AM, 7:22 AM, 1:48 PM, and 9:27 PM; and on 03/28/2022 at 6:53 AM. There were no pain reassessments documented within 120 minutes following the administrations of the oral medications per facility policy.

Patient #8 received Tramadol 50 mg tablet orally for pain on 03/29/2022 at 10:12 PM and on 03/30/2022 at 6:07 PM. There were no pain reassessments documented within 120 minutes following the administrations of the oral medications per facility policy.

Patient #9's medical record was reviewed on 04/07/2022 at 12:06 PM with Quality Coordinators I and J who confirmed the following per interview:

Patient #9 was admitted to the facility on 03/24/2022 for back pain, flank pain, and blood in the urine. Patient #9 was currently still hospitalized at the time of the survey.

A review of the medical record revealed Patient #9 received Fentanyl (a narcotic pain medication) 25 mcg (micrograms) IV on 04/01/2022 at 8:40 PM for pain. There was no pain reassessment documented within 30 minutes following the administration of the medication per facility policy.

On 04/02/2022 at 9:47 PM, Patient #9 received Toradol (a non-steroidal pain medication) 30 mg IV for pain. There was no pain reassessment documented within 30 minutes following the administration of the medication per facility policy.

On 04/03/2022 at 10:51 PM, Patient #9 received Tramadol 50 mg tablet orally for pain. There was no pain reassessment documented within 120 minutes following the administration of the oral medication per facility policy.

Patient #9 received Tylenol 650 mg tablet orally for pain on 04/01/2022 at 4:55 PM; on 04/03/2022 at 10:01 AM and 6:36 PM; on 04/04/2022 at 10:36 PM; on 04/05/2022 at 8:31 AM and 9:26 PM; and on 04/06/2022 at 5:38 AM and 9:05 PM. There were no pain reassessments documented within 120 minutes following the administrations of the oral medications per facility policy.

Patient #10's medical record was reviewed on 04/07/2022 at 12:14 PM with Quality Coordinators I and J who confirmed the following per interview:

Patient #10 was admitted to the facility from 01/09/2022 through 01/14/2022 for seizures and recurrent pancreatitis (infection of the pancreas).

A review of the medical record revealed Patient #10 received Tylenol 650 mg tablet orally for pain on 01/11/2022 at 11:01 PM and on 01/12/2022 at 4:38 AM and 9:27 PM. There were no pain reassessments documented within 120 minutes following the administrations of the oral medications per facility policy.

During an interview on 04/07/2022 at 12:13 PM, Quality Coordinator I stated, "I'm not seeing pain reassessments documented after interventions per policy."

During an interview on 04/07/2022 at 1:15 PM, the medical record review findings were shared with Executive Director of Nursing P. Director P stated, "I know they [nursing staff] were doing their best with keeping up with documentation [during the COVID-19 surge of patients]."