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Based on medical record review, staff interview and policy review it was determined the agency failed to document the process of receiving, investigating and resolving all grievances and/or patient concerns according to policy and procedure. The active census was 12.


Findings include:


Review of Complaint and Grievance Process Number C06-A (revised 10/01/17) states the hospital has established a mechanism for receiving, acting upon, and responding to patient and his or her representative, expressing concern for the patient's treatment and all areas of the quality of care. It is the policy of the hospital to respond to such complaints promptly.


The Patient and the patient's representative may inform the hospital of a complaint or grievance verbally or in writing.
The Hospital staff member receiving the complaint or grievance will initiate the complaint/grievance form and 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.


If the issue is resolved timely and no further action is needed, the issue will be considered a complaint. The hospital staff member will complete the complaint/ grievance form through Section C, sign and date the form and forward it to the Director of Quality Management (DQM).


The investigative procedure should be completed, corrective action taken and a written response sent within 7 days of the complaint. The DQM along with the CEO, will prepare a written response to the patient's or patient representative's grievance. The written response is required whether or not a meeting was held to discuss the investigation with the patient or the patient's representative.


On 10/16/17 a written complaint was filed with corporate office of the overall cleanliness of the facility, hygiene provided to the patient, and various other medical concerns. The administrative staff spoke with the patient on multiple occasions, who was alert and oriented, whom did not want to file a complaint/grievance regarding the cleanliness of the facility and/or the care being provided.

Staff G stated in an interview on 12/14/17 at 5:00 PM the incident was resolved and considered a complaint and not a grievance. Upon request Staff G was unable to provide the required form that is to be completed when a complaint is received and/or a formal written resolution.

Based on medical record review, staff interview, and review of policy and procedure it was determined the registered nurse failed to document wound care as per policy. This affected one (Patient #1) of ten medical records reviewed. The active census was 12.


Findings include:

Review of the Policy and Procedure for Wound Documentation Number WC III-27 (revised 01/01/17) states that Staff Nurses (RN, LPN) Respiratory Therapists, Wound Nurse, Clinical Staff Providing Wound Care will document either on paper or the electronic health record as part of the wound treatment program. The policy provides guidelines for documentation of wound care. Number 3. (b) states dressing changes and wound site care are documented either on paper (SM-NU-745-2) or in the electronic medical record.

Review of the medical record for Patient #1 revealed the patient was admitted on 10/03/17 with wounds to the left medial foot, right lateral calf, perineal area, and to the gluteal area. Further review revealed wound care orders on 10/04/17 to provide wound care to the left medial foot and the right lateral calf three times weekly.

Review of the nursing documentation lacked evidence wound care was being provided and/or the characteristics of the wounds on 10/20/17 and 10/27/17.

The facility was on paper charting and either lacked evidence of nursing documentation and/or to include the characteristics of the wound(s) such assessment of the wound bed, drainage, and odor as per policy.

This finding was confirmed with Staff G on 12/14/17 at 5:15 PM.