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Based on record review and interview, the hospital failed to ensure responsibility for the effective operation of the grievance process to review and resolve grievances, in that,

employees (nurses, supervisors, nurse manager, follow-up call staff) failed to enter and resolve the quality-of-care complaints throughout the Patient #1's admission.

Findings

Patient #1's record included a 1/05/2024 Nurse Note that reflected...notified...that the patient's daughter was upset and demanding to speak with someone...Daughter stated she wanted her mother discharged from our facility immediately...Daughter said she wants her mother transported immediately out of the facility and back home because we are not treating the patient properly...her mother needs to be in a real hospital that can do a CT (cat scan) of her chest. She knows her mother has pneumonia, and we can't find it because it can only be found on CT...

During an interview on 1/17/2024 ending at 11:51 AM, Personnel #3 was asked why the daughter was upset. Personnel #3 stated she said she was upset multiple times from the beginning. That day she was upset with there being no sheet on the bed. We were not taking care of her. We did not put clothes on her. Personnel #3 was asked if these were true. Personnel #3 stated there was not supposed to be a sheet on that kind of bed. We were caring for her and she did have clothes on.

During a telephone interview and record review on 1/18/2024 ending at 12:08 PM, Personnel #1 was asked to clarify items. Personnel #1 was asked for the policy for grievance/complaint. Quality of Care complaints were known by nurses, supervisors, nurse manager, then 2 follow up calls. These were not entered. Personnel #1 was asked that employees and management are required to enter complaint/grievance for the quality-of-care complaints since admission and did not. Personnel #1 stated yes, ma'am. There should have been earlier entries.

The 11/16/2023 last reviewed Patient Rights and Responsibilities policy required, "Administrative Leaders and Medical Staff shall be responsible for ensuring that patient rights and responsibilities are observed and practiced throughout the hospital..."

Based on record review and interview, the hospital failed to ensure nursing supervised and evaluated the nursing care for each patient, in that,

A) 1 of 6 patient's (Patient #1's) COVID test was not completed as ordered, AND

B) 3 of 6 wound patients (Patient #1, #2, and #3) did not receive their 1/01/2024 wound care/dressing change.

Findings

A) COVID Test

Patient #1's record did not document a result for the 1/03/2024 ordered COVID test.

During a telephone interview and record review on 1/18/2024 ending at 12:08 PM, Personnel #1 was asked for the result of the COVID test. Personnel #1 stated I don't see the result.

During an email on 1/18/2024 at 6:16 PM, Personnel #1 stated the COVID test wasn't done.

B) Wound Care

Patient #1, #2, and #3 has dressing changes ordered for their wounds on Monday, Wednesday, and Friday weekly.

Patient #1 did not receive their ordered dressing change on Monday 1/01/2024.

Patient #2 did not receive their ordered dressing change on Monday 1/01/2024.

Patient #3 did not receive their ordered dressing change on Monday 1/01/2024.

During an interview and record review on 1/17/2024 at 1:25 PM, Personnel #1 was asked to review the completion of 1/01/2024 wound care. Personnel #1 navigated the records and confirmed Patient #1, #2, and #3 did not have their wound care completed as ordered.

The 8/18/2023 last reviewed "Wound Assessment and Documentation" policy required, "Nursing and therapy staff provide wound care as ordered via protocol or physician order..."