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Based on document review and interview, the facility failed to provide patient written notification of a grievance outcome and the date of completion in 1 of 10 medical records reviewed (patient 9).

Findings Include:

1. Facility policy, Network Patient Feedback Management (Complaints & Grievances), PolicyStat ID 11749428, last revised 05/2022: indicated under Policy Statements H: Upon resolution of a grievance for a facility on a hospital license, a final written or electronic (email) communication will be sent to the patient (or when applicable the complaintant); under General Information: D. Grievances require written resolution to the patient, patient representative, or complainant and must contain the following: 1. the name of the contact person 2. the steps taken on behalf of the patient to investigate the grievance 3. the results of the grievance process 4. the date of completion.

2. The Incident/Grievance Log lacked documentation of written notification to P9, per policy, that the investigation of the Incident/Grievance reported was completed and of its outcome.

3. In interview on 11/14/24 at approximately 4:53 pm, A1 (Registered Nurse, Quality Director) and A2 (Registered Nurse, Director Acute Care) confirmed no written notification to P9 regarding the Complaint/Grievance investigation outcome was indicated in administrative documents, per policy.

Based on document review and interview nursing staff failed to document patient report of inappropriate touching by staff in patient's electronic medical record in 1 of 10 medical records reviewed (patient 9).

1. Facility policy, Management of an Inpatient Report of Sexual Assault, Rape, or Other Sexual Nature Occurring on Community Health Network Property, PolicyStat ID 15186285, last revised 04/2024: indicated under Policy Statements: C. Caregiver is to document the facts of the event in the patients electronic medical record.

2. Review of P9's MR lacked documentation of patient's complaint of inappropriately touched by staff reported on 4/07/24.

3. In a telephone interview on 11/16/24 at approximately 6:41 am to 6:57 am, N7 (RN) confirmed worked dayshift (7 am - 7 pm) on 4/7/24 and indicated saw P9 that morning. N7 indicated P9 reported 2 staff made the patient feel uncomfortable when staff entered patient's room to change a wet gown after patient spilled some juice in bed. N7 indicated he/she reported P9's complaint in person to N10 (RN) and sent a message to A5 (Administrative Manager) regarding patients' statement.