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Based on record reviews and interviews, the hospital failed to ensure there was a clearly explained procedure for the submission of a verbal grievance reported by a patient's representative (a family member) to the hospital's staff as evidenced by failing to initiate the grievance process when the family member verbally:
a) requested for a second time to ambulate the patient to the bathroom on 11/18/09 to S3, ADON for 1 of 1 focused records reviewed for the grievance process out of a total of 5 sampled patients, (#4);
b) requested to know why the patient had a foley catheter inserted on 11/20/09 to S4, LPN for 1 of 1 focused records reviewed on the grievance process out of a total of 5 sampled patients, (#4); and
c) requested why the patient's IV (intravenous) site was left in his hand on discharge to the ADON, (S3) on 12/5/09 for 1 of 1 focused records reviewed on the grievance process out of a total of 5 sampled patients, (#4). Findings:

There was no complaint/grievance log for 2009 presented during the survey conducted from 12/21/09 through 1/4/10.

S1, Administrator, Grievance Coordinator was interviewed on 1/4/10 at 4:45 pm. He confirmed the hospital did not have a grievance log for 2009. He indicated there was no complaints/grievances filed in 2009. He denied knowledge that patient #4's family had re-requested a second time to ambulate the patient (#4) to the bathroom on 11/18/09 to S3, ADON. He further indicated the second request from the patient's family member to ambulate the patient to the bathroom was a grievance. He reported that the grievance process was not followed to notify the Grievance Coordinator, S1. He confirmed that the patient's (#4's) family had requested to know why the patient had a foley catheter inserted on 11/20/09. He indicated the patient's family request to know why the pateint had a foley catheter inserted was a grievance. He reported that he was not contacted about the patient's family not being notified as to why the pateint had a foley catheter inserted on 11/20/09 as the Grievance Coordinator, S1. He indicated that the grievance process was not followed nor was the Grievance Coordinator, S1 notified. He denied notification that the patient (#4) was discharged to home with the IV left in his left hand on 12/4/09. He indicated the IV left in the patient's left hand was a grievance. He further indicated that the Grievance Process was not implemented by notifying the Grievance Coordinator, S1. He reported that the patient's family member should had been notified by letter with all of the components required to be included in the report within 7 days, not 30 days later 1/4/10. He stated that the patient's family member will receive a letter with the required components of the hospital's internal investigation results, today.

Review of the Case Manager's Notes written on 11/16/09 by S5, RN, CM with no documented time read, "...Spoke /c (with) pt's (patient's family member identified and named) -...wished (relationship to patient named) to amb. (ambulate) more ... met with ADON, (S3), OT (S6) and myself (S5) ... (family member) is agreeable and approves of plan. (family member) will check back in couple of days ...".

An interview was conducted with S5, RN, CM on 1/4/10 from 11:00 am to 11:05 am. She confirmed that the Case Manager Notes written on 11/16/09 were documented that the patient's (#4) family had concerns about the patient's plan of care. She indicated she did not follow up with the family member after the meeting on 11/16/09. She reported that she did not initiate the grievance process by notifying the grievance coordinator, S1. Another interview was held with S5, RN CM on the same day from 11:35 am to 11:50 am. She recalled from memory that the one of the family member ' s plan of care issues was that the family wanted the patient to ambulate to the bathroom. She reported that S3, ADON agreed to ensure that the patient ' s staff members, who were tending to him was aware of the family ' s request. She indicated that she did not follow up with the family member in 2 days and she should have.

S3, ADON was interviewed on 1/4/10 from 12:50 pm to 1:30 pm. He confirmed that the patient's (#4's) family member had requested to ambulate the patient to the bathroom during the meeting held with staff and the family member on 11/16/09. He indicated that he had spoke with all of the staff that had provided nursing care to the patient that same day, 11/16/09 and ensured that they were aware of the family member's request to ambulate the patient to the bathroom. He reported that he had followed up with the ambulation of the patient to the bathroom through direct observations, record reviews and interviews from 11/16/09 through 12/4/09. He indicated he had no documented evidence of his follow up observations, record reviews and/or interviews that the patient was ambulated to the bathroom from 11/16/09 through 12/4/09. He verified there was no documented evidence in the patient's medical record from 11/16/09 through 12/4/09 that the patient was ambulated to the restroom by staff. He indicated that the family member had made a request to ambulate the patient to the bathroom and is not a complaint/grievance. He reported he did not follow up with the family member in regards to her request to ambulate the patient to the bathroom on 11/16/09. He stated that the family member presented on 11/18/09 and rerequested that the patient be ambulated to the bathroom. He recalled instructing the family member that he was following up with the patient's ambulation to the bathroom from staff during all shifts. He indicated that the family member was satisfied with him following up with the patient with all staff members. He indicated the second request to ambulate the patient to the bathroom was a request from the family member and this was not a complaint/grievance. He further indicated that the family member was satisfied that he was following up with the patient's staff members to ensure that the patient was being ambulated to the bathroom. He reported that he did not notify the DON (S2) and/or Grievance Coordinator, S1 on 11/16/09 or 11/18/09 of the family members request because she was satisfied that he was following up with the patient's staff members and ensured that the patient was being ambulated to the bathroom as requested 11/16/09 and 11/18/09. He denied that the family's second requeston 11/18/09 was a complaint/grievance in which the complaint/grievance process should had been implemented by notifying the Grievance Coordinator as per the Grievance Process.

Review of patient #4 ' s nurse narrative notes written on 11/20/09 at 1810 (6:10 pm) by S4, LPN read, "...Family present. Voiced concerns about Foley. Educated family on foley catheters, how they work, how inserted etc. (and so on)...". Further review of the nurse narrative notes revealed there was no documented evidence that the patient's family (representative) was notified why the patient had a foley catheter inserted on 11/20/09.

In an interview with S4, LPN on 12/30/09 from 8:30 am to 10:00 am, she confirmed the Narrative Notes written on 11/20/09 at 1810 (6:10 pm) were documented by her during her shift from 6:00 pm to 6:00 am. She indicated that the patient's (#4's) family member had questioned her about, "Why the patient had a foley catheter inserted that day." She had educated the family about the foley catheter procedure and purpose. She indicated that she did not instruct the family about why the patient had a foley catheter inserted because did not know. She reported that the reason that the foley catheter was inserted would require some investigation and she would have to contact S8, MD to find out why he had ordered the foley catheter insertion for the patient. She indicated that she had not reported the family's question of about why the foley was inserted to the physician, S8, charge nurse, S10, and/or nursing assistants (CNAs), DON, S2, and/or ADON, S3 during her shift that night, 11/20/09 from 6:00 pm through 6:00 am, nor did she report the question about the foley to the oncoming staff members, the charge nurse, LPN and/or CNA, who would be tending to the patient ' s care needs the next morning, 11/21/09. She could not give the surveyor the definition of a complaint and/or grievance. She did not recall what the hospital's, Grievance Process or Policy was to follow if a complaint and/or grievance was verbally reported to her by a patient, patient's representative and/or family member, so the Grievance Process policy was reviewed by S4, LPN during the interview. She guessed that she should have notified the person next in charge, the charge nurse, S10 that same night and the patient's physician, S8 could be notified the next morning because it was not an emergency situation and it could wait until the next morning. She indicated that she did not know who the hospital ' s Grievance Coordinator was. She reported that she did not follow the Grievance Process to notify the Grievance Coordinator, S1.

S3, ADON was inteviewed on 1/4/10 from 12:50 pm to 1:30 pm. He reviewed S4, LPN documentation on 11/20/09 at 1810. He verified the family member had concerns about with the patient's (#4's) foley catheter. He confirmed that he had no knowledge that the patient's family member wanted to know why the patient had the foley catheter inserted on 11/20/09. He indicated this was a grievance because the family member was not instructed as to why the patient had the foley catheter inserted on 11/20/09. He verified there was no documented evidence that the grievance process was implemented by S4, LPN, S10, RN CN, and/or S2, DON by notifying S1, Grievance Coordinator as indicated in the Grievance Process.

An interview was held with S2, DON on 1/4/10 from 3:50pm to 4:50 pm. He denied knowledge that the patient ' s (#4's) family member (representative) verbal request to ambulate the patient to the bathroom during the meeting that was held with staff and the family member on 11/16/09. He indicated that the ADON (Damian) had followed up with the ambulation of the patient to the bathroom through direct observations, record reviews and interviews from 11/16/09 through 12/4/09. He reported that the ADON had not documented his follow up observations, record reviews and/or interviews that the patient was ambulated to the bathrom from 11/16/09 through 12/4/09. He verified there was no documented evidence in the patient's medical record from 11/16/09 through 12/4/09 that the patient was ambulated to the restroom. He agreed that the family member had made a request to ambulate the patient to the bathroom and that was not a complaint/grievance. He indicated knowledge that the family member had presented on 11/18/09 and re requested that the patient be ambulated to the bathroom to the ADON (damian). He stated that the ADON (damian) had reported to him that the family member was satisfied with him following up on the patient with staff. He indicated this second request made by the family member to ambulate the patient to the bathroom was a request and not a complaint/grievance. He indicated that the family member was satisfied with the ADON (damian) following up with the patient's staff members to ensure that the patient was being ambulated to the bathroom. He reported that the Grievance Coordinator, S1 was not notified on 11/16/09 or 11/18/09 of the family members request because she was satisfied that the ADON was monitoring the patient's staff members and ensuring that the patient was being ambulated to the bathroom as per the request. He indicated that the second request from the family member on 11/18/09 was a complaint/grievance in which the complaint/grievance process should had been initiated and implemented by notifying the Grievance Coordinator, S1.

During the same interview with S2, DON on 1/4/10 from 3:50 pm to 4:50 pm, he reviewed S4, LPN documentation of patient #4 on 11/20/09 at 1810. He verified the family had concerns with the patient's foley catheter insertion. He confirmed that he had no knowledge that the patient's family member wanted to know why the patient had the foley catheter inserted 11/20/09. He indicated this was a grievance because the family member was not instructed as to why the patient had the foley catheter inserted on 11/20/09. He stated there was no documented evidence that the grievance process was initiated and/or implemented by S4, LPN, S10, RN, CN, S2, DON and/or S1, Grievance Coordinator.

In the same interview with S3, ADON on 1/4/10 from 12:50 pm to 1:30 pm, he recalled that the patient ' s (#4's) family had notified him the day after the patient was discharged from the hospital (12/5/09) and stated that the patient was discharged with the IV site in his left hand. He indicated that the family refused to bring the patient back to the hospital for staff, S7, Registered Nurse to remove the patient ' s IV, so the nurse (S7) instructed the family member over the telephone how to remove the IV. He recalled that the Registered Nurse, S7 had instructed the family member to bring the patient back to the hospital if the patient's left hand bled. He indicated that the family member was satisfied with removing the patient ' s IV site at home because the family member did not want to bring the patient back to the hospital in the rain, snow and icy roads. He denied notifying the family member of the hospital's internal investigation that were conducted, what the investigation results were, and/or what nursing interventions were implemented to ensure that patients are not discharged to home with an IV site. He indicated that he did not follow the Grievance Process to notify the Grievance Coordinator, S1 about the IV site left in the patient's left hand on discharge to home.

Review of the hospital's policy titled, " Grievance Process", with reference: JCAHO RI 1.3.4, page 1 of 3, effective: 6/28/00, revised: 03/20/03 presented as the hospital's current Grievance policy read, "... All grievances are to be submitted to the Grievance Coordinator... All grievances receive immediate priority and must be investigated with efforts made toward resolution within 24 hours... If a grievance cannot be resolved within 24 hours, the Quality Improvement Physician Advisor will be notified and requested to intervene ... The patient will be provided with written notice of the name of the Grievance Coordinator, the steps taken to investigate and resolve the grievance with the final result of the grievance and the date of the grievance completion...". Further review of the Grievance Policy revealed there was no documented evidence of the definitions of a complaint and/or grievance for the staff members to refer to, nor was there was no documented evidence of how a staff member is to handle a complaint/grievance from a patient or patient's representative.

Based on record reviews and interviews, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient as evidence by failing to:
ensure the physician(s) were notified of the patient's: 1) left flank bruise on 11/11/09 and left flank area swollen larger that the right flank on 11/20/09 (#5) for 2 of 2 focused records reviewed for nursing services out of a total of 5 sampled patients and 2) upper extremity edema for 2 of 2 focused records reviewed for nursing services out of a total of 5 sampled patients (#4). Findings:

Patient #5:

Review of the medical record for patient #5 revealed he was admitted on 11/10/09 at 2010 (10:10 pm) by S9, Nephrologist with the diagnosis of Pyelonephritis and Malnutrition .

Review of the Narrative Notes written by S13, RN on 11/11/09 at 0615 (6:15 am) read, "...large bruise to the (L) flank area...". There was no documented evidence in the patient's medical record that S13, RN evaluated and supervised the patient's left flank bruise during her shift on 11/11/09. Further review of the medical record revealed there was no documented evidence that the physician(s) S9, Nephrologist was notified of the patient's left flank bruise on 11/11/09 by S13, RN.

S2, DON was interviewed on 1/4/10 from 1:35 pm through 3:30 pm. He verified patient #5 had a large, left bruise noted to his left flank by S13, RN during her assessment of the patient on 11/11/09 at 6:15 am. He confirmed there was no documented evidence that S13, RN had supervised and reevaluated the patient's left flank bruise during her shift on 11/11/09. He indicated that there was no documented evidence that S13, RN had notified the physician, S9, Nephrologist of the patiant's left flank bruise noted during her observation of the patient at 6:15 am. He reported there was no documented evidence that S13, RN had given the oncoming nurse report of the patient's left flank bruise. He indicated that the patient's left flank bruise should had been reported to the physician, S9 immediately.

Review of the Narrative Notes written on 11/15/09 at 0715 (7:15 am) by S12, RN read, "...(L) flank area slightly larger (more swollen) than (R) flank...". Review of the patient's medical record revealed there was no documented evidence that the physician(s), S9, Nephrologist was notified of the patient's left flank area more swollen than the right flank on 11/15/09 by S12, RN. Further review of the medical record revealed there was no documented evidence that the RN, S12 supervised and reevaluated the patient's left flank swelling larger than the right flank during her shift from 6:00 pm through 6:00 am on 11/15/09.

An interview was held with S12, RN on 12/29/09 from 2:20 pm through 3:15 pm, she verified the patient had the left flank area more swollen than the right flank on 11/15/09 at 7:15 am during her observation of the patient. She confirmed there was no documented evidence in the patient's medical record that she supervised and reevaluated the patient's left flank swelling on 11/15/09. She verified there was no documented evidence in the medical record that she notified the physician(s), S9 of the patient's left flank swelling on 11/15/09. She indicated this was a change in the patient's condtion. She further indicated that she should had reported the patient's left flank swelling to the physician within one hour that the left flank swelling was noted during the patient's assessment.

Patient #4:
Review of the medical record for patient #4 revealed he was admitted on 11/10/09 at 5:00 pm by S9, Nephrologist with the diagnosis of mild malnutrition and ESRD (end stage renal disease.

Review of the Nurses Notes written by S4, LPN on 11/20/09 at 1810 (6:10 pm) read, "... upper extremity edema...". Review of patient #4's medical record revealed there was no documented evidence that the LPN (S4) had evaluated and reevaluted the patient's upper extremity edema. Further review of this medical record, revealed there was no documented evidence that S4, LPN had notified the physician(s), S9 or S8 of the patient's upper extremity edema on 11/20/09. There was no documented evidence in the medical record that S10, RN CN had supervised and reevaluated the patient;s upper extremity edema on 11/20/09.

An interview was conducted with S4, LPN on 12/30/09 from 8:30 am to 10:00 am. She verified that the patient had upper extremity edema on 11/20/09 at 1810. She reported there was no documented evidence in her narrative notes or in the patient's medical record that she had assessed, evaluated, and/or reevaluated the patient's upper extremity edema during her shift from 6:00 pm through 6:00 am. She indicated that there was no documented evidence in the patient's medical record as to which upper extremity was noted with edema, nor did she determine the degree of the upper extremity edema during her assessment of the patient. She reported there was no documented evidence in the medical record that she notified the charge nurse, S10, RN to come and evaluate the patient's upper extremity edema during her shift. She indicated there was no documented evidence in the patient's medical record that S10, RN CN had supervised and/or re-evaluated the patient's upper extremity edema on 11/20/09. She verified there was no documented evidence that she reported the pateint's upper extremeity edema to the oncoming nursing staff, S11, RN. She reported there was no documented evidence that she informed the physician(s) S9 and/or S8 of the patient's upper extremity edema during her shift. She indicated this was a change in the patient's condition that should had been reported to the pateint's physician(s), S9 and S8 within one hour of her observation.

An interview was held with S9, Nephrologist on 1/4/10 from 10:10 am through 11:00 am. He verified there was no documented evidence in patient #5's medical record that he was notified of the patient's left flank swelling larger than the right flank. He indicated he needs to be notified of any changes in the patient's condition, left flank swelling larger than the right immediately. During the same interview with S9, Nephrologist, he verified there was no documented evidence that staff (S4, LPN) had notifited him that patient #4 had upper extremity edema. He indicated that he needs to be notified immediately of any changes in the patient's condition, right upper extremity edema.

In an interview on 12/30/09 from 3:30 pm through 4:45 pm with S2, DON, he confirmed there was no notification to the physician(s), S9 or S8 of the changes in the patient's condition(s), patient #5's-left flank swelling larger than the right flank (11/15/09) nor patient #4's -right upper extremeity edema (11/20/09). He indicated that the physician(s), S9 and S8 should have been notified of the patient's left flank swelling was larger than the right flank (#5) and the patient's upper extremity edema (#4) within the hour that the nursing staff had made these observations of the patients.