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Based on record review and interviews, the facility failed to provide Patient #1 with a resolution to her grievance. This had the potential to affect any patient who files a grievance.

Findings included:

Record review on 07/18/14 of written patient grievance completed by patient #1 on 02/14/14 revealed but was not limited to the following: " I was to be given Xyrem two times at night but had only been given one per night so I explained I could have a cataplexy attack. On Friday February 14 during group, I went head down and my legs and arms went numb. I am in a lot of pain today and in a wheelchair in case I have another attack."

The Patient Advocate documented under investigation on 02/14/14 time not given the following: " I informed (Registered Nurse RN #1) of the situation and it seems according to the chart the correct meds were given." Under " This grievance was resolved date and time", nothing was documented.

Record review on 07\18\14 of facility policy and procedure entitled Patient Advocacy\Conflict & Grievance Resolution, last reviewed January 2012, revealed but was not limited to the following: "The Office of the Patient Advocate shall be available to assist individuals in resolving dilemmas about care decisions, addressing complaints and grievances or recommending changes in policies and services offered. All reports in which the patient or family requests a written report from the facility shall be considered a grievance. A written response shall be provided to the individual within seven days informing them of resolution of grievance or status of the investigation.

Interview with Patient #1 on 07/18/14 at 10:00 AM revealed she filed a written grievance regarding the her belief the facility was not giving her medication as ordered. She stated she was to receive one dose of Xyrem at bedtime and then a second dose two and one-half to four hours after bedtime. She stated she was to be woken up to take the second dose. She indicated she had always taken the medication this way in order to prevent the cataplexy attacks which left her numb. She stated she believed she fell out of her chair on 02/14/14 because she had not been given her medication the way she was supposed to be given her medication. She stated that no one had resolved her written grievance.

Interview on 07/18/14 at 12:40 PM with the facility Patient Advocate revealed she did not get back with Patient #1 regarding the results of the grievance because she had spoken with RN #1 who told her the medications were given as ordered.

Interview on 07/18/14 at 1:10 PM with RN #1 revealed that she reviewed the medication administration record for Patient #1 and found that her medications were given as ordered by the physician. She confirmed that she did not discuss patient #1's grievance with her.