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Based on policy and procedures, chart reviews and interviews the facility failed to address and resolve a grievance in 1(#1) out of 10 (#1-10) charts reviewed.

Review of the Multi-Disciplinary Note dated 9/19/2014 at 3:40 PM stated, "Worker met with patient #1's daughter regarding pt progress. She was upset that pt was not alert and had an upper respiratory infection. Worker advised that charge nurse came and spoke to them about patient progress. She stated she didn't know what was going on. "I don't know where to go pick him up. Will they call and let me know?" Worker advised nursing staff will contact if status change. She stated, "They said the doctor was making rounds, but I didn't get to see him." Worker advised that the nurse can review labs and meets with medical team twice weekly to give you an update. She acknowledged understanding, but was still unsatisfied and left a note to request call from the doctor. Gave note to charge nurse and DON to contact the physician."

Review of the facility's policy and procedure "Complaint and Grievance Process" stated, "Definition of a Complaint: An expression of dissatisfaction however made, about the standard of service, actions or lack of action by staff or regarding the facility and is resolved by staff at the time the complaint is made requiring no further resolution.

Definition of a Grievance: An allegation, however made, of a violation of a patient's rights, quality of care, premature discharge, and/or a complaint that is not resolved at the time the complaint is made and requires further action for resolution.

Employees are expected to resolve the concern within their ability at the time the concern is reported. Depending on the nature and severity of the Grievance and/or inability of the therapist/RN to resolve the issue, will forward to Clinical Director/DON as soon as feasible.

The employee receiving the grievance will discuss verbally or in writing the formal grievance with Administration and the appropriate Department Director within 24 hours of the grievances."

Review of the complaint and grievance log revealed there were no entries of a complaint or grievance for patient #1.

An interview was conducted on 11/7/2014 with staff #4. Staff #4 was asked to explain the statement patient #1's daughter made, "I don't know where to go pick him up. Will they call and let me know?"

Staff #4 stated, "She was upset about her father's health and was asking where would she pick him up when he died? Staff #4 reported she did not write a complaint or grievance on this occasion. Staff #4 reported she let the director of nurses and the charge nurse know about the complaint so they could discuss the medical issues with her." Staff #4 stated, "Looking back at this now I should have filed a complaint. I felt she had calmed down before she left and would receive a call from the physician."

An interview was conducted on 11/7/2014 with staff #2 confirmed she did not call the daughter, physician, or write a grievance.

Based on chart reviews, policy and procedures, and interviews the facility failed to follow its own policy and procedures. The facility failed to inform the patient of their patient rights in a timely manner in 3(#1-3) out of 5 (#1-5) charts reviewed.

Review of patient #2's chart revealed patient #2's signature on the "Request for Voluntary Admission" form on 9/12/2014. The following admission forms were not signed by the patient and in the patient signature line "Pt refused to sign" was found on the following forms;
1. Consent for Treatment
2. Consent for Telemedicine Treatment
3. Authorization and Informed Consent Form
4. Community Agreement
5. Advanced Directive Acknowledgement
6. Financial Responsibility
7. An Important Message From Medicare About Your Rights
8. Acknowledgement of Receipt of HIPPA Notice of Privacy Practices.
9. Pneumonia and Influenza Vaccine Protocol/Screening."

Review of the policy and procedure "Rights and Responsibilities" stated, "Every client shall receive a written copy of the patient Bill of Rights. The patient will sign the "Acknowledgement of Rights" form stating they reviewed and understand their rights. For voluntary patients this will be done prior to admission to the unit. For involuntary patients, this will be done within 24 hours of admission to the facility."

Review of Patient #1's chart revealed no documentation found of an attempt to explain to the patient the above forms, patient rights, or treatment of care.

An interview with staff #2 confirmed the findings and stated, "I just went over this again with the staff and I do not know why this is not done."

Review of patient #3's chart revealed the patient was admitted to the facility on 10/25/2014 at 11:00 AM. The physician orders read admission legal status "EDW" (Emergency Detention warrant) which is in-voluntary. Patient #3 had a Emergency Detention Warrant on the chart.

A "Request for Voluntary Admission" form was found on 10/29/2014 with the patients signature. This form changes the patients status from in-voluntary status to a voluntary status. There was no physician order found to change the status of the patient.

Review of patient #3's nurses notes on 10/25/2014 stated, "Patient arrived to facility at this time via GSMC security transport. Alert oriented to self only disheveled appearance. patient irritable yelling at nurse "leave me alone get away from me." when asked to sign admit paperwork."

Review of Patient #3's chart revealed no admissions forms with patient refusal for admission date of 10/25/2014.

The following admission forms were found with a unknown signature (not patient #3's name) on the legal representative designee line dated 10/29/2014. There was no documentation found of a legal representative. There was no documentation found in the chart of an explanation of rights to patient #3.

1. Consent for Treatment
2. Consent for Telemedicine Treatment
3. Authorization and Informed Consent Form
4. Community Agreement
5. Advanced Directive Acknowledgement
6. Consent for Donation of Anatomical Gifts
7. Acknowledgement of Receipt of HIPPA Notice of Privacy Practices.
8. Notice of Physician Availability.

Review of patient #1's chart revealed she was admitted to the facility on 8/6/2014. The physician orders read legal status was a Order of Protective Custody (OPC). Review of the admission paperwork revealed the following pages were blank in the chart with no dates, times, or signatures;

1. Consent for Treatment
2. Consent for Telemedicine Treatment
3. Authorization and Informed Consent
4. Acknowledgement of Receipt of HIPPA Notice of Privacy Practices
5. Community Agreement
6. Advanced Directive Acknowledgment
7. Notice of Physician Availability
8. Consent for Donation of Anatomical Gifts
9. Pneumonia and Influenza Vaccine Protocol/Screening."

An interview with staff #10 on 11/6/2014 revealed she was the admissions coordinator and was told to change the patient status to voluntary as soon as possible. Staff #10 reported she was unaware that a physicians order was required to change a patients admission status. Staff #10 reported if a patient was admitted under a court order the facility was not required to have the patient sign admission paperwork that includes patient rights.

An interview with staff #1 and #2 revealed they were unaware patient rights needed to be signed if the patient was under a court commitment.

Based on chart reviews and interviews nursing failed to ensure patient safety by performing complete physical assessments, monitoring infections, and assessment of antibiotic use in 1(#2) of 10 (1-10) charts reviewed.

Review of patient #2's chart revealed a physician order written by the nurse practitioner on 9/18/2014 at 4:30 PM. The order was for Clindamycin (Antibiotic) 300 mg by mouth every six hours for 10 days for Cellulitis (a bacterial infection involving the skin). No documentation found of where the Cellulitis was located.

Review of the Daily nurses notes revealed the following comments on skin integrity;

9/18/2014 at 8:30 AM "Skin: No new issues." No documentation found of Cellulitis or assessment of antibiotic.

9/19/2014 at 7:30 PM "Skin: No new issues." No documentation found of Cellulitis or assessment of antibiotic.

9/19/2014 at 8:30 AM "Skin: no issues." No documentation found of Cellulitis or assessment of antibiotic.

9/20/2014 at 8:30 AM " Skin: check boxes checked on Tear and Integumentary Asses.

Review of a Skin and Braden Reassessment Documentation form dated 9/20/2014 at
11:00 AM revealed a series of questions with a score of 13. The form revealed if a score of less than 18 equals at risk for skin breakdown. Under skin assessment the nurse documents a skin tear to the top of the left and right hands. There was no documentation found of size, color, when the tears occur, treatment, or physician notification. There was no documentation found of cellulitis.

9/20/2014 at 7:30 PM "Skin: no new problems." No documentation found of Cellulitis or assessment of antibiotic.

Patient #2 was discharged to the hospital on 9/21/2014.

An interview with staff #2 confirmed the above findings and reported the nursing staff has a communication book to read when there are issues and new information to get out. Staff #2 reported she has been working on nursing documentation and will continue to follow it closely.