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Based on interview, record review, and a review of facility policy, it was determined the facility failed to have an effective process for prompt resolution of patient grievances. A verbal complaint was made to facility staff regarding the lack of incontinence care provided to Patient #2 on 10/15/11. There was no evidence the facility followed established policies to investigate and resolve the grievance.

The findings include:

A review of the facility's Patient Grievance Policy (dated 01/30/09) revealed a verbal complaint received from a patient's representative that could not be resolved promptly at the time received (on the spot) by staff would be considered a grievance. Additional review of the policy revealed the grievance would be entered into the facility event reporting system and a timeframe of seven days to issue a response to the patient for a grievance that would require investigation.

A review of the medical record for Patient #2 revealed the facility admitted the patient on 10/13/11, with diagnoses including Alzheimer's Disease, Dementia, Bed Confinement, Late Effect Injury, and Joint Contractures. Additional review of the medical record revealed the patient was incontinent of bowel and bladder.

An interview conducted with Registered Nurse (RN) #1 on 12/29/11, at 3:20 PM, revealed Patient #2's spouse had complained to RN #1 that facility staff had not assessed Patient #2 for a long period of time and, as a result, the patient had dried stool on the skin. Additional interview with RN #1 revealed staff was asked to assess the patient, however, the patient's family member had reportedly cleansed and changed the patient, and there were no concerns identified. According to RN #1, the concerns voiced by the spouse of Patient #2 were reported to the Unit Manager. RN #1 stated she became busy after she reported the concern to the Unit Manager, and did not enter the complaint into the facility's computerized grievance system.

An interview with the Unit Manager on 12/29/11, at 3:40 PM, confirmed RN #1 had made the Unit Manager aware of the complaint reported by the spouse of Patient #2. Further interview with the Unit Manager revealed the spouse had also voiced concerns related to turning, repositioning, checking, and changing the patient with the Unit Manager. According to the Unit Manager, the complaint was discussed with facility staff the day it was received to ensure patient care was provided. The Unit Manager stated she was not aware the complaint had not been entered into the facility's computerized grievance system.

A review of the facility's computerized grievance log revealed no evidence the complaint made by Patient #2's spouse had been documented or investigated, or that the facility had informed Patient #2's spouse of the results of the complaint.

An interview conducted with the facility's Community Chief Regulatory Affairs Officer (CCRAO) revealed the CCRAO was not aware of any complaints voiced by Patient #2 and/or the patient's family member. Further interview revealed the complaint would have been considered a grievance and should have been entered into the facility's computerized grievance system to allow for investigation, tracking, and to provide required response to the patient's family regarding the grievance.

Based on interview, record review, and review of facility policies it was determined the facility failed to ensure a patient's representative (legal guardian) had the right to make informed decisions related to the care of one of ten patients (Patient #1). The facility failed to obtain consent for treatment from Patient #1's legal guardian.

The findings include:

Review of the facility's policy entitled "Informed Consent" (dated 05/05) revealed the purpose of the policy was to safeguard the patient's rights. The policy indicated patient rights were to be clearly defined and the definition would be clearly defined in a written agreement. Continued review of the policy revealed the agreement would be signed by the patient and/or the patient's representative. According to the policy, if a signature was other than the patient's, staff was to place a note below the signature and define the relationship to patient.

Review of Patient #1's record on 12/29/11, at 12:30 PM, revealed the facility admitted Patient #1 to the Emergency Department (ED) on 09/02/11, with diagnoses of a possible seizure. A "Conditions of Treatment and Responsibility of Payment" document found in the record was signed by someone other than the patient or patient's legal guardian, with no note written to define the relationship of this person to the patient. The record further revealed the facility performed a physical exam, a chest x-ray, laboratory tests, and a Computerized Tomography (CT) scan on Patient #1 and discharged Patient #1 home from the Emergency Department. Continued review of Patient #1's record revealed "Aftercare Instructions" that had been signed by the patient and a "Face Sheet" which identified Patient #1 had a legal guardian. The record review revealed no documentation the facility staff asked if the patient had a guardian or, if so, who the guardian of the patient was prior to treatment of Patient #1.

Interview with Patient #1's guardian on 12/29/11, at 2:50 PM, confirmed the facility had not contacted the guardian to obtain consent for treatment of the patient on 09/02/11. The guardian stated he/she was not aware the patient had been to the ED until the patient's case manager from another facility had contacted the guardian on 09/02/11, by telephone to inform the guardian that Patient #1 had been discharged from the facility's ED.

Interview with the facility's Physician Assistant on 12/29/11, at 1:45 PM, revealed that Patient #1 was brought into the facility by an emergency medical service (EMS) on 09/02/11, for possible seizure. The interview further revealed Patient #1 was accompanied by another adult and information such as a list of the patient's medications was obtained. The interview further revealed the Physician Assistant provided treatment to Patient #1 during the patient's admission to the ED of the facility. The Physician Assistant further revealed that her role was not to question a patient regarding guardianship and stated that the triage nurse obtained that information.

Interview with the triage nurse, Registered Nurse (RN) #1, on 12/29/11, at 4:15 PM, revealed when a patient presented to the Emergency Room and requested treatment, the triage nurse obtained a signature on a consent form for treatment. At that time, according to RN #1, the triage nurse would question the patient about the patient's guardianship status. The interview further revealed because Patient #1 was accompanied by another adult who stated she was Patient #1's case manager, no further investigation was conducted regarding the patient's guardianship.