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Based on the complaint investigation (PR00000459), the review of policies/procedures and facility compliant files with the patient satisfaction Director (employee #2), it was determined that the facility failed to perform a prompt resolution of patient grievances and be responsible for the effective operation of the grievance process.

Findings include:

1. On 2/3/12 at 10:00 am accompanied by the patient satisfaction director (employee #2), incidents, accidents and grievances filed were reviewed. During the review, 5 out of 10 cases with grievances filed in October 2011, 5 out of 8 cases with grievances filed in November 2011 and 6 out of 7 cases with grievances filed in December 2011, the facility proceeded to investigate the complaint, however no evidence was found of the investigation process performed by the facility and no evidence was provided related to the resolution and response to the patient related to the resolution of these cases.

2. On 2/3/12 at 10:00 am accompanied by the patient satisfaction director (employee #2), incidents, accidents and grievances filed were reviewed. During the review, a case was identified of a grievance filed by a patient's relative on 12/22/11 related with services rendered to the patient during her stay at the Medicine Ward. The facility proceeded to investigate the complaint and called the patient's representative two times (by cell phone) but the person did not answer, no evidence was found of the hour and date of the calls and no evidence was found of the resolution that the facility concluded of this investigation and did not contact the patient with a written letter to notify the facility's resolution.

Based on the complaint investigation (PR00000459), the review of Informative Guidelines and the Privacy Notification provided to each patient at admission with the patient's satisfaction Director (employee #2), it was determined that the facility failed to specify in the informative Guidelines the time frame that the facility has to review and investigate the grievance and to provide a response to the patient or their representative.

Finding include:

On 2/2/12 at 10:30 am the Informative Guidelines and the Privacy Notification provided to each patient at admission was reviewed with the patient satisfaction Director (employee #2), provided evidence that patients are oriented related to the Grievance contact telephone number from the facility, medicare and health department . No evidence was found that the patient was informed at a specific time frames that the facility investigated the complaint or provided a resolution to the patient.

Based on the complaint investigation (PR00000459), the review of policies and procedures and facility compliant files with the patient satisfaction Director (employee #2), it was determined that the facility failed to provide the patient with written notice of its decision the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

1. On 2/3/12 at 10:00 am accompanied by the patient satisfaction director (employee #2), incidents, accidents and grievances filed were reviewed. During the review, 5 out of 10 cases with identified grievances filed in October 2011, 5 out of 8 cases with identified grievances filed in November 2011 and 6 out of 7 cases with identified grievances filed in December 2011, the facility proceeded to investigate the complaints, however no evidence was found related to a written notice of its decision the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

2. On 2/3/12 at 10:00 am accompanied by the patient satisfaction director (employee #2), incidents, accidents and grievances filed were reviewed. During the review, a case was identified of a grievance filed by a patient's relative on 12/22/11 related with services rendered to the patient during her stay at the Medicine Ward. The facility proceeded to investigate the complaint and called the patient's representative 2 times (by cell phone) but the person did not answer and no evidence was provide of the hour and date of the calls and no evidence was found of the resolution that the facility concluded of this investigation and no evidence was found related to a written notice of its decision of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Based on the complaint investigation (PR00000459), the reviewed of policies and procedures with the Director of Nursing (DON) (employee #1) and ten records reviewed, it was determined that the facility failed to promote the patient's right to have nursing staff and practitioners that provide care in the hospital comply with advance directives related to the lack of a complete policy that addresses the procedure of "Do Not Resuscitated" (DNR) and failed to ensure that patients or their representatives formulate advance directives and comply with these directives related to written DNR or "Do Not Intubate" (DNI) orders in accordance with the patient's signed consent for DNR or DNI for three out of ten records reviewed (R.R #3, #7 and #8).

Findings include:

1. During the review of policies and procedures related to Do Not Resuscitated (DNR) on 2/2/12 at 1100 am with the DON (employee #1), it was found that the facility provided evidence of a policy that contains the policy and the purpose of the policy. However, no evidence was found related to the procedure to follow when a DNR order is placed.

2. The facility failed to inform patients or their representatives that they have the right to formulate advance directives and comply with these directives related to DNR and DNI order requests as reviewed on 2/2/12 from 10:45 am till 4:00 pm:
a. R.R #3 is a 50 years old male who was admitted on 12/22/11 with a diagnosis of Hepatic Failure. The record review was performed on 2/2/12 at 2:00 pm with the patient satisfaction Director (employee #2) it was found that the patient's relative signed a consent for DNR and DNI on 1/30/12 however, no evidence was found of the hour that the patients' relative signed the consent. On 1/30/12 at 12:00 noon the physician ordered DNR and DNI. No evidence was found of the physician's justification and patient's relative orientation related to the DNI order in the physician's progress note.

b. R.R #7 is an 89 years old female who was admitted on 2/1/12 with a diagnosis of Acute Myocardial Infarct, Diabetes Mellitus Type II. The record review was performed on 2/2/12 at 11:55 am with the patient satisfaction Director (employee #2), it was found that the patient's relative signed a consent for DNR and DNI on 1/30/12 in the Emergency Room (ER) however, no evidence was found of the hour that the patients' relative signed the consent. No evidence was found related to the physician's order for DNR and DNI until 2/2/12 at 10:00 am. No evidence was found of the physician's justification and patient's relative orientation related to the DNI order in the physician's progress note. The registered nurse documents in the nurse's progress notes that the patient's relative signed the DNR and DNI consent however no evidence was found that the nurse assessed the DNR and DNI protocol. In the event that an emergency arises it is not clear what will happen with the patient since the patient or his relative signed the DNI consent, but there is no physician's order for the DNI. The facility's policies and procedures were reviewed on 2/2/12 at 2:30 pm and it states that "Do Not Resuscitate" orders will be valid during the stay of the patient and should be checked every 24 hours during the stay. However, no evidence was found in the physician's progress notes and in the physician's orders related to the DNR and DNI checked every 24 hours during the stay.

c. R.R #8 is an 87 years old female who was admitted on 1/20/12 with a diagnosis of Sepsis. The record review was performed on 2/2/12 at 1:35 pm with the patient satisfaction Director (employee #2) and it was found that the patient's relative signed a consent for DNR and DNI on 2/1/12 however, no evidence was found of the hour that patients' relative signed the consent. The physician ordered DNR and DNI on 2/1/12 at 8:30 pm. No evidence was found on the physician's progress notes that the patient's relative was oriented related to the DNR and DNI order. The registered nurse documented in the nurses progress notes performed on 2/1/12, DNR and DNI however no evidence was found if the patient's relative was oriented and understood the orientation related to the DNR and DNI protocols.

Based on the complaint investigation (PR00000459), observational tour of the Medicine/Surgery ward with the Director of Nursing (employee #1) and Nursing Supervisor (employee #3) and interview, it was determined that the facility failed to provide care in a safe setting related to appropriate surveillance related to unlocked maintenance carts, failed to ensure that drugs and biologicals are protected in a proper and secure manner in the medication cart and failed to ensure that all patients are given a comfortable environment related to the temperature of their rooms.

Findings include:

1. During the observational tour of the Medicine/Surgery ward with the Director of Nursing (employee #1) and Nursing Supervisor (employee #3) on 2/2/12 from 10:30 through 11:45 am and on 2/3/12 from 8:30 am through 10:00 am, it was determined that the maintenance carts were found in the hallway with chemicals to clean the facility and equipment and were found unlocked and accessible to non-authorized persons (patients and visitors).

2. During the observational tour of the Medicine/Surgery ward with the Director of Nursing (employee #1) and Nursing Supervisor (employee #3) on 2/2/12 from 10:30 through 11:45 am and on 2/3/12 from 8:30 am through 10:00 am, the following were observed when the Registered Nurse (RN) prepared and administered medications during the drug pass:

a. The RN was observed administering medications to the patient in room #231, however she maintained the medication cart open in the patient's room entrance with the door open and then passed by bed #231B and ran the curtain to administer the medications. The RN stated during an interview on 2/2/12 at 10:50 am that the cart was closed but she did not have the key to lock it.

b. The three medication carts were observed at different hours during the medication pass on 2/12/12 and the three RNs (Registered Nurses) were observed performing the same practice with the medication cart, leaving it unattended in the hallway, unlocked and accessible to non-authorized persons (patients and visitors).

c. On 2/3/12 at 10:00 am the medication cart was observed in the hallway in front of patient room #238 in the open position with the key in the lock accessible to non-authorized persons.

3. The Nursing Supervisor (employee #3) stated during an interview on 2/3/12 at 11:00 am that their policies/procedures states that the medication cart is to be maintained closed and locked during the medication pass and under the nurses' supervision.

4. During the observational tour of the Medicine/Surgery ward with the Director of Nursing (employee #1) and the Facility's Engineer (employee #5) on 2/3/12 from 8:30 am through 10:00 am, the temperature of patient's rooms were measured with a laser thermometer and provided evidence of temperatures between 58?F-69?F for nine out of 20 patient's rooms. The Facility's Engineer (employee #5) stated during interview on 2/3/12 at 9:00 am that he controls the temperature according with the preference of the patients in the rooms. The patients in rooms #203 and #225 (the temperature was 58?F) stated during an interview on 2/2/12 at 9:30 am that the temperature was not to their preference, it was too cold. The facility failed to ensure that all patients are given a comfortable environment related to the temperature of their rooms.

Based on the complaint investigation (PR00000459) and ten records reviewed (R.R) with the patient satisfaction Director (employee #2), it was determined that the facility failed to promote the patient's right to be free of restraints and failed to continually assess and monitor three out of ten records reviewed (R.R #3, #5 and #6).

Findings include:

1. R.R #3 is a 50 years old male who was admitted on 12/22/11 with a diagnosis of Hepatic Failure. The record review was performed on 2/2/12 at 2:00 pm with the patient satisfaction Director (employee #2) provided evidence of a physician telephone order for Ativan 2 mg IM for one dose and restraint protocol on 12/24/11 at 4:40 am. The physician order did not provide evidence of the type of restriction to be used, hours that the patient is to be restrained and extremities to be restrained. No evidence was found that the restraint protocol was signed by the physician and the nurse. The nurse's progress notes performed on 12/24/11 at 4:40 am evidenced that the patient was disoriented, he removed his intravenous fluids, referred that he wanted to go home, did not follow instructions, observed aggressive and refused treatment, the physician was called and ordered by telephone Ativan 2 mg IM per one dose and restraint protocol. However, no evidence was found of the nurse's restraint daily evaluation from 12/24/11 from 4:40 am till 6:00 am. The physician placed an order on 12/24/11 at 8:45 am, on 12/25/11 at 8:30 am and on 12/26/11 at 8:00 am for restraint protocol, however did not specify the type of restraint of the extremity to be restrained and the time to be restrained. No evidence was found in the physician's progress notes of the behavioral assessment that justifies the restraint order. The nurse's progress notes provided evidence that the patient was restrained from two extremities on 12/24/11 at 8:00 pm and restrained from four extremities on 12/25/11 at 7:00 am. However the physician's order not provide evidence how many extremities to be restraint.
2. R.R #5 is an 81 years old male who was admitted on 1/17/12 with a diagnosis of Chronic Liver Disease, Congestive heart failure (CHF) and Myocardial Infarct. The record review was performed on 2/2/12 at 12:00 pm with the patient satisfaction Director (employee #2) and intensive care nursing supervisor (employee #7) and provided evidence that the physician placed an order on 1/19/12 at 2:00 pm for restraint protocol. The physician's order did not provide evidence of the type of restriction to be used or the hour the patient was to be restraint. The restraint protocol was signed by the physician and no evidence was provided of the date and hour that the physician signed the protocol and lacks the type of restraints, hours to be restrained and the extremities to be restrained. No evidence was found in the nurse's notes of the assessment of the patient's behavior to see if the patient needs a restraint order. No evidence was found in the physician's progress notes that the physician evaluated the patient's behavior to consider the restraint order. Evidence was found that the nurse started the restraint on 1/19/12 at 7:00 am till 1:00 pm, without a physician's restraint order. Evidence was found in the restraints' daily evaluation that the patient was restrained on 1/20/12 from 7:00 am through 1/21/12 at 6:00 am, however no evidence was found related to a physician order to restrain the patient. Evidence was found that the nurse released patient restraint on 1/21/12 from 7:00 am till 3:00 pm and started the restraint from 4:00 pm till 7:00 pm without and physician order and no evidence was found that the nurse re-assessed the patient's behavior and notified the physician previous to restraining the patient. Evidence was found that the physician placed an order to restrain the patient by extremity on 1/22/12 at 10:40 am and no evidence was found related to the nurse's daily restriction evaluation. Evidence was found that the patient was restrained on 1/23/12, 1/24/12, 1/25/12, 1/26/12, 1/28/12, 1/29/12 1/30/12, 1/31/12, 2/1/12 without a restraint order.
3. R.R #6 is a 96 years old male who was admitted on 1/30/12 with a diagnosis of Myocardial Infarct and Syncope. The record review was performed on 2/2/12 at 11:50 am with the patient satisfaction Director (employee #2) and intensive care nurse supervisor (employee #8) provided evidence that the physician placed an order on 1/31/12 at 5:10 pm for restrictions of the superior extremity. The physical restraint order did not provide evidence of the type of restriction to be used, hour the patient was to be restrained. The restraint protocol was placed by the physician on 1/31/12 at 8:50 am, however it lacks the type of restraint and time the patient was restrained. Evidence was found that the nurse started the restraint on 1/31/12 at 1:00 pm, however no evidence was found in the nurse's note the assessment of the patient's behavioral needs for the restraint order. No evidence was found in the physician's progress notes that the physician evaluated the patient behavior to considering the restraint order. The restraint daily evaluation performed by the nurse provided evidence that the restraint was initiated on 1/31/12 at 7:00 am, however no evidence was found related to the nurse's assessment performed on the patient until 1:00 pm that the nurse started to assess the patient's restraint. On 1/31/12 at 10:00 pm the nurse took a telephone order to continue with restraints, the physician countersigned the order on 2/1/12, however no evidence was found of the type of the restraint and hour of the restriction. The restriction daily evaluation performed on 2/1/12 provided evidence that the patient was restrained from 7:00 am till 11:00 am and was released from restrains from 12:00 noon till 7:00 pm and be restrained from 8:00 pm till 6:00 am, however no evidence was found in the nurse's notes related to an assessment of the patient's behavior previous to the release of the restraints and no evidence was found that the physician discontinued the restraint. No evidence was found related to a new order to restrain the patient 7 hours after he was released on 2/1/12.

Based on the complaint investigation (PR00000459) and ten medical records reviewed, review of policies and procedures (P&P) related to the restraint protocol, it was determined that the facility failed to ensure that the order for the use of restraints is never used as on a "as needed basis" (PRN) for two out of ten records reviewed (R.R #5 and #6).

Finding include:

1. R.R #5 is an 81 years old male who was admitted on 1/17/12 with a diagnosis of Chronic Liver Disease, Congestive heart failure (CHF) and Myocardial Infarct. The record review was performed on 2/2/12 at 12:00 noon with the patient's satisfaction Director (employee #2) and intensive care nursing supervisor (employee #7) and provided evidence that the physician placed an order on 1/19/12 at 2:00 pm for restraint protocol. The nursing restraint daily evaluation sheet provided evidence that the patient was restrained as a PRN order because the nurse documented that the patient was released from the restraint on 1/21/12 from 7:00 am till 3:00 pm and started the restraint from 4:00 pm till 7:00 pm without a physician's order.

2. R.R #6 is a 96 years old male who was admitted on 1/30/12 with a diagnosis of Myocardial Infarct and Syncope. The record review was performed on 2/2/12 at 11:50 am with the patient satisfaction Director (employee #2) and intensive care nurse supervisor (employee #8) and provided evidence that on 1/31/12 at 10:00 pm the nurse took a telephone order to continue with the restraints, the physician countersigned the order on 2/1/12, however no evidence was found of the type of restraint and hour of the restriction. The daily nursing restraint evaluation sheet provided evidence that the patient was restrained as a PRN order because the nurse documented that the patient was restrained from 7:00 am till 11: 00 am and was to be released from the restraints from 12:00 noon till 7:00 pm and was restrained from 8:00 pm till 6:00 am, however no evidence was found in the nurse's notes related to an assessment of the patient's behavior previous to the release of the restraint and no evidence was found that the physician discontinued the restraint. No evidence was found related to a new order of the restraint of the patient until 7 hours later on 2/1/12.

Based on the compliant investigation (PR00000459), observational tour of the Medicine/Surgery ward with the Director of Nursing (employee #1) and Nursing Supervisor (employee #3), interviews with patients, nursing staff, review of staffing patterns, work assignments and ten records review, it was determined that the facility failed to provide nursing services to patients in accordance with the patients' plan of care related to disposable diaper changes and assist patients during baths for three out of forty-nine (patients #1, #3, #4 and two patient in room #226).

Findings include:

1. During the observational tour of the second floor (medicine/surgery ward), nursing personnel (registered nurses (RN)) were observed on 2/3/12 at 10:45 am administering medications while assisting patients with personal hygiene (assisting with bed baths). On 2/2/12 the second floor had a census of 49 patients with nursing staffing of 4 RNs and 5 LPNs. The nursing supervisor stated that there are 10 patients who require bed baths and those who require assistance in the shower. Patient's rooms (#201, #212, #219 and #226) were visited on 2/2/12 from 10:45 through 11:55 am and patients were waiting for their bath.

2. During observations made and interviews with licensed practical nurses (LPN) (employee #6 and #11) on 2/2/12 from 10:45 am till 11:55, assigned to provide baths to the patients stated that they still have to give baths to five patients in the surgery area and five other patients were in the medicine area to be cared for by LPN personnel. The two LPNs stated during interviews on 2/2/12 at 11:05 am that the majority of patients require a lot of assistance for every aspect of daily living.

3. On 2/2/12 at 11:00 am the sister of a patient stated that her brother was wet from urinating on himself and they did not bathe him yet. The patient was visited in room #212A and was observed in disposable briefs and not covered by sheets as he was waiting for his bath. During LPN (employee #11) interview on 2/2/12 at 11:10 am she stated that she has a lot of bed baths to perform but she feeds the patients breakfast first and then performs the bed bath.

4. On 2/2/12 at 11:30 am the patient in room #219 (isolation room), the patient in room #201 (isolation room) at 12:00 noon and the patient in room #226 were waiting for their bath assistance. The patient in room #212 received his bath after 11:30 am. The family members of the patients in rooms #201 and #219 (isolation rooms) stated on 2/2/12 at 1:30 pm that nursing staff performed baths for these patients after 1:30 pm.

5. Review of nursing assignments on 2/2/12 at 1:30 pm provided evidence that the Nursing Supervisor (employee #3) did not categorize and assign patients according with the patients' needs. Assigned tasks for personnel to perform on patient are generalized, not specified per patient and not prioritized in order of need and care required such as "bath assistance", "changing disposable briefs " and "feeding assistance". The facility failed to take into consideration patient's comfort and preference when providing food while with urine or with feces instead of bathing the patient first and then feeding.

6. The Director of Nursing (employee #1) stated during an interview on 2/3/12 at 2:00 pm that presently we need seven more registered nurses (R.N) to complete our nursing staffing pattern for the medicine/surgery ward. I have twenty-three R.N's who have shifts of twelve hours and nineteen LPNs with shifts of eight hours according with the degree of care required by admitted patients, the assignments and tasks are assigned for nursing personnel to assure adequate care for patients.

a. R.R #4 is a 59 years old male who was admitted on 2/1/12 with a diagnosis of Anemia. The patient's record was reviewed on 2/2/12 at 1:45 pm and it was found that the patient is totally dependent on activities of daily living and with communication problems. During observations with the Director of Nursing (employee #1) on 2/2/12 at 11:10 am, the patient was observed not oriented, in disposable briefs, not covered by sheets as he waiting for his bath, accompanied by his sisters. Nursing personnel provided the bath at 11:30 am.

Based on the compliant investigation (PR00000459), observational tour of the Medicine/Surgery ward with the Director of Nursing (employee #1) and Nursing Supervisor (employee #3), interviews with patients, nursing staff, review of staffing patterns, work assignments and ten records reviewed, it was found that the facility failed to ensure that nursing staff developed appropriate nursing interventions in response to patient's needs and failed to implement care plans for two out of ten records reviewed (R.R #1 and #9).

Findings include:

1. Two out of ten records reviewed for care plans on 2/2/12 through 2/3/12 from 10:30 am till 2:00 pm provided evidence that patients do not have written care plan in a timely manner during the patients' hospital stay related to their hematology needs.

a. R.R #1 is a 69 years old female who was admitted to the medicine ward on 1/15/12 with Congestive Heart Failure, Diabetes Mellitus and High Blood Pressure. The patient's record was reviewed on 2/3/12 at 10:30 am and was found that the Registered Nurse (RN) transfused two units of PRBC for low hemoglobin (8.3) on 1/29/12 and 1/31/12. However, the registered nurse did not activate the hemoglobin levels care plan according to the patient's needs during the hospitalization and according to the patient's changes during the in-patient stay.

b. R.R #9 (closed record) is a 78 years old female who was admitted to medicine ward on 12/19/11 with Severe Deshydratation, Chronic Kidney Failure and Multi-resistant Urinary Tract Infection (UTI). The patient's record was reviewed on 2/3/12 at 2:45 pm and was found that the RN assessed the patient as a high risk to create an ulcer (Braden scale) on 12/19/12 and nursing personnel document to change position every two hours since 12/20/12. However, the registered nurse do not activated the ulcer prevention care plan according to the patient's needs during the hospitalization and according to the patient's changes during the in-patient stay.

Based on the compliant investigation (PR00000459), observational tour of the Medicine/Surgery ward with the Director of Nursing (employee #1) and Nursing Supervisor (employee #3) and ten records reviewed (active and closed), it was determined that the facility failed to ensure that the initial implementation of the patient's discharge plan is performed according to facility policies/procedure for one out of ten records reviewed (R.R #9).

Findings include:

1. During ten records reviewed on 2/2/12 and 2/3/12 from 10:00 am till 3:30 pm one record did not have discharge planning. No evidence was found of goals and objectives established to coordinate patient's discharge planning and no evidence was found of the revision of patients' needs according to patient changes during the inpatient stay.

a. R.R #9 (closed record) is a 78 years old female who was admitted to the medicine ward on 12/19/11 with Severe Dehydration, Chronic Kidney Failure and Multi-resistant Urinary Tract Infections (UTI). The patient's record was reviewed on 2/3/12 at 2:45 pm and was found that the registered nurse (RN) assessed the patient has a high risk to develop ulcers (Braden scale) on 12/19/12 and nursing personnel documented to change the patients' position every two hours since 12/20/12. On 12/19/12 at 10:30 am in the nursing history/admission it was found that the patient required assistance for eating, foley catheter, bed ridden and renal changes. The nurse's notes on the admission history assessment did not identify the social worker referral that pertained to this patient's discharge plan. On 12/24/12 the primary physician discharged summary was found referring the patient for Home Care services. Also, no evidence was found of the discharge planning assessment and arranging for necessary post-hospital services for this patient.