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Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow its grievance policy in regards to the investigation of a filed grievance, as evidence by staff interviews were not conducted, actions taken and findings were not documented and the re-education of all staff did not occur for one (1) of ten (10) sampled residents. (Patient #1)

The findings include:

Review of the facility's policy regarding Patient Complaint and Grievance Process, dated February 2013, revealed the facility's process included a review of the documented grievance information provided by the complainant. The department manager assigned the grievance would complete the investigation and document the findings obtained during investigation along with actions taken. A response letter informing the complainant of the facility findings and any actions taken to rectify would be sent timely to the complainant.

Review of Patient #1's clinical record revealed the facility admitted the patient on 02/26/15 with a diagnosis of Respiratory Failure. The patient had a recent acute care hospitalization from a motor vehicle accident that resulted in cervical spine, multiple bilateral rib and facial fractures. Continued review revealed Patient #1 was discharged on 03/01/15.

Interview with Patient #1's son-in-law, on 03/17/15 at 10:42 AM, revealed the facility admitted Patient #1 to the long term acute care facility on the evening of 02/26/15. The son-in-law stated while at the facility staff did not meet the needs of Patient #1 timely. He stated he filed a grievance regarding the lack of timely response by the staff to requests made by the family and the patient and when the call light was used. He stated he received a response letter from the facility stating the facility had identified the staff had not answered Patient #1's call light timely and they would be making improvements to their system.

Interview with the Patient Relations Representative, on 03/19/15 at 10:50 AM, revealed Patient #1's daughter contacted him regarding the lack of timely response by staff to Patient #1's call light. He stated it was determined to be a grievance and needed to be investigated. He documented the information and then informed the Unit Manager. He stated the Unit Manager was responsible for investigating the grievance.

Interview with the Unit Manager, on 03/19/15 at 11:35 AM, revealed the facility required staff to answer call lights timely and nursing to meet the requested needs made by the patients and families. The Unit Manager stated she did not interview staff assigned to Patient #1 in order to determine if there were times they could not answer the patient's call light timely. She stated she could not provide any documented evidence of her investigation or findings. She stated the facility identified patient call lights were not being answered timely through a report and staff received re-education on answering call lights accordingly. She stated she provided training on 03/09/15 for the day shift staff. However, review of the training documentation revealed not all staff received the re-education. The Unit Manager stated she did not follow up to ensure all staff she managed received the re-education.

Interview with the Nursing Administrator, on 03/19/15 at 10:20 AM, revealed it was determined through a facility run report from the call light system that staff did not answer Patient #1's call light timely. She stated there was a twenty (20) minute time frame where staff did not answer Patient #1's call light. She stated she attempted to call the son-in-law three times and was unable to contact him to obtain more specific information about the care and services that were not met when the call light was not answered. She stated since she was unable to contact the son-in-law, the investigation into the grievance was not completed per the facility policy. She stated the report identified the call light was not answered timely so the facility addressed that issue. She stated the facility sent Patient #1's family member a grievance response letter, stating the facility had identified issues with call light response times and that staff would be re-educated. However, she did not realize all staff had not received the re-education. She stated normally she would get a report back from the managers informing her that all staff had been re-educated. She stated she had not received any reports as of 03/19/15 regarding call light re-education.

Interview with the Administrator (ADM), on 03/19/15 at 4:10 PM, revealed the needs of the patients should be met timely upon request.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to meet the needs of a patient in pain as evidence by a request for pain medication three times, in a fifty-seven (57) minute time period was not administered until surveyor intervention for one (1) of ten (10) sampled patients. (Patient #2)

The findings include:

Review of the facility's policy regarding Administration of Medications, dated August 2014, revealed the facility would administer medications safely, accurately and efficiently by qualified personnel.

Review of Patient #2's clinical record revealed the facility admitted the patient on 02/20/15 with a history of bilateral total leg amputation up to the waist and was treating the patient's pressure wound.

Review of the Physician Orders, dated 02/21/15, revealed Patient #2 was ordered Hydrocodone 5 mg with Acetaminophen 325 mg 1 tab every six (6) hours and Oxycodone immediate release 20 mg intravenous push every twelve (12) hours as needed for pain. The patient had an order for Promethazine 12.5 mg intravenous push every six (6) hours as needed for nausea.

Observation of Patient #2, on 03/19/15 at 9:35 AM, revealed the patient was in bed with the call light cord in reach and the patient made facial grimaces during the interview.

Interview with Patient #2 at this time revealed the patient had to request pain medication early or it would take 2 hours sometimes to get the requested pain medication. The patient stated his/her right side had a sharp stabbing pain. Patient #2 stated his/her pain medication could be administered every 12 hours as needed and if he/she had break through pain another pain medication was available every 4 hours as needed for pain. The patient stated at times he/she needed a medication for nausea because the pain or the medication would make his/her stomach upset.

Observation of Patient #2's room, on 03/19/15 from 9:10 AM until 10:07 AM, revealed the patient put on his/her call light at 9:10 AM and a staff member answered the call bell through the intercom system in the room at 9:11 AM. Patient #2 requested pain medication and the staff member on the intercom said they would tell Patient #2's nurse about the request. Observation at 9:12 AM revealed Certified Nursing Assistant (CNA) #1 walked up to Patient #2's room door and asked the patient what he/she needed and then went in the room and turned off the call light. The patient responded he/she wanted pain and nausea medication. CNA #1 stated he would let Patient #1's nurse know of the request. CNA #1 then left and went 2 doors down to room 506 and talked to CNA #2.

Interview with Certified Nursing Assistant (CNA) #1, on 03/19/15 at 9:55 AM, revealed he informed CNA #2 of Patient #2's pain medication request. The CNA stated he should have informed the nurse instead of CNA #2.

Interview with CNA #2, on 03/19/15 at 9:57 AM, revealed after CNA #1 told her about Patient #2's pain medication request. She stated she then went to LPN #1 and informed her of Patient #2's request and she said okay.

Additional observations, on 03/19/15 during the timeframe of 8:54 AM until 10:07 AM, revealed Patient #2's intravenous pump alarmed for 33 minutes. Registered Nurse (RN) #1 entered Patient #2's room at 9:27 AM and addressed the alarming pump. Patient #2 again requested pain medication. RN #1 said he would find the nurse to let her know about the request for pain medication. The RN exited the room and proceeded to walk up and down the hall calling for LPN #1.

On 03/19/15 at 9:48 AM, a request was made to the Unit Secretary to find LPN #2.

Interview with LPN #1, on 03/19/15 at 9:50 AM, revealed CNA #2 and RN #1 did not inform her of Patient #2's request for pain medication and that she already had a request for pain medication from another patient and that patient's request would be handled first. She stated after that task was completed she would administer Patient #2's pain medication.

Interview with RN #1, on 03/19/15 at 10:05 AM, revealed he located LPN #1 at the nursing station and informed her of Patient #2's request for pain medication.

Interview with the Unit Manager, on 03/19/15 at 11:35 AM, revealed all staff were required to answer call lights timely and nursing should meet the requested medication needs voiced by the patients. She stated the facility identified patient call lights were not being answered timely and the staff received re-education on answering call lights accordingly. However, review of training documentation revealed not all staff received the re-education. The Unit Manager stated she did not follow up to ensure all staff received the re-education.

Review of the Team Huddle training sign in sheets, dated 03/09/15, revealed LPN #1, RN #1, CNA #1 and #2 names and signatures were not on the sheet as receiving the re-education for answering call lights timely.

Interview with the Nursing Administrator, on 03/19/15 at 10:20 AM, revealed it should not take an hour for a patient to receive a requested pain medication. She stated LPN #1 could have asked someone else to administer the pain medication for her. She stated the facility identified call light response times were not timely and re-education was provided by the Unit Managers and Supervisors. However, she did not realize all staff did not receive the re-education. She stated normally she would get a report back from the managers informing her that all staff had been educated. She stated she had not received one as of 03/19/15 for the call light re-education.

Interview with the Administrator (ADM), on 03/19/15 at 4:10 PM, revealed patients should not have to wait one hour for pain medications. The needs of the patients should be met timely upon request.