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Based on interview, record review and a review of facility documentation, the facility failed to ensure the provision, in response to a grievance, a written notice of its decision that contains the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 10 sampled patients (#1).

Findings:

Review of the medical record of patient #1 revealed a discharge from the facility on 2/01/12. A review of the grievance log revealed that the patient had filed a complaint by telephone on 2/09/12. The complaint included concerns regarding positioning, the development of a pressure sore, the use of an improper bed and a delay in therapy. The Risk Manager was asked for a copy of the facility's final written response to the patient regarding her grievance. She produced a letter dated 4/03/12. Upon review of the letter, dated 4/03/12, it did not mention the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

A review of facility policy "Patient & Family Complaint and Grievance Policy" revealed the following: "All grievances will be reviewed through the Grievance Committee and responded to in writing. The written response shall include the name of the hospital contact, steps taken to investigate the complaint, results of the process and date of completion of the process."

During an interview of the Risk Manager on 4/30/12 at approximately 6:30 PM, she confirmed the finding.

Based on interview, record review and a review of facility documentation, the facility failed to ensure that the patient's identified needs in the form of physician notification regarding wound development for 1 of 10 sampled patients (#1).

Findings:

A notation in physician progress notes of 1/30/12 at 1:45 AM read, "Blister 1.5 cm (centimeters) X (by) 2 cm." It accompanied a photograph. Since it was not signed, there was no way to determine if it was placed by a physician. A nurse's note on 1/30/12 at 5:10 AM read, "Blister noted on buttock, picture taken and placed in chart .... No c/o (complaint of) pain this shift ...." The skin assessment of this day described a dry wound base, pink and intact but ecchymotic peri-wound area. As for physician notification upon discovery of this wound, there was no evidence that this was done.

A review of policy "Skin/Wound Care: Assessment, Prevention, Treatment and Wound Culture" revealed, "If a wound is identified upon admission and is not consistent with the admitting diagnosis, contact the physician ...." Although this wound was not discovered upon admission, it was not consistent with the admitting diagnosis (per overall record review).

A review of facility policy "Assessment/Reassessment" revealed the following: "Abnormal findings in assessments will be communicated to the physician and other disciplines as appropriate." This policy was not followed, as indicated by the lack of evidence that a physician was informed of the wound described above.

During an interview of the Risk Manager on 4/30/12 at approximately 6:30 PM, she confirmed the finding.

Based on interview, record review and a review of facility documentation, the facility failed to ensure the completion of medical records in the form of a required discharge summary within 30 days of discharge for 1 of 10 sampled patients (#1).

Findings:

Review of the medical record of patient #1 revealed the patient was discharged on 2/01/12. There was no Discharge Summary in the medical record.

A review of Medical Staff Rules & Regulations revealed the following: "Charts shall be completed within thirty (30) days following the patient's discharge." The physician was in violation of this requirement.

During an interview of the Risk Manager on 4/30/12 at approximately 6:30 PM, she confirmed the finding.

Based on interview and record review, the facility failed to ensure the performance of a reassessment of the patient's discharge plan to address the factor of a skin wound which could affect continuing care needs upon discharge for 1 of 10 sampled patients (#1).

Findings:

Review of the medical record of patient #1 revealed a notation in physician progress notes of 1/30/12 at 1:45 AM which read: "Blister 1.5 cm (centimeters) X (by) 2 cm." Since it was not signed, there was no way ensure that it was placed by a physician. There was no evidence through the remainder of the patient stay of any physician knowledge of the wound. The record revealed that the wound was still in existence on the day of discharge (2/01/12). Nurse's notes of 2/01/12 at 3:41 PM mentioned the provision of discharge instructions to the patient. The discharge orders did not mention a buttocks wound. Since there was no evidence of physician notification throughout the patient's stay and no physician orders regarding post-discharge treatment of the site, if any, the facility could not provide evidence that continuing care needs regarding the site had been addressed.

During an interview of the Risk Manager on 4/30/12 at approximately 6:30 PM, she confirmed the finding.