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Based on record review and interview, the facility's written notice to 1 of 1 patient (Patient #1) who complained about several issues during confinement on 05/02/13 through 05/08/13, did not include the specific time frame for the evaluation, completion, and the resolution of the complaint.

Findings included:

Patient #1 voiced out several issues to an administrative assistant via telephone call on 08/23/2013. A response letter sent to Patient #1 dated 08/26/13 reflected that the issues would be evaluated. The letter did not indicate a specific date when the facility would follow-up with a written response. The facility's policy and procedure required 21 business days to complete evaluation of a patient complaint and/ or grievance.

In an interview on 01/06/14 at 11:15 AM, Personnel #1, the Director of Risk and Patient Safety Officer was informed of the above findings and confirmed the findings.

Policy: "Patient Grievance and Complaint Management" revised 04/2013 page 4 required "...if the grievance may not be resolved ...in seven business days, the complainant should be informed ...that the facility will follow-up with a written response within 21 business days."

Based on record review and interview, the Registered Nurse (RN) did not supervise and evaluate the nursing care for 1 of 1 patient (Patient #1) who was hospitalized from 05/02/13 through 05/08/13, in that there were no interventions for increased temperatures and/or reassessments after providing antipyretic medications.

Findings included:

Patient #1 was admitted on 05/02/13 for persistent fever. On the following dates, there were no nursing interventions and/or reassessments performed:
1. On 05/03/13 at 8:00 AM the patient's temperature (T) was 100.6F (Fahrenheit).
2. On 05/04/13 at 8:06 AM and 2:04 PM, the patient's T were 99.7F and 100.9F respectively.
3. On 05/06/13 at 7:30 AM, 8:12 AM, 9:00 AM, and 5:15 PM the patient's Ts were 102.8F, 100.9F, 100.8F, and 101.1F respectively.
4. On 05/06/13 at 8:00 PM the T was 101.1F. Tylenol was given as prescribed. No nursing reassessment was conducted.
5. On 05/07/13 at 3:30 AM, 7:44 AM, and 3:37 PM the patient's Ts were 102.0F, 99.2F, and 100.3F respectively.

In an interview on 01/13/14 at 3:20 PM via phone call, Personnel #3 was informed of the above findings. Personnel #3 confirmed the findings. Personnel #3 was asked what the temperature parameters were to provide antipyretic medications. Personnel #3 replied the facility does not have written parameters for providing antipyretic medications. It was up to the physician to include the temperature so the nurse would know when to administer the "fever" medication. Personnel #3 stated the nursing competency skills were based from "Lippincott" nursing book.

"Lippincott Procedures - Temperature Assessment" revised 04/05/13
"Normal body temperature is commonly thought of as 98.6F (37C)...Mean temperature is lower in older adults ..."

Based on record review and interview, the facility's medical record entry was not accurately written in that, a "CT scan of abdomen and pelvis" result reflected that the examination was performed with and without contrast. The Physician's Order dated 05/02/13 indicated the examination was to be performed "without contrast," citing 1 of 1 patient (Patient #1) who was hospitalized from 05/02/13 through 05/08/13.

Findings included:

Patient #1 was admitted on 05/02/13 for persistent fever. A physician's order for "CT scan of abdomen and pelvis without contrast" was written. Review of the CT scan abdomen and pelvis dated 05/02/13 reflected the heading to be: "Exam: CT Abd Pelvis W/O Cont (contrast)." The next line reflected "Exam: CT Abdomen Pelvis with Contrast." The written result was unclear if the examination was performed with and/or without contrast.

In an interview via electronic mail (email) on 01/14/14 at 6:20 PM, Personnel #3 (Administrative Director of Clinical Services) was informed of the above findings. Personnel #3 stated that this was an error. The radiologist dictated the exam as "with contrast" but the examination was performed "without contrast."

In an interview on 01/23/14 at 12:11 PM via phone, Personnel #4 (Director of Health Information Management) was informed of the above findings. Personnel #4 was asked if the facility had a policy and procedure in writing accurate clinical entries by health providers. Personnel #4 replied she could not find the requested policy.