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Based on record review and staff interview, the facility failed inform each Medicare patient, with a standardized notice about the patient's rights for 1 of 8 patients in the case sample.

Finding includes:

Patient #5 was admitted on 6/14/14 for diagnoses of sudden onset of altered mental status, weakness, impaired speech, hypertensive emergency and intubated for respiratory failure. A representative on behalf of the patient signed the form, "An Important Message from Medicare About Your Rights" (IM) on 6/14/14. The patient had a lengthy hospitalization which included specialized rehabilitation services and was discharged home on 7/11/14. Record review however, found the patient did not receive a copy of the signed IM within 2 calendar days of the patient's discharge.

On the morning of 10/24/14, this was confirmed by the ADON that Patient #5 was not provided with a copy of the signed IM form prior to discharge. The ADON stated this was confirmed by the manager of the admissions office who had the responsibility to ensure it was given.

Based on a review of the facility's grievance/complaint log, staff interview and a review of the facility's policy and procedure, the facility did not ensure for 1 of 7 complaints, that a written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion was done.

Finding includes:

The facility's policy, "Patient Complaints and Grievance Process," Policy No. 850-111-02, noted: "C. Responsibilities of Patient Relations...b. If the grievance will not be resolved within (seven) 7 days, Patient Relations will inform the patient or patient's representative that Patient Relations is still working to resolve the grievance and the anticipated timeframe in which the patient or patient representative can expect a written response...d. A written explanation of the hospital's determination regarding the grievance is communicated to the patient or the patient's representative...In all cases, Patient Relations provides a written response to each patient's grievance that includes the following: (1) Name of the hospital contact person (2) Steps taken to investigate the grievance (3) Results of the grievance process (4) Date of completion (usually the date of the letter).

On the morning of 10/24/14, during a concurrent review of the complaint log with the patient advocate, she confirmed for Patient #7, there was no letter or other written response sent to the complainant. The facility received a 9/11/14 communication from the patient's representative via the facility's quality hotline, but did not have a written response or any documentation showing resolution of the grievance following the hospital's policy and procedure.

Based on observation and staff interviews, the facility failed to ensure the physical environment of the Maui North nursing floor was kept in good condition and repair.

Findings include:

On 10/23/14, during an afternoon tour of the Maui North unit, it was found one of the isolation anteroom's wall behind the sink had a blackish stain on it. In addition, it was observed that most of the door frames of the patient rooms in the 29 bed unit, were chipped, splintered and/or the paint was peeling off. The door jambs in some of the rooms were also in need of repair.

During a follow-up interview with the ADON and the Quality Improvement (QI) officer on 10/23/14, they confirmed the nursing unit was in need of repair and that Maui North was one of the older units.

Based on observation and staff interview, the facility failed to ensure licensed staff followed basic safe practices for medication administration.

Finding includes:

On 10/23/14, during an afternoon tour of the Maui North unit, a licensed staff was observed with a couple of prefilled saline flush syringes in his/her right pocket and was putting another one into the same pocket. Interview with the ADON after the tour revealed licensed staff was not to be carrying medications in their pocket. On 10/24/14, the ADON confirmed the licensed staff had the syringes in his/her pocket with the intent of seeing a patient to flush an intravenous line. The ADON acknowledged that placing the syringes in one's pocket was not an acceptable standard of practice for safe handling of medications and basic infection control practices.