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Based on document review, interview, and policy review the facility failed to communicate timely resolution of a grievance for two of three patients with documented complaints (#13 & #11) and one complainant, whose complaint was not acknowledged (#5) resulting in the potential loss of rights to all patients being served by the facility. Findings include:
On 10/29/2014 between 1100 and 1600 during medical record review in 2 of 3 patients with documented complaints which have not been resolved. Patient #13 complained on 08/18/2014 which remains un-resolved and subsequent documentation of resolution and communications are absent. Patient #11 complained on 04/28/2014 and remains un-resolved and subsequent documentation of resolution and communications are absent. Patient #5 (the complainant) complained on 10/23/2014 which was not written up as a formal complaint and therefore has not received any written documentation related to resolution. On 10/29/2014 at approximately 1600 staff H stated, "we are a little behind in responding."
On 10/30/2014 at approximately 0900, during an interview of staff H, who stated, "Ideally, a complaint is solved immediately by the staff, in a grievance we contact the patient within 7 days and send a letter of resolution within 45 days."
On 10/30/2014 between 0930 and 1300 during review of the facility's grievance policy and procedure titled, "Response to Complaint and Investigation." ID:691622 (currently under review for revision) last approval 05/2011 and expired 04/2014. Page 2 bullet "#2. The investigation shall be commenced as soon as reasonable possible but in no event more than five (5) business days following the receipt of the complaint or report...a. an interview of the complainant,,,c. vi..Preparation of a summary report..."
On 10/30/2014 between 0930 and 1300 during review of the facility's grievance policy and procedure titled, "Complaints/Grievances, Customer-Handling of." ID: 996571, Last Revised: "03/2014" read in the section titled, "Formal Complaint/Grievance: # 2. (bullet 6) Problem resolution and follow-up-The completed Patient Complaint/Grievance Form should be sent to Risk Management within five (5) working days where a written response detailing the nature and outcome of the investigation will then be sent to the complainant within 30 days."

Based on medical record review, interview and document review the facility failed to inform patients of their health status, failed to ensure the patients right to make an informed decision, and failed to involve the patients in their care plans in 4 of 7 (#3, #5, #6, & #8) medical records reviewed. Findings include:

On 10/29/2014 medical records were chosen by diagnosis of abscess with microbiology cultures sent to the lab, the following was found:
On 10/29/2014 at 1300 the medical record for patient #3 was reviewed. Patient #3 was admitted on 04/19/2014 to the ED for a right thigh abscess, cultures where sent to the lab, the patient was discharged home on an antibiotic with the instructions, "will be called if antibiotic needs to be changed." On 04/21/2014 the culture results were reported back to the ED, and on 04/22/2014 it is documented "OK taking Bactrim" no other follow up with the patient is documented.
On 10/29/2014 at 1330 the medical record for patient #5 was reviewed. Patient #5 was admitted on 05/27/2014 to the ED for an abscess on his knee, cultures where sent to the lab, the patient was discharged home on the antibiotic (Bactrim) for 10 days. On 05/29/2014 the culture results where reported back to the ED as positive for MRSA and a FAX report was generated to DR. PA (the patient's primary care physician). This report was generated automatically by the computer system and verified that it was sent and received. "On 05/31/2014 @ 0752,OK taking Bactrim" is documented and signed by staff K, no other follow up with the patient was documented.
On 10/29/2014 at 1400 the medical record for patient #6 was reviewed. Patient #6 was admitted on 06/24/2014 to the ED for an abscess, cultures were sent to the lab, the patient was discharged home on antibiotics with the instructions that he would only receive a call if the antibiotic was not correct. On 06/26/2014 the results were reported back to the ED as positive for MRSA. On "06/27/2014 @ 0820, OK, correct antibiotic" was documented and signed by staff L, no other follow up with the patient is documented.
On 10/29/2014 at 1500 the medical record for patient #8 was reviewed. Patient #8 was admitted on 08/08/2014 to the ED with the diagnosis of abscess of the left arm, cultures were sent to the lab, the patient was sent home on antibiotic. On 08/10/2014 the cultures were returned to the ED as positive for MRSA. On" 08/11/2014 @0900, OK, correct antibiotic" is documented by staff K, no other follow up with the patient is documented.
On 10/30/2014 at 0900 the Policy and Procedure (P&P) for follow up care was reviewed. Policy #1008863 titled, "Follow Up Care -Documentation Of" last revised "10/2011" stated "#1. Review all microbiology lab reminders.... #3. a. A follow up call to inform the patient or primary care physician of the results ..... b. If a patient cannot be reached after repeated attempts within a 24-72 hour period, a certified letter will be sent to the last known address ...."
On 10/30/2014 at 0930 the P&P for patients rights was reviewed. The document titled. "Patients Rights, #008945, dated "10/2013", is the educational material given to everyone admitted to the facility, either for inpatient or outpatient services. It states under the heading "Quality Care, bullet #2 (Patient will) Participate in decisions regarding your health care and treatment plan."