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Based on interview, policy review and procedure review, and clinical record review, the facility failed to ensure Patient #10, #11, and #12 had received written notices regarding the outcome of their complaints, failed to ensure Patient #5, #6, and #9 had signed consent-to-treat forms, failed to ensure Patient #5, #6, and #9 had signed confirmation of notification of patient rights including advance directives, failed to ensure Patient #1 and #2 had proper physician orders for use of restraints, failed to ensure Patient #1 and #2's restraint use was included in their nursing plans of care, and failed to ensure Patient #1 and #2's need for continued restraint was documented every two hours. The sample size was 10 patients, the facility's census was 29 patients.

Findings:

See A123, A131, A166, A168, and A175 for details.

Based on interview, policy review, and clinical record review, the facility failed to ensure Patient #10, #11, and #12 received written notices that delineated the steps taken to investigate their families' complaints and the results of said investigations. The facility's census was 27 patients.

Findings:

A review of the facility's complaint log for 2010 was completed on 11/09/10. The complaint log revealed a complaint dated 06/24/10 from Patient #10, whose family complained the patient had not received a bath, and that sometimes, after calling out with the nurse's call light, it would take 15 minutes for staff to provide a bedpan. The complaint indicated an investigation was done; however, it did not indicate a letter containing a written response to the grievance was sent.

The complaint log revealed a complaint from Patient #11's family dated 06/14/10 that stated the patient hadn't been turned every two hours. The complaint indicated an investigation was done; however, it did not indicate a letter containing a written response to the grievance was sent.

The complaint log revealed a complaint from Patient #12's family dated 05/24/10 that stated at times no one would assist the patient with meals, that there were times when the nurse's call light was out of reach, and staff were nonresponsive to questions. The complaint indicated an investigation was done; however, it did not indicate a letter containing a written response to the grievance was sent.

A review of the facility's Complaint and Grievance Process (12/04 review) stated: "The Risk Manager, along with the Chief Executive Officer, will prepare a written response to the patient's grievance."

In the afternoon of 11/08/10, Staff A and G confirmed that neither Patient #10, #11, nor #12's families had received letters in response to their grievances.

Based on clinical record review, policy and procedure review, and staff interview; the facility failed to ensure all patients admitted to this facility had signed consent forms for treatment and signed confirmation of notification of patient rights. This affected three of ten clinical records reviewed (Patients 5, 6, and 9).

Findings include:

The clinical record for Patient 5 was reviewed on 11/09/10. The patient was admitted to the facility on 11/05/10. The clinical record contained a Consent for General Medical Treatment form, a Patient Bill of Rights form, an Assignment of Benefits/Release of Information form, a Privacy Practices form, a Message from Medicare form, an Advance Directives form, and a Do Not Resuscitate Care and Comfort form signed by the patient's power of attorney on 11/08/10. The clinical record lacked documentation of a verbal consent to treat or attempts to reach the patient's power of attorney to complete the above documents.

The clinical record for Patient 6 was reviewed on 11/09/10 at 10:20 AM. The patient was admitted to the facility on 11/08/10. The clinical record lacked signatures of the patient or his/her legal representative on the Consent for General Medical Treatment form, the Patient Bill of Rights form, the Assignment of Benefits/Release of Information form, the Privacy Practices form, the Message from Medicare form, or the Advance Directives form. The clinical record lacked documentation of a verbal consent to treat or an attempt to reach the patient's legal representative to complete the above documents.

Staff F was interviewed on 11/09/10 at 10:20 AM. Staff F stated that Patient 6 was alert and oriented and did not know why the consent form and the other admission forms were not completed at admission on 11/08/10. Staff F stated the facility has 24 hours from admission to obtain a signature on the consent forms.

The clinical record for Patient 9 was reviewed on 11/09/10 at 11:10 AM. The patient was admitted to the facility on 11/05/10. The clinical record lacked signatures of the patient or his/her legal representative on the Consent for General Medical Treatment form, the Patient Bill of Rights form, the Assignment of Benefits/Release of Information form, the Privacy Practices form, the Message from Medicare form, or the Advance Directives form. The clinical record lacked documentation of a verbal consent to treat or an attempt to reach the patient's legal representative to complete the above documents.

At 11:10 AM on 11/09/10, Staff H was interviewed. Staff H verified the consent form and other admission forms were not signed by Patient 9 or the patient's legal representative. Staff H stated these forms should have been completed on admission to the facility so he/she did not check them for signatures as this patient was admitted four to five days ago.

The policy and procedure for Consent for General Medical Treatment was reviewed on 11/09/10. The policy stated the Consent for General Medical Treatment was to be signed by the patient or the patient's legal representative upon admission to the facility and the form was part of the admission packet.

These findings were discussed with Staff C at 11:20 AM on 11/09/10.

Based on clinical record review, policy and procedure review, and staff interview; the facility failed to ensure restraint usage was added to the patient's plan of care. This affected two of two clinical records reviewed with restraint usage (Patients 1 and 2).

Findings include:

The clinical record for Patient 1 was reviewed on 11/08/10. The patient was admitted to the facility on 10/31/10. Restraint flowsheets documented the patient was restrained from 11/01/10 at 12:00 AM thru 11/08/10 at 10:00 AM. The care plan in the clinical record for this patient lacked documentation of restraint usage.

The clinical record for Patient 2 was reviewed on 11/08/10. The patient was admitted to the facility on 10/22/10. Restraint flowsheets documented the patient was restrained from 10/22/10 at 9:30
PM thru 11/07/10 at 3:30 PM. The care plan in the clinical record for this patient lacked documentation of restraint usage.

The Restraint Policy and Procedure was reviewed on 11/08/10. The policy stated the use of restraints was to be documented in each patient's plan of care.

These findings were discussed with Staff C on 11/09/10 at 1:15 PM.

Based on clinical record review, observation, policy and procedure review, and staff interview; the facility failed to ensure restraint orders were obtained for all restraint usage. This affected two of two clinical records reviewed with restraint usage (Patients 1 and 2).

Findings include:

The clinical record for Patient 1 was reviewed on 11/08/10 at 2:35 PM. The patient was admitted to the facility on 10/31/10. Restraint flowsheets documented the patient was restrained from 11/01/10 at 12:00 AM thru 11/08/10 at 10:00 AM. The clinical record contained a partial order for soft left limb restraint, but lacked a date, time, and physician signature. The clinical record lacked documentation of a verbal order for restraint usage. On 11/08/10 at 2:35 PM, the patient was observed to have both wrists restrained with soft restraints.

The clinical record for Patient 2 was reviewed on 11/08/10. The patient was admitted to the facility on 10/22/10. Restraint flowsheets documented the patient was restrained from 10/22/10 at 9:30 PM thru 11/07/10 at 3:30 PM. The medical record contained a Restraint Protocol Order dated 10/23/10 at 2:30 PM for bilateral mitten restraints due to the patient pulling out his/her nasogastric tube, however, the medical record lacked documentation of a written restraint order from the physician. The medical record lacked documentation of any additional restraint orders.

The Restraint Policy and Procedure was reviewed on 11/08/10. The policy stated a written or verbal physician's order was needed for any restraint usage. The policy also stated that if a patient was attempting to remove or dislodge a medical device, the order may be written on the Physician Order Restraint Protocol. This protocol would then be in effect for the length of time the patient exhibited the clinical criteria for the restraint.

These findings were discussed with Staff C on 11/09/10 at 1:15 PM.

Based on policy and procedure review, clinical record review, observation, and staff interview; the facility failed to ensure restraint use, comfort and privacy issues, range of motion, repositioning, fluids and nutrition, toileting, monitoring of restraint usage, and the need for continuation of restraints was documented on all restrained patients at least every two hours. This affected two of two clinical records reviewed with restraint usage (Patients 1 and 2).

Findings include:

The Restraint Policy and Procedure was reviewed on 11/08/10. The policy stated staff were to document on the Restraint Flowsheet restraint use, comfort and privacy issues, range of motion, repositioning, fluids and nutrition, toileting, monitoring of restraint usage, and the need for continuation at least every two hours.

The clinical record for Patient 1 was reviewed on 11/08/10 at 2:35 PM. The patient was admitted to the facility on 10/31/10. Restraint flowsheets documented the patient was restrained from 11/01/10 at 12:00 AM thru 11/08/10 at 10:00 AM. The Restraint Flowsheets lacked documentation of the above assessments on 11/01/10 from 2:00 PM until 8:00 PM, on 11/02/10 from 6:00 PM until 8:00 AM on 11/03/10, and on 11/08/10 after 10:00 AM. On 11/08/10 at 2:35 PM, the patient was observed to have both wrists restrained with soft restraints.

The clinical record for Patient 2 was reviewed on 11/08/10. The patient was admitted to the facility on 10/22/10. Restraint flowsheets documented the patient was restrained from 10/22/10 at 9:30 PM thru 11/07/10 at 3:30 PM. The Restraint Flowsheets lacked documentation of the above assessments on 10/22/10 from 9:30 PM until 12:00 AM on 10/23/10, on 10/24/10 from 6:00 PM until 12:00 AM on 10/25/10, on 10/29/10 from 8:00 PM until 8:00 AM on 10/30/10, on 10/30/10 from 6:00 PM until 8:00 AM on 10/31/10, on 11/04/10 from 2:00 PM until 8:00 PM, and on 11/06/10 from 10:00 PM until 11:00 AM on 11/07/10.

These findings were discussed with Staff C on 11/09/10 at 1:15 PM.