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Based on policy review, record review, complaint review, the facility failed to provide a timely review and response for a grievance for Patient #1, one (1) of one (1) patients reviewed.

Findings include:

Review of the hospital's Policy and Procedure Manual revealed, "Patient Complaint or Grievance Policy". The policy's initiated date was 04/1996 and latest reveiwed/revised date was 03/2009:
"1. Purpose:
A. It is the policy of (name of Hospital) that all patients have access to a procedure for submitting concerns, greivnces, complaints or comments. Every Patient has the right to file a complaint with any staff member.
B. To establish a mechanism to assure all patient and/or family concerns or grievance situations are properly documented, reviewed and resolved in an organized, timely and consistent manner.
C. To provide a means of tracking, followup and resolution through as ongoing performance improvement evaluation."


Review of facility documentation revealed that on 01/10/10 at 3:00 p.m. Patient #1's daughter called the facility and reported to the nurse that she had noticed a bruise on her mother's arm and a bump on her head when visiting her mother on 01/08/10. The nurse assessed the patient at 3:30 p.m. and documented a reddish purple bruise under the patient's right upper arm and two (2) small bruises on her right scapula. Photos were taken. No bumps or lesions were found on the patient's head.

During an interview on 02/24/10 at approximately 1:15 p.m. the nurse stated that the physician was not notified of the findings, the findings were not reported to the nurse manager/supervisor/clinical coordinator, no incident report was completed and the aides had not reported any unusual findings to the nurse.

There was no documented evidence that the facility investigated the cause of the bruising or that the family was notified of the results of the concern.

These findings were discussed during an interview with the Clinical Coordinator on 02/24/10 at approximately 2:45 p.m. and discussed during the exit conference with the Chief Nursing Officer at approximately 5:10 p.m. No additional documentation was offered or provided by the facility.

Based on policy review, medical record review and staff interview, the facility failed to ensure that Patient #1, one (1) of one (1) patients reviewed, was provided with a written response of their grievance resolution process.

Findings include:

Review of the hospital's Policy and Procedure Manual revealed, "Patient Complaint or Grievance Policy". The policy's initiated date was 04/1996 and latest reviewed/revised date was 03/2009:
"1. Purpose:
A. It is the policy of (name of Hospital) that all patients have access to a procedure for submitting concerns, greivnces, complaints or comments. Every Patient has the right to file a complaint with any staff member.
B. To establish a mechanism to assure all patient and/or family concerns or grievance situations are properly documented, reviewed and resolved in an organized, timely and consistent manner.
C. To provide a means of tracking, followup and resolution through as ongoing performance improvement evaluation."

An interview with the nurse on 02/24/10 at approximately 1:15 p.m. revealed that there was no documented evidence that the physician was notified of the findings, the findings were not reported to the nurse manager/supervisor/clinical coordinator, no incident report was completed and the aides had not reported any unusual findings to the nurse.

There was no documented evidence that the facility investigated the cause of the bruising or that the family was given a written response of the results of the concern.

These findings were discussed during the exit conference with the Chief Nursing Officer on 02/24/10 at approximately 5:10 p.m. No additional documentation was provided by the facility.

Based on clinical record review and staff interview, the facility failed to ensure that Patient #1, (1) one of (1) one patients reviewed, was free from neglect.

Findings include:

Review of the facility's "Suspected Abuse and Neglect" (effective date:09/01/10; Review date 03/08/08) revealed: "Purpose: All instances of suspected abuse or neglect (whether internal or external to the program) are of concern to the issues of patient care. These will be investigated and reported as is required by state law. Definitions: Neglect is the failure by those legally responsible for the maintenance and care of an individual to provide the proper or necessary support, education (as require by law), medical, nutrition, or housing.

Review of the facility's "Anticoagulation Therapy" (initiated date 01/09; No reviewed/revised date) revealed:
hmonitoring of anticoagulant therapies is needed to ensure quality patient care. Both organizations have indicated concern over anticoagulant therapy being a high risk treatment secondary to adverse drug event potential, complexities in dosing, and need to monitor therapy to ensure quality outcomes.
Policy: The Departments of Pharmacy Services, Nursing, Laboratory, and Food and Nutrition Services shall provide monitoring of anticoagulant therapy to improve efficacy and safety.

A baseline PT/INR, a PTT, and CBC are recommended to be drawn less than 48 hours prior to initiation of anticoagulant therapy. A test for occult stool should also be performed if a recent test has not been performed. In the event that base line labs are not available, a pharmacist will be available to order these labs. 4. In all patients receiving anticoagulation therapy a complete blood count (CBC) is a recommendation at least once every 3 days for the duration of therapy. "

Medical review for patient #1 revealed that the patient was admitted to the facility on 12/31/09. A base line CBC was obtained on 01/01/10. Heparin therapy was not initiated until 1/04/10 (>48 hours after CBC). There was no documentation in the clinical record that a baseline PT/INR and a PTT had been obtained at any time during the hospitalization. There was no documentation that a test for occult stool had been performed. There was no documentation that a CBC had been drawn every 3 days as recommended per policy. There was no documentation that the Food and Nutrition Services had monitored the anticoagulant therapy to improve efficacy and safety. There was no documentation that the pharmacy had monitored and evaluated the anticoagulant therapy.

These findings were discussed during the exit conference with the Chief Nursing Officer on 2/24/10 at approximately 5:10 p.m. No additional documentation was provided.