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Based on observations, medical record review, family/family interviews, staff interviews and review of facility documents the facility failed to provide contact information to file a complaint/grievance with the state licensing agency for five of five patients in the survey sample. (Patients #1-#5)

The findings included:

An observation conducted on February 7, 2012 at 10:48 a.m. when entering the facility did not reveal the State licensing agency's contact information for filing a complaint or grievance was posted.

Review of the admission information given to patients or their representatives did not include written information related to filing a complaint/grievance with the State licensing agency or provide the agency's contact information (Name, address and toll free telephone number).

Review of medical records for Patients #1 through Patient #5 revealed forms signed by the patient or family member titled "Patient's Rights" and "Patient's Responsibilities." The forms did not include written information for filing a complaint/grievance with the State licensing agency and did not provide the State licensing agency's contact information.

An interview was conducted on February 7, 2012 at 2:48 p.m. with Patient #5. Patient #5 reported he had not been aware of the possibility of filing a complaint with the State licensing agency.

An interview was conducted on February 7, 2012 at 3:26 p.m. with the spouse of Patient #1. Patient #1's spouse reported not being aware of the ability to file a complaint or grievance with the State licensing agency. Patient #1's spouse stated "That should be included with all the other information they provide."

An interview was conducted on February 7, 2012 at 3:38 p.m. with Staff # 1, the Director of Quality. Staff #1 reviewed the patients' rights and responsibilities information given to patients and or their representatives. Staff #1 acknowledged the information did not include the contact information for the State licensing agency. Staff #1 stated, "It's not there. It should be there." Staff #1 stated, "I don't know when it was left off. All the forms in all the charts are going to be the same." Staff #1 reviewed Patient #1 -#5's written rights information. Staff #1 reported that none of the patients admitted to the facility from October 2011 through current patients had received contact information for filing a complaint/grievance with the State licensing agency.

Based on medical record review and staff interview the registered nurses failed to ensure that patient's need for every two hour turning and repositioning had been accomplished by assigned nursing personnel for four of four patients with a physician's order to reposition/turn. (Patients #2- #5)

The findings included:

Patient #2 admitted to the facility on October 17, 2011 had a physician's order for the patient to be turned and repositioned every two hours. Review of Patient #2's medical record revealed documentation by the surgeon, consulted for the patient's wound care, which included reminders to the staff to turn the patient every two hours. Review of nursing data entered by nursing assistants reveal inconsistent documentation that Patient #2 had been turned or repositioned every two hours.

Patient #3 was admitted to the facility on December 12, 2011 with a physician's order to be turned and repositioned every two hours. Patient #3 had been admitted to the facility with multiple pressure ulcers. Review of nursing data entered by nursing assistants revealed inconsistent documentation that Patient #3 had been turned or repositioned every two hours.

Patient #4 was admitted to the facility on January 20, 2012 with a physician's order to be turned and repositioned every two hours. The data entered by the nursing assistants revealed inconsistent documentation that Patient #4 had been turned or repositioned every two hours.

Patient #5 had been admitted to the facility on January 24, 2012 with a physician's order to be turned and repositioned every two hours. Patient #5 had been admitted to the facility with a coccyx pressure ulcer. The data entered by the nursing assistants revealed inconsistent documentation that Patient #5 had been turned or repositioned every two hours.

An interview was conducted on February 9, 2012 at 3:15 p.m. with Staff #3 (Chief Clinical Officer). Staff #3 reviewed with the surveyor the nursing documentation for Patients #2 to #5. Staff #3 acknowledged the patients had physician orders to be turned and or repositioned every two hours. Staff #3 reported the facility's expectation would be for nursing staff to follow the physician order and for responsible staff to follow through with carrying out the order. Staff #3 reported the facility had been aware of an inconsistency in staff's documentation and follow through with turning and repositioning patients. Staff #3 stated, "One of the patient/family complaints I receive during Leadership rounds is that the staff are not turning the patients. It is a question we ask them during rounds." Staff #3 acknowledged the care of the patient was the responsibility of the registered nurse (RN). Staff #3 reported the RN was responsible to follow up with nursing assistants to ensure the tasks assigned were completed. Staff #3 reported the facility was aware and had offered in-services to staff, but had not made the concern a matter of their quality assurance program.