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Based on interview and record review, the facility failed to follow its complaint/grievance process.

The facility failed to document and fully investigate multiple concerns expressed by the family of Patient # 5.

Findings include:

TX 00214009

Review of Intake # 00214009 revealed documentation of several issues regarding the care and treatment of Patient # 5. Issues documented included that Patient # 5 fell out of the wheelchair and hurt her leg. Further review of the intake, it read: " I have spoken with administration; they said they'd look into it. ...facility has done nothing to resolve the issues.."

Interview (telephone) on 04-30-15 at 9:30 a.m. with daughter of Patient # 5, she stated she had still not received a response from the facility regarding her concerns.

Record review of Patient # 5's clinical record revealed she was 81 year old female admitted to the facility on 12-03-14 with left foot cellulitis and third toe left foot status post amputation.

Record review of facility Complaint/Grievance Log 2014-2015 failed to reveal documented complaints or grievances concerning Patient # 5.

Interview on 05-01-15 at 4:40 p.m. with Director of Quality Management (DQM) # 8 she stated Patient # 5's daughter had telephoned her. She was unsure of the date. Patient # 5's daughter said her mother had fallen from her wheelchair because the brakes had failed. In addition, she said Patient # 5 injured her leg.

DQM # 8 went on to say she checked all of the wheelchairs and they were functioning. She also spoke with the physical therapist; there was no evidence that Patient # 5 fell. DQM # 8 said she spoke with Patient # 5 and assessed her leg. There appeared to be dried abrasions on her right shin.

The DQM # 8 said she did not complete a Grievance Form or document her investigation. DQM # 8 said that although had spoken with Patient # 5 when she investigated; she did not provide any feedback or information to the patient's daughter.

Record review of facility policy titled "Patient Complaint/Grievance Process," dated 2/2013 read: " ...If the complaint is not resolved immediately:...The supervisor must : 1. initiate an initial investigation...2 Initiate the Complaint and Grievance Form...DQM responsibilities: ...8. Once the investigation is complete:...c. complete the complaint log with the conclusions and actions..9. Once an action has been taken: a. assure the complaining party is aware of the investigation and actions taken,.."

Based on observation,interview, and record review, the facility failed to promote patient's safety rights for 6 of 10 sampled patients ( Patients # 1, # 2, # 4, # 5, # 7, # 9).

The facility failed to ensure timely response to call lights in order to meet patient needs.

Findings include:

TX 00214009

Observation on 05-01-15 at 10:00 a.m. revealed a constant "'melodious" alarm noise at the nurses station on the 300 hallway. Registered Nurses (RN)# 2 and # 3 were the only staff at the station. Neither appeared to be hearing or noticing the alarm. After approximately 7 minutes, surveyor questioned RN # 2 as to the source of the alarm. RN # 2 got up from the chair and used the intercom system to ask the patient in Room # 302 what she needed.

Additional observation on 05-01-15 at 10:40 a.m. revealed the same constant alarm noise at the nurses station. There was no staff at the station. After approximately 8 minutes, surveyor located a nurse aide and pointed out the ringing call light in room 304.

Review of Intake # 00214009 revealed documentation of several issues regarding the care and treatment of Patient # 5. One of the care issues was Patient # 5 often had to wait "excessive times for her call light to be answered by staff..."

Record review of discharged Patient # 5's clinical record revealed she was 81 year old female admitted to the facility on 12-03-14 with left foot cellulitis and third toe left foot status post amputation.

Interview (telephone) on 05-01-15 at 7:45 a.m. with discharged Patient # 5 , she stated : "...The nurses wanted me to call them when I needed to get up so that I wouldn't fall. I had a recent toe amputation. One time, I called them because I had to go to the bathroom. I waited about 20 minutes and called again. When you 're my age, you can't wait too long. The nurse told me over the intercom she couldn't come right then and to 'just go ahead and go in my diaper & they would clean me up later.' I had to go ahead and soil myself; I had no other choice."

Interview on 05-01-15 at 10 : 00 a.m. with current Patient # 9 she stated she was bedbound and totally dependent on staff for her care. Patient # 9 said the "staff was very, very busy and always rushing around. Not uncommon to have to wait for call light to be answered." Patient # 9 went on to say that "not long ago, she had to wait 45 minutes for the nurses to come and change her colostomy bag. It was leaking and the fluids were burning my skin..."

Interviews on 05-01-15 between 9:30 a.m. and 10:30 a.m. with current Patients # 1, # 2, #4, and # 7: all described delays in staff answering call lights. Most of the patients said they understood the staff was very busy ; the staff usually apologized for the delays.

Interview on 05-01-15 at 4: 30 with Director of Quality Management (DQM) # 8 she stated the facility did not consider call light response an issue. She said the patient satisfaction scores on this issue were good. She did acknowledge there was an occasional complaint regarding call lights; these were addressed and resolved as they occurred. In addition, DQM # 8 said she facility changes the call light sound every 6 months so that staff does not fail to hear the call light due to alarm fatigue. She also reported that a random check of call light response was conducted on various halls each month.

Record review of facility policy titled " Patient Call Devices," dated 2/2012, described assessment of appropriate call light devices to meet patient needs. The policy did not address the expectation of call light response.

Based on observation, interview, and record review, the facility failed to prepare and administer medication in accordance with accepted standards of practice and facility policy.

Facility left medications unattended at the bedside of 1 of 4 sampled patients in the 300 hallway ( Patient # 7) .

TX 00214009

Review of Intake # 00214009 revealed documentation of several issues regarding the care and treatment of Patient # 5. One of the documented issues was "often nurses left medication on the table and did not stay and make sure patient took it."

Observation on 05-01-15 at 10:20 a.m. during initial tour of the 300 hallway, revealed Patient # 7 awake, alert and sitting in bed.

Further observation revealed a clear plastic cup that contained approximately 1 (one) inch of white powder located on Patient # 7's nightstand. When asked, Patient # 7 said it was a "laxative powder." She went on to say it was left there by the medication nurse; could not remember the exact day it was left.

Continued observation revealed an additional clear plastic cup that contained approximately 1 (one) 1/2 inches of white powder located on Patient # 7's "over the bed" table. When asked, Patient # 7 said she "thought it was some type of nutrition powder."

Interview on 05-01-15 at 3:30 p.m. with Director of Quality Management (DQM) # 8, she stated that medications should not be left at the bedside.

Record review of facility policy titled;" "Administration of Medications," dated 01/2007, read: "...1. Administration:...b. Following the dispensing of drugs from pharmacy, medications are to be administered by the practitioner who prepares them. 2. All medications must be properly stored/secured prior to administration. Prepared medication must never be left unattended..."