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Based on interview and document review, it was determined the facility staff failed to document patient's rights were provided for one (1) of six (6) patients included in the survey sample, Patient #4.

The findings included:

Review of Patient #4's electronic medical record (EMR) was conducted on 1/10/2017 at 5:00 p.m., with Staff Member #6. Patient #4 was admitted to the facility on 11/16/2016 for rehabilitation. Staff Member #6 navigated Patient #4's EMR to the screen designated for the documentation that the patient or representative had been provided a copy of their patient rights. The section of the EMR screen for documenting the presentation of patient's rights, their understanding, and whether the information was provided to the patient or the patient's representative was blank.

The surveyor and Staff Member #4 continued the review of Patient #4's EMR at 9:00 a.m. on 01/11/2017. Staff Member #4 reviewed Patient #4's EMR for documentation the patient or his/her representative was provided with patient's rights information. Staff Member #4 stated, "The rights were not documented as given." Staff Member #4 reviewed Patient #4's EMR for scanned documentation. Staff Member #4 stated, "I can't find that documentation was scanned in at this point." The surveyor restated Staff Member #4's findings that "At 9:14 a.m. on 01/11/2017 [Patient #4's name]'s electronic medical record did not contain evidence the patient or [his/her] representative was provided information regarding patient rights." Staff Member #4 stated, "Yes, at this point, I have not found documentation the patient or family received patient's rights information.

An interview was conducted on 01/11/2017 at approximately 9: 20 a.m., with Staff Member #1 and Staff Member #4. Staff Member #1 reported that an information package was provided to all patient's on admission in their "WITH (Wellness Information and Tools for Health)" binder. Staff Member #1 and Staff Member #4 agreed they were unable to provide documentation that Patient #4 actually received the "WITH" binder.

Based on interview, document review and complaint investigation it was determined the facility's quality program failed to ensure:

1. The facility leadership developed and adopted policies to promote a non-punitive approach related to staff members reporting medical errors, near misses, or other unsafe situations; and

2. Failed to analyze data related to the absence of reports related to near misses or reporting of other unsafe situations.

The findings included:

1. An interview and review of the facility's quality program was conducted on 01/11/2017 from 3:58 p.m. through 5:31 p.m., with Staff Member #4. The surveyor requested to view facility policies, which encouraged staff to report adverse events, near misses, or other unsafe situations. Staff Member #4 reported that all staff was informed during orientation of their need to report adverse events as well as near misses. The surveyor asked to review the policies or procedures regarding the facility's non-punitive approach to staff members reporting of adverse events, near misses and other unsafe situations. Staff Member #4 was not able to locate a policy on the facility's intranet, which addressed reporting of adverse events, near misses and other unsafe situations would be non-punitive.

Staff Member #4 presented the facility's orientation information related to quality. The first line of the slide presentation was "Don't be afraid to speak up." The slide presentation did not include a non-punitive approach to reporting adverse events, near misses and other unsafe situations. Staff Member #4 presented a document partially titled "Just Culture" which addressed reporting adverse events, near misses and other unsafe situations, but did not include a non-punitive approach. Staff Member #4 confirmed the document was "not something that all staff' could easily access. At 5:31 p.m. Staff Member #4 stated, "We do not have a policy related to non-punitive reporting (of adverse events, near misses and other unsafe situations)."

2. An interview and review of the facility's quality program was conducted on 01/11/2017 from 3:58 p.m. through 5:40 p.m., with Staff Member #4. Staff Member #4 reviewed the quality projects, and tracking of adverse events. Staff Member #4 reported the facility had a electronic system for reporting of adverse events, near misses and other unsafe situations. Staff Member #4 explained and examined the of adverse events, near misses and other unsafe situations data analysis with the surveyor. The analysis revealed the facility did not have reports of near misses in the first (1st) through third (3rd) quarters of 2016. Staff Member #4 reported it was unlikely that no near misses occurred during the three (3) quarters of 2016. Staff Member #4 explained the facility's fourth quarter data would not be analyzed until late January or early February 2017. Staff Member #4 and the surveyor reviewed three of the events for 2016 that Staff Member #4 felt might have been missed entered near misses. Review of the entered data revealed the three (3) incidents were actual incidents and not near misses. Staff Member #4 verbalized understanding that it was desirable to have near misses reported in order to correct system issues which might reduce the number of actual incidents. Staff Member #4 verbalized understanding the need to engage the facility's staff members and establish a non-punitive approach, which would increase their comfort level in reporting near misses.