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Based on record review and interview the facility failed to ensure that one of five (Patient #12) grievances received a written response and two of six grievances were investigated as documented on the response letters to two patients (Patient #13 and Patient #14). The facility census was twenty-three.

Findings included:

Review of the facility policy titled "Complaint and Grievance Process" dated as revised 02/02/07, states the policy purpose is Select Specialty Hospital has established a mechanism for receiving, acting upon, and responding to patient, families, and visitors expressing concern for patient treatment.

....The investigative procedure should be completed, corrective action taken and a written response sent within seven days of receipt of the complaint. ... ...

.....The written response must contain the following: ...
a) A description of the issues raised by the grievance.
b) A description of the steps taken to investigate the issue.
c) The date the grievance was resolved and what steps were taken to resolve the grievance.
d) The name of the contact person at the hospital that the patient can call with additional questions.

Review of the two grievances filed by Patient #12 showed the first one filed on 02/01/10 regarding call light response. There is no record of any written response to Patient #12.

On 02/10/10 Patient #12 again filed another grievance regarding treatment by staff. There is no record of any written response to Patient #12.

Review of the grievance filed by Patient #13's son on 03/24/10 regarding staff treatment. The letter dated 04/01/10 written to the son states "The staff responsible for patient #13's care was interviewed", however, the complaint/;Grievance Log section where Investigative Findings are documented, does not include any interview with staff caring for the patient.

Review of the grievance filed by the wife of patient #14 on 03/24/10 regarding call light response. The letter dated 03/26/10written to the wife states "The staff responsible for Patient #14's care was interviewed", however, the complaint/;Grievance Log section where Investigative Findings are documented, does not include any interview with staff caring for the patient and is blank.

During an interview with on 04/28/10 at 15:20 p.m. Quality Manager, staff M said that during a meeting in 02/10 the Corporate office instructed letters should be sent to all patient complaining, however, Patient #12 did not get any letters.
Review of the facility form titled "Patient /Family Report-Complaint/Grievance", undated, states in section (E) Investigative Findings: (Attach copies of all written documentation utilized during investigation).

Based on observation, the facility failed to protect patient's rights to privacy by placing one (Patient #13) name in public view on one of two patient care halls; and names of all patients receiving rehabilitative services on a whiteboard in the Rehabilitation Department. The facility census was 23.

Findings included:

1. Review of the facility's policy titled, "Patient Rights", revised 03/29/02, gave direction, in part, to include the following:
"Every patient admitted to Select Specialty Hospital has certain rights and responsibilities. These rights are guaranteed and respected by the personnel of Select Specialty Hospital, but must also be adhered to by the physicians, families and visitors of Select Specialty Hospital."
"Confidentiality. You will be assured confidential treatment of your personal and medical records and may approve or refuse their release to an individual outside the Hospital ..."

2. Observation on 04/26/10 at 1:00 p.m. on "A Hall" showed a small, open, blue container, marked "Specimens and Pick Up" at the nurses' desk, set on the ledge where the public could easily view. Inside the container was a label with a patient's name.

3. Observation on 04/27/10 at 2:10 p.m. on "A Hall" showed the same blue container with the same patient's label inside and in public view.



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4. Observation of the Rehabilitation Department on 04/29/10 at approximately 11:00 a.m. showed a white board listing the names of patients who were receiving physical therapy, speech therapy and/or occupational therapy. The white board was visible to any patients receiving therapy within the Department.
5. During an interview on 04/29/10 at 11:15 a.m., staff BB said that every patient within the facility receives therapy at varying levels of intensity and frequency.

Based on observation, and record review, the facility failed to ensure oral fluids were thickened as ordered by the physician for one (Patient # 8) of one reviewed for compliance with dietary orders. The census at the facility was 23.

1. Observation on 04/26/10 at 1:30 p.m. showed RN staff D administering oral medications to Patient #8 using water from the water faucet in the room after Patient #8 refused to utilize thickened fluids on the lunch tray.

2. Review of Patient #8's medical record on 04/26/10 at 1:05 p.m. showed the following (in part):
- A Speech Pathology Clinical Dysphagia Evaluation dated 12/10/09 indicating:
- Documentation of "long term swallow difficulties;"
- Slowed rate of swallow for thin, thick, and soft consistencies;
- Suspected aspiration for thin consistencies, and potentially for soft consistencies;
- Nectar thickening was recommended.
- A physician order dated 02/17/10 at 7:30 a.m. to increase diet to mechanical soft with nectar thick liquids.
- A physician progress note dated 04/25/10 noting "PO (by mouth) diet. Nectar thick."

Based on observation, record review and interview, the facility failed to ensure medications were administered within 30 minutes of the scheduled time for two (Patient #3 and Patient #8) of seven patients observed during medication administration. The facility census was 23.

Findings included:

1. Review of the facility policy titled, "Medication Administration", revised 02/19/10, gave direction, in part, to include the following:
"Follow the '6 Rights' of medication administration. Administer:
1. The Right medication
2. At the Right time
3. In the Right dose
4. To the Right patient
5. By the Right route
6. In the Right circumstance"
"Medications are given at the time ordered or within 60 minutes before or after the time designated."

2. Observation on 04/27/10 at 9:45 a.m. showed Registered Nurse (RN), staff EE, administer the following medications to Patient #3:
Clonazepam (medication used to reduce anxiety) 0.5 mg (milligram) tablet;
Docusate Sodium (treats constipation) 100 mg capsule;
Fentanyl (narcotic pain medication) 150 microgram patch;
Hydrodiuril (medication that helps remove excess fluid) 12.5 mg tablet;
Omeprazole (medication for heart burn) 40 mg capsule;
Oxycodone (narcotic pain medication) 40 mg tablet

Review of Patient #3's medical record showed a document titled, "Medication Administration Record" (MAR). The MAR showed that the medications were scheduled to be administered at 9:00 a.m. and were given at 9:45 a.m.


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3. Observation on 04/27/10 at 9:50 a.m. showed RN staff D administer the following medications to Patient #8:
Famotidine (used to inhibit stomach acid production) 20 mg
Ferrex (a mineral used to prevent and treat iron deficiency) 150 mg
Florastor (used to prevent and treat diarrhea) 250 mg
Isoniazid (an antibiotic used to treat tuberculosis) 300 mg
Magnesium Oxide (dietary supplement) 400 mg
Pyridoxine (combats the toxic effects of Isoniazid) 100 mg
Multivitamin
Ascorbic Acid (Vitamin C) 500 mg

Review of Patient #8's MAR showed the medications were scheduled to be given at 9:00 a.m. and were charted as being given at 9:00 a.m. rather than the actual time they were administered.

4. During an interview on 04/29/10 at 1:05 p.m., Director of Clinical Services, staff A, stated that there was no way they could safely administer all their medications within 30 minutes before and 30 minutes after the scheduled time.

Based on observation, record review and interview, the facility failed to obtain physician's orders that contained all necessary information to administer medications to two (Patient #2 and #3) of six patients observed during medication administration. The facility census was 23.

Findings included:

1. Review of the facility policy titled, "Drug Orders", revised 08/08, gave direction, in part, to include the following:
"Orders for medications must be written clearly by an authorized person and be within legal and practical limits. Orders that do not meet these criteria are considered to be invalid and will not be honored by a pharmacist without further communication with the prescriber."
"Dose ranges for PRN (as needed) orders will not be accepted. The physician must choose a dose at the time the order is written. Instead of a range, it is recommended that step-wise orders be written. For example: Give one Percocet 5/325 tablet every hour hours for pain. Repeat dose in one hour if not effective. Max of two tablets every 4 hours."

Review of the facility policy titled, "Medication Administration", revised 02/19/10, gave direction, in part, to include the following:
"Dose ranges for PRN (as needed) orders will not be accepted. The physician must choose a dose at the time the order is written. Instead of a range, it is recommended that step-wise orders be written. For example: Give one Percocet 5/325 tablet every hour hours for pain. Repeat dose in one hour if not effective. Max of two tablets every 4 hours."

2. Observation on 04/26/10 at 2:50 p.m. showed Registered Nurse, staff DD, administer Dilaudid (narcotic pain medication) to Patient #2.

Review of Patient #2's medical record on 04/26/10 at 3:05 p.m. showed a physician's order written 04/25/10 for the following:
"Dilaudid 2 mg (milligrams) po (by mouth) q (every) 4 h (hours) PRN (as needed) mod (moderate) / severe pain".
The facility document titled, "Medication Administration Record" (MAR) showed the following:
"Hydromorphone (Dilaudid) 2 milligrams po every four hours as needed for severe pain".
The instructions to include "moderate" pain was not transcribed to the MAR.

3. Review of current Patient #3's medical record on 04/27/10 at 10:10 a.m. showed the following:
- A physician's order written 04/26/10 for:
"Tylenol 325 mg 1 or 2 po q 6 h PRN pain if > (greater than) T (temperature) 101 (degrees)".
There were no parameters ordered of when to administer one tablet and when to administer two tablets. The MAR reflected the first option as "Tylenol 1 tablet po every 6 hours as needed for pain/fever"; and the second option as "Tylenol 2 tablets po every 6 hours as needed for pain/fever >101".
- A physician's order written 04/26/10 for:
"Oxycodone (narcotic pain medication) 10 or 15 mg po q 4 h PRN mod - severe pain".
There were no parameters ordered of when to administer 10 mg and when to administer 15 mg. The MAR reflected the first option as "Oxycodone 10 mg po every hours hours as needed" and did not include any reason or justification for when to administer this dose. The second option reflected on the MAR was "Oxycodone 15 mg po every hour hours as needed" and did not include any reason or justification for when to administer this dose.

During an interview on 04/27/10 at 10:25 a.m., Pharmacist, staff C, confirmed the above orders did not include specific parameters and stated that he/she is aware of the requirement. Later, staff C stated that it was late in the evening when he/she took the orders off.

Based on observation and interview, the facility failed to ensure staff followed facility isolation precautions related to application of Personal Protective Equipment (PPE) for one (Patient #22) 15 patients on isolation precautions; failed to follow facility policy and standard of practice for gloving and hand hygiene for one patient (Patient #6) of three patients observed receiving wound care; and the dialysis staff failed to clean the equipment between patient uses for one (Patient #18 ) of one case observed. The facility census was 23.

Findings included:

1. Review of the information provided by the facility with a page titled, "How to Don PPE (Personal Protective Equipment)", gave direction, in part, to include the following:
"Gown
Put on gown (opening in back)
Tie gown
Must be secure at neck and waste"

2. Review of the information provided by the facilitiy with the page titled, "Guidelines Related to PPE and Safe Work Habits, stated on page one at number 10, "Principles of working from clean to dirty must be followed. There is a need to protect both the patient and the healthcare worker. Gloves should be changed and hand hygiene performed when moving from a 'dirty task' such as cleaning stool to a clean task such as bathnig the patient".

3. Observation on 04/28/10 at 2:55 p.m. showed Nurse Practitioner, staff X, enter Patient #22's room. Patient #22 was on contact isolation precautions for multi-drug resistant Pseudomonas (infection resistant to antibiotics). A sign posted at the patient's doorway instructed anyone who entered to wear an isolation gown and gloves. Staff X put an isolation gown on but only slid his/her arms into the gown, and did not secure it around the neck or waste. While listening to the patient's chest, Staff X's isolation gown slid down to be just around the forearms, exposing much of the front of his/her clothing and person.

During an interview on 04/28/10 at 3:10 p.m., staff X stated that he/she was not aware that the isolation gown was not secured around his/her neck and waste and would watch that.

During an interview on 04/28/10 at 3:45 p.m., Infection Control nurse, staff M, confirmed the isolation gown is to be placed over the neck to be secured around the neck and then tied at the waste.



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4. Observation on 04/26/10 at 3:30 p.m. of a left foot dressing change for Patient #6 showed staff AA, Registered Nurse (RN) apply gloves and remove the old dressing. The old dressing contained a moderate amount of drainage.
Staff AA then removed gloves and performed hand hygiene, cleaned the wound and applied the new dressing without changing gloves/performing hand hygiene.

Staff M, Infection Control Designee and staff GG, Infection Control Consultant said during an interview on 04/05/10 at 10:00 a.m. that they would expect nursing to change gloves and conduct hand hygiene after cleaning a wound and applying a new dressing.



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For cleaning of dialysis equipment:

5. Review of the policy from the DaVita contract service for dialysis, " Infection Control in the Hospital Dialysis Setting " showed, in part, "{Point} 34. The outside surfaces of all equipment will be wiped with a bleach solution prior to removal from treatment area".
6. Observation on 04/28/10 at 1:45 P.M. revealed the dialysis nurse, staff W, finished the dialysis treatment for Patient # 18. Staff W cleaned the dialysis machine, but failed to clean the cart holding the Reverse Osmosis water treatment tanks and cart.
During an interview on 04/29/10 at 8:55 a.m., DaVita Dialysis Facilities Administrator, staff Z, stated that the dialysis supply cart should stay outside the patient's room and the nurse only take the supplies in the room that are to be used for that patient. Staff Z stated that the equipment is to be wiped down after every patient.