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Based on interview and record review the facility failed to provide the complainant with a written notice of its decision that contains the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion in that 1 of 1 patients (Patient #2) next of kin filed a grievance with the Director of Nurses (DON) and the grievance process was not followed.

Findings included:

In May of 2019 the daughter of Patient #2 went to the DON with a complaint that Patient #2 was not receiving her medications, but the nurses were charting that the medication was being given. The Supervisor Discussion Tracking Form dated 05/02/19 reflected Personnel #4 charted on the Electronic Medication Administration Record (EMAR) that insulin was given and also documented on the dialysis hand off report that no insulin was given. The documents were not consistent with the actual event.

During and interview on 07/01/19 at 1125 Personnel #1 stated "once the complaint was elevated to the level of the DON this should have become a grievance". There was no incident report regarding the medication error.

The policy titled Resolution of Patient Complaints/Grievances Revised 12/17 reflected..."The Circumstances which indicate a grievance: When the staff present are unable to resolve the issue. If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance..."

Based on interview and record review the facility failed to ensure that all drugs and biological's were administering accordance with Federal and State laws and regulations, and in accordance with he approved medical staff policies in procedures in that 1 of 1 patients (Patient #2) chart reflected medication being given with no corresponding charges for the medication being removed from the Pixis system.

Findings included:

Patient #1 was admitted on 03/27/19 for long term care. Personnel #4 charted on the Electronic Medication Administration Record " 04/29/19 at 0740 HUMAlog SS (sliding scale) ...2 Unit Subcutaneous Lower Left Quadrant ...1130 2 Unit Subcutaneous Lower Left Quadrant ...1630 2 Units Subcutaneous Lower Left Quadrant..." Personnel #5 charted Plavix 75 mg Tablet ...05/08/19 0800 ...05/09/19 0900 ..."

The Supervisor Discussion Tracking Form dated 05/02/19 reflected ..." Reason for discussion: on 04/29/19 Personnel #4 charted on EMAR that insulin was given and also documented on dialysis hand off report that no insulin was given. The documents were not consistent with the actual event. Personnel #4 however, confirmed that no insulin was given to patient based on poor appetite that the EMAR documentation was done in error. .."

During and interview on 07/01/19 at 1105 Personnel #2 stated The Pharmacy Charge Sheet shows no charge for Plavix on 05/08/19, 05/09/19 and 05/10/19. The EMAR shows Plavix was given on 05/08/19 and 05/09/19 and held on 05/10/19 because the patient was in dialysis. Personnel #2 stated the HUMAlog was charted as given 3 times on 04/29/19 during the day shift, but the charge sheet shows the insulin was only pulled during the night shift. The only way to get medication for administrations is through the Pixis. "

The policy titled Medication Administration revised 06/18 reflected..."F. Documentation of Administration...Document medication administration...after each time of administration..."

Based on interview and record review the facility failed to ensure that the medical records were accurately written in that 1 of 1 patient's (Patient#2) medical records contained falsely documented medication administration records.

Findings included:

Patient #2 was admitted on 03/27/19. Personnel #4 documented on "04/29/19 at 0740 HUMAlog SS (sliding scale) ...2 Unit Subcutaneous Lower Left Quadrant ...1130 2 Unit Subcutaneous Lower Left Quadrant ...1630 2 Units Subcutaneous Lower Left Quadrant ...Personnel #5 documented..." Plavix 75 mg Tablet ...05/08/19 0800 ...05/09/19 0900 ..."

During and interview on 07/01/19 at 1105 Personnel #2 stated The Pharmacy Charge Sheet shows no charge for Plavix on 05/08/19, 05/09/19 and 05/10/19. The EMAR shows Plavix was given on 05/08/19 and 05/09/19 and held on 05/10/19 because the patient was in dialysis. The Humalog was charted as given 3 times on 04/29/19 during the day shift, but the charge sheet shows the insulin was only pulled during the night shift. The only way to get medication for administrations is through the Pixis.