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Based on medical record review, facility policy review, and interview, the facility failed to ensure a complaint grievance was fully investigated for one (#5) of five residents reviewed.

The findings included:

Patient #5 was admitted to the facility on April 15, 2011 with diagnoses to include Acute and Chronic Respiratory Failure, Trach, Mechanical Ventilation, End Stage Renal Disease, Dialysis, Pacemaker, Morbid Obesity, Malnourished, Dysphagia, and Naso-gastric Tube Feeding.

Medical record review of the Physician's Progress Notes, dated May 3, 2011, at 10:35 a.m., revealed "...yeast to scrotum, perinnium (perineum) skin folds and buttock...wrote (prescription) for Bara cream (moisture barrier cream)...also intradry sheets (dressing placed in skin fold to wick moisture away)...Family met with (Administrator) about concerns..."

Review of the facility document, dated May 3, 2011, no time noted, revealed the patient's sisters complained "...call light response takes 30 - 40 minutes...CNA's (Certified Nursing Assistants) are putting wash cloths over peri area to catch urine and not changing it...not getting good baths...not being turned every two hours...yeast on scrotum and arm pits..."

Medical record review of the Nurse's Notes, beginning May 2, 2011, at 8:33 a.m., through May 3, 2011, at 11:24 p.m., did not reveal any complaints being voices to the nursing staff. Continued review revealed the patient was oriented to person only with occasional awareness of place but not time; had a Braden score of 15 (low risk for development of pressure sores); had slightly limited mobility; was noted with dermatitis covering one half of the perineal and buttock area for which barrier cream was being used; and was turned by two staff every 2 hours using a lift sheet.

Review of the CNA rounding sheets revealed it was documented the patient was turned every two hours; and checked, cleaned and/or changed due to incontinence every two hours.

Review of facility documents revealed the Nurse Manager's follow-up, dated May 3, 2011, to a family complaint, time not documented, included "...explained to daughters the yeast could be due to certain medications...listened to concerns...working with a CNA who is reportedly not making rounds...immediate meeting with CNA's regarding family's concerns, team work, dialysis patients..." Continued review revealed "...issue not resolved..." Continued review revealed the Administrator, Risk Manager, and Chief Clinical Officer were notified of the complaint on May 3, 2011. Continued review revealed a written response was sent to the family on May 4, 2011, acknowledging the complaint issues and indicating the Management staff will be making rounds to assure the patient's needs are being met and the Administrator signed off on May 5, 2011.

Medical record review of the of the Physician's Progress Note, dated May 6, 2011, no time documented, revealed "...Apparently daughter very mad last p.m....Issues addressed between her and Administrator..."

Review of Nursing Notes, dated May 6, 2011, at 6:34 a.m., revealed "...no signs/symptoms of pain exhibited" Continued review of the Nursing Notes dated May 6, 2011, at 9:30 a.m., revealed "...was in patient's room giving IV (intravenous) medications...the daughter started screaming...using vulgarity...said she had called 45 minutes ago for pain medication for (named patient)...asked if the nurse did not respond why she (the daughter) did not call for the supervisor...(daughter) said why in the h*** should I get my a** out of bed to find you. (informed daughter) she would not have to get up...could have called for (night shift supervisor) and (night shift supervisor) would have come immediately...night shift supervisor) went to the front desk to ask about the page for pain meds...(ward clerk) said told (nurse) and (nurse) pager did not go off...."

Review of the Medication Administration Record, dated May 6, 2011, revealed Hydrocodone 5 mg (milligrams)/Acetaminophen 325 mg per feeding tube was given at 6:23 a.m. and documented as being effective by 7:00 a.m.

Review of the facility policy Patient Complaint/Grievance Process, number H-PC- 05-007, dated as revised December 2008, revealed "...Patients have the right to express concerns and expect resolution in a timely manner...A verbal complaint that is made by a patient, or on the patient's behalf that can be resolved on the spot by the staff present. If the complaint cannot be resolved at the time of the complaint by the staff present, is postponed for later resolution, is referred to other staff for resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance...Grievance is a written or verbal complaint...regarding any aspect of the patient's care...that cannot be resolved on the spot by the staff present ...Lodging and managing a complains...The staff person receiving the complaint logs it in the Complaint/Grievance Log ...Upon receipt of the complaint, the DQM (Department of Quality Management) or designee enters the complaint on the Complaint/Grievance Log...Managing the Log...Each of the following 10 elements are required: Patient Name...Complaint/Grievance Issue...Date Issue Received...Source of the Complaint/Grievance...Method of Receipt...Date Grievance Report Completed...Written Response...Date Response Letter Sent...Date Issue Closed (Resolved)...Comments..."

Interview in the office of the Chief Clinical Officer on June 6, 2011, at 1:30 p.m., with the Chief Clinical Officer confirmed the complaint of May 6, 2011 was not documented into the Complaint/Grievance Log for follow up pewr facility policy. Continued interview confirmed the complaint was only partially resolved and required further follow up to determine if there were issues with the individual nurse paging system.
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