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Based on observation, interview and record review the facility failed to post or provide contact information to patients or their representatives on how to file a complaint/grievance with the appropriate State agency for six (Patients #1, #2, #3, #4, #5,and #6) of six current patient records reviewed The facility census was 25.

Findings included:

1. Record review of the facilities policy number RI.7.6 titled, "Complaint/Grievance Process", revised April 2010, showed the following:
-all patients receive information explaining that they may file a grievance with a representative of the Hospital. The information will also explain that patient's may file a grievance with the State of Missouri Department of Health and Human Services. The information includes the telephone number and address for the Missouri Department of Health and Human Services.
-An attachment to this policy showed "Patient Grievance Form" which indicated it was part of the "Patient Admission Packet". Instructions on this form explain how a patient could file a grievance and the address and phone number to the Missouri Department of Health and Senior Services.

2. Observation on 10/15/12 of the facility's main lobby and waiting room area showed one posting of the Patient's Rights and Responsibilities. This posting contained no information on how to file a grievance or how to contact the appropriate State agency to file a concern. No other information regarding Patient's Rights was available to read in the waiting room area.

3. Review of the facility document titled, "Patient Rights and Responsibilities" which the facility provided in the "Admission Packet" showed the following:
- You have the right to express concerns about your care or possible violations of your rights either verbally or in writing and to receive a prompt resolution without fear of coercion, discrimination, reprisal, or unreasonable interruption in your treatment. You may direct your complaint to any hospital staff or physician.

The facility did not provide information on how to file concerns about the quality of care at this facility with the Department of Health and Senior Services, Post Office Box 570, Jefferson City, MO 65102 or to include either the toll-free telephone number of (800)392-0210 or the direct number (573)751-6303.

4. During an interview on 10/15/12 at 2:35 PM, Staff D, Charge Nurse, stated that every patient or family member is required to sign a copy of the Patient's Right and Responsibilities document at the time of admission. A copy of this document is placed in the patient's medical record and the original is given to the patient or family member.

5. Record review of the current medical records for Patients #1, #2, #3,
#4, #5, and #6 showed a signed copy of the Patient's Rights and Responsibilities document. None of the documents contained information on how a patient or family member could file concerns about the quality of care at this facility with the Department of Health and Senior Services.

6. During an interview on 10/15/12 at 2:45 PM family member of Patient #1 stated that she could not recall any information on how to file a concern with the Department of Health and Senior Services. She did remember signing and receiving a copy of the Patient's Rights and Responsibilities document.

7. During an interview on 10/16/12 at 10:55 AM family member of Patient
#6 stated that she could not recall any information on how to file a concern with the Department of Health and Senior Services. She did remember signing and receiving a copy of the Patient's Rights and Responsibilities document.

8. During an interview on 10/17/12 at 3:10 PM Staff O, Director of Nursing, stated that the "Patient Grievance Form" [which contained the address and phone number to the Missouri Department of Health and Senior Services] was supposed to part of the Admission Packet and she was not sure why it was not being included.

Based on observation, interview and policy review the facility failed to ensure the Pharmacy department removed expired medications from the patient medication storage bins or the medication room. Five vials of expired Insulin (medication used to control blood sugar) were available in the medication room. This deficient practice placed patients at risk to receive outdated, unusable drugs. The facility census was 25.

Findings included:

1. Record review of the facility policy titled, "Multiple-Dose and Single Dose Containers- Infection Control" dated, January 2010, showed:
- Multiple-Dose sterile drugs may be used for 28 days after initial entry.
- The expiration date should be clearly noted on the Multi-Dose Vial.
- All expired, damaged or contaminated medications will be segregated until removed.

2. Observation on 10/15/12 at 1:20 PM in the Medication Room showed a shelf with separate medication storage bins for each patient for storage of patient specific Insulin and ointments.
-Bin for Room #103 contained a vial of Novalog Insulin with a written expiration date of 10/14/12.
-Bin for Room #106 contained a vial of Levemir Insulin with a written expiration date of 10/14/12 and a vial of Novalog Insulin with a written expiration date of 9/25/12.
-Bin for Room #207 contained a vial of Novalog Insulin with a written expiration date of 10/03/12.
-On the counter in the medication Room was a vial of Novalog Insulin labeled for Patient #40 with a written expiration date of 9/21/12.

3. During an interview on 10/15/12 at 1:30 PM, Staff AA, Registered Nurse (RN), stated that the vials should be removed from the area when it is beyond the expiration date. Staff AA stated he is not sure why the vials are still in the medication room.

4. During an interview on 10/15/12 at 2:45 PM Staff T, Staff Pharmacist, stated that it was unacceptable to have medication (Insulin) available after the expiration date. Staff T stated that Insulin expires 28 days after it is first accessed.

5. During an interview on 10/16/12 at 1:45 PM Staff F, Director of Pharmacy, stated that this situation (expired medication in patient's bin) has caused them to rethink their process. Staff F stated that some of the medications were from patients that had been discharged.

Based on interview and record review the facility failed to have a mechanism in place for on-going reassessment of the discharge planning process. The facility census was 25.

Findings included:

1. During an interview on 10/16/12 at 1:30 PM Staff P, Case Manager, stated that the facility did not have any Quality Assessment Performance Improvement (QAPI) activities for the assessment of effectiveness of the facility's discharge planning process.

2. During an interview on 10/16/12 at 3:45 PM Staff W, Director of Quality Management, stated that the facility sends out a survey to patients and keeps track of the disposition of patients on discharge. She also stated that there were not any other QAPI activities for the assessment of the effectiveness of the facilities discharge planning process.

3. Record review of the facility survey titled, "Patient Perception of Care Survey," showed no questions that assess the effectiveness of the facilities discharge planning process.

4. During an interview on 10/17/12 at 8:30 AM Staff V, Chief Executive Officer (CEO), and Staff W stated that the facility did not have any policies related to discharge planning QAPI.