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Based on review of documentation and interview with staff, it was determined the facility failed to document any investigation of the concerns of patient #2 regarding the quality of care. The facility also failed to follow its own policies and procedures.

Findings included:

A review of facility policy entitled, "Patient Grievance Process," stated "To establish a process for prompt resolution of patient grievances to assure all patient concerns are addressed, resolved and follow-up is completed with the patient or patient's family in the most expeditious manner possible." Review of the policy revealed a definition for a concern and a grievance. The policy stated the definition for a "Concern: a written or verbal concern or objection from a patient, or the patient's designated representative, regarding the quality or appropriateness of patient care that can be effectively addressed and resolved by informal means without a formal grievance procedure or the necessity of providing a written response. Generally a concern can be solved quickly by the staff member receiving the concern." The policy stated the definition for a "Grievance: A written or verbal request by a patient or designated representative to have the facility formally review the patient's concern or objection about the quality or appropriateness of patient care. Generally a grievance would require an investigation and/or may require management level personnel to resolve the grievance. This grievance cannot be resolved promptly by staff present at the time of the grievance." Further review revealed "2. All grievances will be reviewed by the Sr. Clinical Coordinator and CNO no more than 3 weeks after the grievance is filed and the patient will receive a written notice of its decision ..." The policy also stated all grievances received post discharged requesting follow up will be documented on a Patient Concern Response form by the employee receiving the grievance. The form will to be forwarded to the Department/Clinical Director for investigation and resolution.

1. According to the complaint intake form, the patient's representative had dates and the names of the staff members who failed to file the complaint regarding the quality of care received. For example:
a) On 12/15/2011, a telephone call to the facility operator was placed to notify the staff member the patient representative wanted to file a complaint. The facility operator directed the call to staff member #8. The patient representative stated staff member #8 initiated the complaint.
b) On 12/21/2011 at 1:55pm, a telephone conversation with staff member #9 regarding the fall patient #2 sustained which caused possible rib fractures, Thoracentesis Procedure performed without the consent of the patient representative, and other concerns. The patient representative stated that staff member #9 would complete the complaint.
c) On 12/29/2011, the patient representative stated a telephone call was placed to the unit manager at Windsor Gardens and South Hampton Community Hospital had not returned the telephone call.
d) On 1/13/2012 and 1/24/2012, the patient representative followed up on the phone calls placed with staff member #9 and still had not received a returned call.

2. A review of the medical record of patient #2 revealed a face sheet (patient's personal information ie: address, billing information) which had a hand written note dated 12/21/2011. The staff member from South Hampton Community Hospital obtained the information from the unit manager of Windsor Gardens Nursing Home. The unit manager was calling for the representative of patient #2. The call was in regards to a fall patient #2 allegedly sustained at South Hampton Community Hospital. The unit manager was calling the facility to request information regarding the incident report.

In an in person interview on July 9, 2012 at approximately 1:30pm with staff member #1, it was confirmed that the facility failed to perform an internal investigation regarding the information obtained above. In the same interview staff member #1 stated there was no documentation the complaint was filed to the proper departments for investigation. In multiple interviews with staff members #1 and #2 on July 9, 2012, it was confirmed the facility had staff members who failed to perform their assigned duties and are no longer working for the facility.

Based on review of documentation and interview with staff, it was determined the nursing staff failed to evaluate the nursing care provided to patient #2.

Findings included:

Facility policy entitled, "Consent for Medical and Surgical Treatment," stated "2. Minors and Incompetent patients will be treated only upon obtaining consent based on protocol as outlined in this policy." In the General Comments section stated, "3. The patient/responsible party signs form to indicate that consent is given for stated procedure/treatment and which is understood along with risks and hazards. 6. The following definitions are given for clarification: Incompetent Adult- lacks ability to understand and appreciate the nature and consequences of a treatment decision including the significant benefits, harms of, and reasonable alternatives to proposed treatment decision." In the Disclosure and Consent section stated, "5. The Disclosure and Consent form will be ...I or (we) will be struck out; all blanks filled in correctly before the patient or his/her representative, and physician /nurse sign. 6. The physician's first and last name will be used on the Disclosure and Consent form. 7. All Disclosure and Consent forms must be witnessed by one person. This can be the Physician or a nurse who observes the patient or representative signing the form. 10. The consent form will be signed by the individual receiving care with following exceptions ...Incompetent patients. 15. It is the responsibility of the nurse in charge to review the informed consent and insure that proper procedure has been carried out."

Review of the medical record of patient #2 revealed the following:

Patient #2 was admitted from 12/6/2011 through 12/15/2011.

Physician documentation on 12/6/2011, 12/7/2011, and 12/13/2011revealed the patient had a past history of dementia (which is a loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior). Physician progress notes dated 12/14/2011 at 6:00pm stated patient #2 was confused when he stands up in the middle of the room. Nursing daily assessments revealed the patient was confused at times and responded to simple commands.

1. Facility document consent form for a PICC (Peripherally Inserted Central Catheter) line dated 12/9/2011 was signed by patient #2 and was incomplete. The local analgesic medication box was left blank. The section which stated the alternatives to the procedure and the probability of success which had been explained to the patient was left blank. Only the last name of the physician was on the consent form. The sections where the patient was to check a box on the consent form were all left blank.

2. The consent form dated 12/10/2011 for PICC line was signed by the patient's representative and had the necessary boxes checked. Only the last name of the physician was on the consent form.

3. Review of facility document entitled, "Disclosure and Consent Medical and Surgical Procedures," revealed a consent form dated 12/15/2011 at 9:30am to perform a thoracentesis. Patient #2 signed the consent form but the radiology technician dated the consent form. The consent form had only the name of the physician and was signed by the physician and the radiology technician. Facility policy stated the consent forms would have the first and last names of the physician and the witnessed by a nurse. The facility failed to follow its own policy.

4. Review of the radiology report dated 12/15/2011 revealed the physician dictated the informed consent was obtained. The report also stated "utilizing local anesthesia." Further review stated, "unsuccessful attempt at right-sided thoracentesis. Only small amount of Pleural effusion was present."

In multiple interviews on July 9, 2012 with staff member #1, the above was confirmed that the nursing staff failed to properly evaluate the quality of care for patient #2. In an interview with staff member #2 on July 9, 2012 at approximately 5:05pm, it was confirmed that the facility will review its own policies and procedures. In multiple interviews with staff members #1 and #2 on July 9, 2012, it was confirmed the facility had staff members who failed to perform their assigned duties and are no longer working for the facility.

Based on review of documentation and interview with staff, it was determined the facility failed to properly execute the patient's rights for advanced directives.

Findings included:

Review of the medical record of patient #2 revealed a history of dementia (which is a loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior.) Physician documentation revealed the patient had dementia. Nursing daily assessments revealed the patient was confused at times and responded to simple commands.

A review of facility document entitled "Notice to Patients Regarding Your Right To Make Advanced Health Care Decisions," revealed the form was signed by the patient's representative on 12/06/2011. The question, "Do you have a Durable Power of Attorney for Health Care," the patient's representative checked the box "yes." The facility failed to obtain a copy of the Durable Power of Attorney as evidence by there were no documents found in the medical record. There was no documentation the facility spoke with the patient's representative regarding obtaining a copy of the Durable Power of Attorney.

In multiple in person interviews on July 9, 2012 with staff member #1, it was confirmed that the facility failed to request and obtain a copy of the Durable Power of Attorney from the patient's representative.