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Based on record review and interview the facility failed to implement it's grievance policy revised 12/2011 to send written notification within seven (7) days to complainants regarding the status of a complaint investigation;

The facility failed to send the written notification to a family member who made a complaint regarding his dis-satisfaction with the care and services his mother received as a patient in the facility. Citing one (1) patient named in a complaint investigation ,patient (#1).

Findings:

Review of complaint narrative revealed the complainant made the following allegations:
His mother had few baths while she was a patient in the hospital.
Staff took more than an hour to assist patient when she used the commode,
it took two days for doctors to explain why his mother was not getting regular fluids;
and when he voiced his concerns to the Case Manager she was not receptive and was rude, as a result he had to go to the Director of Nursing with his concerns.

During an interview on 11/20/2012 at 9:15 am at the facility with the Chief Executive Officer (CEO) she stated there was no documentation of a formal complaint made by the family , however the Director of Nursing did inform her of the family's concerns and that the matter was investigated and revealed there were some nursing issues and some truth of the Case Manager being rude.

The CEO stated a written response was not sent to the family and she did not have evidence that corrective measures were implemented.

Review of the facility's grievance policy revised 12/2011 revealed the following information:

"The grievant should be notified within seven (7) calendar days that the grievance has been received and an investigation is in progress. An initial grievance acknowledgement letter is sent via certified mail/signature required. A second copy of the letter will be sent via regular mail."

There was no evidence that this policy was implemented.

Based on record review and interview the facility failed to enforce it's patient care policy revised 4/2012 to ensure a patients have adequate hygiene care. The facility failed to provide documentation that patient (#1) had a bath for three days while she was a patient in the hospital.

Findings:

Review of a complaint narrative revealed allegations that Patient (# 1) did not have a bath on multiple days.

Review of the facility's Nursing Policy/Procedure revised 4/2012 revealed the following information:

"To ensure a patients have adequate hygiene, to promote comfort and increase self esteem.

It is the policy of the facility to provide patients with the opportunity to bathe or shower on a regular basis or as medical condition permits".

During an interview on 11/20/2012 at 10:15 am at the facility with the Chief Executive Officer (CEO) she stated patients are given a bath daily and it is documented on the nursing notes in the patient's clinical record.

During an interview on 11/20/2012 at 12:35 pm on the Medical Unit (where Patient #(1) was admitted) with a Registered Nurse she stated all patients are given a bath daily. She stated rooms with odd number were done on the night shift and those with even numbers were done on the day shift.
According to the Nurse all baths should be recorded on the patient's bath record by the nurse and if a bath was not done a reason should be documented.

Review of bath record for Patient (# 1) revealed the patient was admitted to the facility on 10/16/2012. She was placed with a 1:1 sitter for high fall risk. The 91 year old patient was completely dependent on staff for her hygiene and bathroom needs.

There was no documentation that the patient had a bath on 10/20, 10/21 and 10/24/2012. There was no documentation that the patient refused and no medical indication for not giving a bath.