HospitalInspections.org

Based upon review of hospital policies and procedures, medical records, patient grievances, Quality/Risk Management Reports of Events, and administrative and staff interviews, the hospital failed to meet the Condition of Participation for Patient Rights as evidenced by:

A. Failure of the Governing Body to ensure: 1) Policies and Procedures related to the Grievance Process were followed as evidenced by the failure to include all patient grievances in the Quality Assurance/Performance Improvement Program of the hospital so that the Quality Assurance Coordinator could review and analyze the findings of the investigation through the hospital's Quality Assurance/Performance Improvement Program, and 2) policies and procedures were followed related to reporting to appropriate state agencies allegations of abuse/neglect within 24 hours. (A119)

B. Failure of the hospital's direct care personnel to follow the patient grievance process policy and procedure related to: 1) reporting to appropriate supervisor/administrative hospital personnel patient allegations of verbal/physical abuse, 2) the Registered Nurse initiating the required patient complaint forms when informed of allegations of verbal/physical abuse. This failure was evident in 2 of 5 sampled records. (A122)

C. Failure of the hospital administrative, nursing and social service departments to follow policies and procedures relative to: 1) reporting at the time of occurrence, alleged patient abuse to the appropriate supervisor/administrative staff in accordance with hospital Policy #RI-00-07 for Identifying and Reporting Patient Patient Abuse and Neglect, 2) conducting a comprehensive investigation into the allegations of verbal/physical abuse which included obtaining written statements or interviews with direct care personnel who were present when the alleged abuse occurred, and 3) report alleged or suspected cases of patient abuse within 24 hours according to State Law R.S.2009.20 B.(1) to appropriate state agencies as identified in hospital policies and procedures. This failure was evident in 2 of 5 records sampled. (A145)

Based upon review of hospital policies and procedures, Patient Occurrence Reports filed in November 2010, and administrative and staff interviews, the Governing Body failed to ensure the grievance process was effectively operated as evidenced by: 1) failing to ensure all patient grievances were forwarded to the Quality/Risk Management Coordinator for review and analysis through the hospitals Quality Assurance/Performance Improvement Program, 3) failing to follow policy and procedure related to reporting to appropriate state agencies allegations of possible abuse within 24 hours. Findings:

On 11/23/10, 11:00 AM, interview with Registered Nurse (RN) S7 and Licensed Practical Nurse (LPN) S9 revealed when asked about the routing of patient complaint forms, RN S7 stated if a patient had a complaint, they would complete the form titled "Patient Report of Concern". The form would then be placed in the plastic bin that was located on the wall behind the nursing station. Inspection of the bin revealed there were numerous pink and white pages located in the bin and when RN S7 was asked what other forms were placed in the bin, she stated the daily patient census and other information that needed to be routed to different departments (administration, Director of Nursing, etc). RN S7 further stated each morning MHT S11 would collect the information, including the Patient Report of Concern forms, from the bin and disperse the forms to the appropriate departments.

Interview with MHT S11 on 11/23/10, 11:25 AM, revealed each morning, Monday through Friday, she collects the information from the bins which are located on each unit. The Quality/Risk Manager (S3) received all incident/accident reports and patient complaints. The other information, such as the patient census, staffing schedules and so forth, were given to the Director of Nursing. When asked who picked up the patient complaints from the bins on the weekends, MHT S11 stated the staff would contact the Director of Nursing for any patient complaints.

Interview with the Quality /Risk Manager, S3, and the Director of Regulatory Compliance RN S4 on 11/23/10, 1:05 PM, revealed when asked about the submission of patient complaint data, S3 stated the patient complaints were not always brought to her so all complaints were not captured through the Performance Improvement Program. When questioned about the complaints from patient #1 and patient #2, S3 stated when she came to work the morning of 11/16/10, the complaints had been slipped under her door. She asked the Director of Regulatory Compliance (RN S4) if she had slipped the complaints under her door, and S4 responded she was not aware of the complaints. S3 stated at this time both RN S4 and herself went to the Hospital Administrator, S1, with patient #1, and #2's alleged complaints of abuse. S3 further stated when they asked the Administrator if she was going to report these incidents to the State Agency of the Department of Health and Hospitals (DHH), the Administrator responded "lets's wait and not report just yet because one patient is gone (patient #2) and the other is going to leave (patient #1). I will have the RN investigate the allegations first". After approximately 1 and 1/2 hours later, S3 stated she went back to the Hospital Administrator to remind her the hospital needed to report the allegation within 24 hours. S3 further stated she asked to report the allegation but was told "no let's wait because if we report this right now we'll be in more trouble." Interview with the Hospital Administrator on 11/23/10, 2:30 PM, revealed when asked why she did not report the allegation to the State Agency (DHH) within the 24 hour period as per the hospital policy, the Administrator responded "I just forgot".

Further interview with Quality/Risk Manager S3 revealed when questioned about the grievance process policy and procedure, S3 stated approximately 4-5 weeks ago it was decided she would process and investigate all patient grievances; however, this process was inconsistent and depending on who received the patient grievance, such as administration or nursing, it would be decided by them who would conduct the investigation. S3 further stated if the patient complaint was routed to another department for investigation, she would not always receive the complaint information for capture through the Performance Improvement Program.

Interview with the Hospital Administrator (S1) on 11/23/10, 2:20 PM, revealed when asked when she had reported the abuse allegations to the State Agency (DHH), S1 responded it was around 5:00 PM on 11/19/10, and provided the e-mail that had been sent to the State Agency. Review of the e-mailed information revealed it was dated 11/19/10 and timed 5:18 PM and provided the following information "I have an allegation from an adult male patient who stated that a mental health tech pushed him during the night of 11/15/10 at approximately 0230. I have just become aware that this allegation has not been reported." "Date and Time facility administration became aware of the allegation: (Hospital Administrator S1) was notified by (Quality/Risk Management Coordinator S3) on 11/16/10, 9:00 AM. Complaint was referred to the nursing department for further investigation. Actions taken by the facility to safeguard the patient: This staff member has not been allowed to work and as per recommendation of the Director of Nursing (S2's name), the termination process has been initiated. Further investigation is being continued at this time."

There failed to be evidence the Hospital Administrator identified to the State Agency (DHH) that patient #2 had also filed a complaint alleging verbal abuse against Mental Health Technician, S13, on the same date and time as patient #1, 11/15/10.

Review of the policy #RI-00-07 titled "Identifying and Reporting Patient Abuse and Neglect" revealed "Quality Risk Management Coordinator/Administrator/Director of Nursing-Designee: #2. Reports alleged or suspected cases of patient abuse or neglect in accordance with any appropriate laws, as follow: b. Report allegations regarding any patient to the Louisiana Department of Health and Hospitals (DHH) at (telephone number listed) within 24 hours of identification of the suspected or alleged abuse/neglect." Further interview with the Hospital Administrator revealed when asked about the time lapse from when the alleged incident of abuse was reported on 11/15/10 and the reporting to the State Agency (DHH) on 11/19/10, the Administrator stated it was not reported within the 24 hour time frame because she "just forgot".

The Governing Body failed to ensure the operation of the grievance process was effective relative to 1) reviewing and resolving patient concerns, 2) that all patient complaints were processed through the Quality Assurance/Performance Improvement Program, and 3) policies and procedures for reporting within 24 hours to the appropriate State Agency was implemented

Based upon review of 2 of 5 medical records (#1, #2) hospital policies and procedures, patients complaint forms, and administrative and staff interviews, the hospital failed to ensure the policy and procedure for the patient grievance process was followed as evidenced by: 1) failure of the Social Worker to report to the psychiatric unit charge nurse after a patient #1 voiced concerns of mistreatment, and 2) failure of the Registered Nurse S8 to have patient #1 implement a "Patient Report of Concern" after an event which occurred during the early morning hours of 11/15/10. Findings:

Review of the patient grievances filed from 11/10/10 to 11/22/10 revealed on 11/15/10, patient #1 completed a "Patient Report of Concern" with the following written information "At approximately 0230 hours, I walked up hall to get my detox meds due to waking up 0130 craving. I took a shower to try to eliminate the cravings but it was useless. I had previous walked to the front already but allowed my embarrassment to suppress my intentions of asking for help. The next trip up hall (Mental Health Technician S13) became enraged and put his hands on me. I then attempted to explain that if he were to look at my chart he would see that I am suppose to receive my medication when the cravings overtake my mind and body. Instead of calming down he again put his hands on me forcing me back to my room. After awhile the nurse apparently reviewed my chart and brought my meds. I asked that someone please review the camera and see the actions of the Tech. I only hope that this Tech doesn't end up hurting someone who is only begging for help. Please follow through with this investigation so everyone can see that this man is not qualified for this job. He will end up hurting someone."

Interview with Social Worker S6 on 11/22/10, 3:00 PM, revealed during the morning group session on 11/15/10, patient #1 voiced a complaint that during the early morning hours of 11/15/10 a Mental Health Technician had "mistreated" him. According to S6 she instructed patient #1 to report this mistreatment to the nurse.

Further review of the "Patient Report of Concern" forms revealed on 11/15/10, patient #2 hand wrote "A Tech verbally abused me over me getting up at 3:00 AM out of bed and going into the lounge area. The reason I got up at 3:00 AM was because the same tech was verbally and physically abusing another patient in the hall by my room for the same reason as me. He told me I had to stay in my room till 6:00 AM. The tech left work at 5:00 AM and the next shift members let us up as soon as he left."

During a telephone interview with RN S8 on 11/24/10, 9:40 AM, she stated during the early morning hours of 11/15/10, she overheard patient #1 say to MHT S13 "Don't hit me man". After overhearing these comments made by patient #1, RN S8 stated she then went down the hall "to see what was going on". Review of patient #1's medical record revealed RN S8 failed to document in the Multi-disciplinary Progress Notes there was any occurrence between the patient and MHT S13.

Review of policy #RI-00-011 titled Patient Grievance Process - Report of Concern, Procedure: "...If notified of a complaint or concern by a patient, the employee will report the information to the charge nurse on the patient care unit. The charge nurse and staff member reporting the complaint or concern will meet with patient in an attempt to resolve the problem. If the staff at this level are unable to alleviate the problem, the patient will be provided with a "Patient Report of Concern" form to complete." "...If the patient, patient's family member or visitor declines to fill out a formal "Patient Report of Concern" then the staff member which received the initial complaint will complete a "Patient Report of Concern" form and forward it to the Director of Regulatory Compliance or Quality Management Coordinator as soon as possible but in all cases not to exceed 24 hours. The employee or charge nurse will notify the Director of Nurses and/or Director of Regulatory Compliance. The Director of Regulatory Compliance will review the report and investigate further and seek professional advice if indicated. After completion of any further investigation the risk manager will then complete the lower portion of the form designated for follow-up and resolution."

There failed to be documented evidence the Social Worker, S6, followed the Patient Grievance Process Policy and Procedure by failing to notify the charge nurse on 11/15/10 when patient #1 voiced he was "mistreated" by a Mental Health Technician during the night. RN S8, who was the charge nurse on the adult unit the night of 11/14/10 till the morning of 11/15/10, failed to follow the Patient Grievance Policy and have patient #1 complete a "Patient Report of Concern", or if the patient refused to complete a report of concern, to complete the form herself.

Based upon review of hospital policies and procedures, 2 of 5 Medical Records (#1, #2), Patient Occurrence Reports, and administrative and staff interviews, the hospital failed to follow policy and procedure related to Identifying and Reporting Patient Abuse and Neglect as evidenced by: 1) failure of the hospital staff to report patient complaints related to verbal abuse, 2) failure to report alleged or suspected cases of patient abuse within 24 hours to the appropriate state agencies as outlined in the hospital's policy and procedure, and 3) failure to thoroughly investigate abuse allegations related to staff interviews and obtaining written statements from direct care staff present when the alleged abuse occurred. Findings:

Review of the forms "Patient Report of Concern" from 11/10/10 to 11/22/10 revealed on 11/15/10, patient #1 completed a "Patient Report of Concern" with the following written information "At approximately 0230 hours, I walked up hall to get my detox meds due to waking up 0130 craving. I took a shower to try to eliminate the cravings but it was useless. I had previous walked to the front already but allowed my embarrassment to suppress my intentions of asking for help. The next trip up hall (Mental Health Technician S13) became enraged and put his hands on me. I then attempted to explain that if he were to look at my chart he would see that I am suppose to receive my medication when the cravings overtake my mind and body. Instead of calming down he again put his hands on me forcing me back to my room. After awhile the nurse apparently reviewed my chart and brought my meds. I asked that someone please review the camera and see the actions of the Tech. I only hope that this Tech doesn't end up hurting someone who is only begging for help. Please follow through with this investigation so everyone can see that this man is not qualified for this job. He will end up hurting someone."

Further review of the "Patient Report of Concern" forms revealed on 11/15/10, patient #2 hand wrote "A Tech verbally abused me over me getting up at 3:00 AM out of bed and going into the lounge area. The reason I got up at 3:00 AM was because the same tech was verbally and physically abusing another patient in the hall by my room for the same reason as me. He told me I had to stay in my room till 6:00 AM. The tech left work at 5:00 AM and the next shift members let us up as soon as he left."

On 11/24/10, 9:40 AM, a telephone interview with RN S8 revealed she was on the 11PM to 7AM night shift of 11/14/10 to the morning of 11/15/10. When asked if she remembered an incident between MHT S13 and patient #1, RN S8 stated during the early morning hours of 11/15/10, patient #1 had gotten up and was out in the hall and MHT S13 was with him. At one point RN S13 stated she overheard patient #1 tell MHT S13 "don't hit me man" while MHT S13 was trying to get the patient back inside his room. According to RN S8, after overhearing this statement made by the patient she got up to see what was going on.

Review of the medical records for patients #1 and #2 revealed RN S8 failed to document in the Multi-Disciplinary Progress Notes the occurrence/event between MHT S13 and the patients during the early morning hours of 11/15/10.

Review of policy #RI-00-07 titled "Identifying and Reporting Patient Abuse and Neglect" revealed the following:
Responsibilities for identifying and reporting patient abuse and/or neglect which may occur during hospitalization:
1. Each employee, affiliate, or agent who has cause to believe that a patient has been or may be adversely affected by abuse or neglect must report the incident promptly to their supervisor and to the Administrator or his/her designee.
2. The employee documents all information concerning the occurrence on the hospital quality/Risk Management Report of Event Form, being as descriptive and as factual as possible.
Quality Risk Management Coordinator/Administrator/Director of Nursing-Designee:
1. Upon notification of alleged patient abuse/neglect, the administrative staff receiving this information will immediately initiate the investigation process. If after regular business hours, nights and weekends, the administrator, Director of Nursing/Designee, or Quality/Risk Management Coordinator/Designee will report to the facility to initiate staff to patient and/or patient to patient interviews. Administrative/nursing/risk management staff will promptly and objectively investigate the event. a. Interview staff and the alleged perpetrator and victim. b. Reviews documentation, medical records, patient records, and hospital reports. c. Obtains written statements from witnesses and alleged perpetrator.
2. Reports alleged or suspected cases of patient abuse or neglect in accordance with any appropriate laws, as follow: b. Report allegations regarding any patient to the Louisiana Department of Health and Hospitals at (telephone number listed) within 24 hours of identification of the suspected or alleged abuse/neglect.

Interview with the Quality/Risk Management Director, S3, on 11/23/10, 1:05 PM, revealed when she entered her office on the morning of 11/16/10, two "Patient Report of Concern", completed by patient #1 and #2, had been slipped under her door. According to S3, since the patient's do not have access to her office, the report had to have been placed under her door by an employee. S3 further stated she then asked Regulatory Compliance Director, S4, if she had slipped the report under her door and S4 replied "no". S3 stated she and S4 then went to administration and presented the two patients "Patient Report of Concern" to the Hospital Administrator for review.

Review of the form titled "Quality/Risk Management Report of Event" relating to patient #1's complaint revealed Social Worker S6 documented "During morning group on Monday 11/15/10, patient had multiple complaints. I directed patient to the nurses station to fill out a report of concern." The form was dated 11/15/10 and signed by Social Worker S6; however, the remainder of the form (front and back) was blank for questions related to the event which included answering Who, What, and When, Description of Occurrence/Complaint, Patient's reaction to the event, Physicians notification, Medical Record Documentation, the RN's assessment of the patient's physical condition. Hospital personnel completing the form were to identify the date of the event, time, and where the event occurred (department, room, or other). At the bottom of the front of the form, the hospital personnel were to print and signs their name in the underlined section. the back of the form contained an Occurrence Checklist and under the listing for "Complaints" hospital personnel were to identify, by check mark, patient complaints related to the event, such as "complaints from patient/family" or "staff behavior".

Interview with Social Worker S6 on 11/22/10, 3:00 PM, revealed during the morning group session on 11/15/10, patient #1 voiced a complaint that he had been "mistreated" during the early morning hours of 11/15/10 by a Mental Health Technician. According to S6 she instructed patient #1 to report this complaint to the nurse.

Interview with the Hospital Administrator S1 on 11/23/10, 10:10 AM, revealed when she reviewed the "Patient Report of Concern" forms completed by patients #1 and #2, she instructed the Registered Nurse, S7, to investigate the allegations. Review of the investigation conducted by RN S7, dated 11/16/10, revealed only patients #1 and #2 were interviewed. There failed to be evidence the two Mental Health Technicians, the Registered Nurse and the Licensed Practical Nurse present during the 11/14/10 to 11/15/10, 11PM-7AM shift, were interviewed.

Further interview with Hospital Administrator S1 revealed when asked if she contacted the State Agency Louisiana Department of Health and Hospitals within 24 hours of receiving patient #1's complaint, S1 replied "no". Since the Director of Nursing was out sick, she directed the Adult Unit Charge Nurse, RN S7, to conduct the investigation. When asked when the State Agency (DHH) was notified, S1 stated they were notified by e-mail on 11/19/10 in the late afternoon. Review of the information sent to the State Agency (DHH) from Hospital Administrator S1 revealed the e-mail was dated 11/19/10 and timed 5:18 PM with the following information "I have an allegation from an adult male patient who stated that a mental health tech pushed him during the night of 11/15/2010 at approximately 0230. I have just become aware that this allegation has not been reported."..."Date and Time facility administration became aware of the allegation: (Hospital Administrator S1) was notified by (Quality/Risk Management Coordinator S3) on 11/16/10 at 9:00 AM. Complaint was referred to the nursing department for further investigation. Actions taken by the facility to safeguard the patient: This staff member has not been allowed to work and as per recommendation of the Director of Nursing, (S2's name), the termination process has been initiated. Further investigation is being continued at this time."

According to the Patient Report of Concern forms completed by patients #1 and #2, and the report of alleged abuse the Hospital Administrator submitted to the Louisiana Department of Health and Hospitals on 11/19/10, Mental Health Technician S13 was identified as the staff member involved in the abuse allegation. Review of the personnel file for MHT S13 revealed there failed to be documented evidence the employee had been counseled or his employment terminated as identified by the Hospital Administrator S1 when the alleged abuse was reported to the Louisiana Department of Health and Hospital. Interview with the Director of Nursing (DON) S2 on 11/24/10, 9:20 AM, revealed when asked if MHT S13 had been interviewed regarding the allegations made by patients #1 and #2, she stated she had spoke with MHT S13 on the telephone; however, she did not document the conversation. When asked why MHT S13 had not been terminated, DON S2 stated "because he has not been in for work."

Interview with the Regulatory Compliance Director S4 on 11/23/10, revealed a mandatory in-service was held on 11/12/10 for all direct care staff and included "Identifying and Reporting Patient Abuse and Neglect" and "Reporting and Analysis of Events". According to S4, if the employee did not attend this mandatory meeting, they would not be allowed to work. When asked if MHT S13 had attended the mandatory in-service, S4 stated MHT S13 did not attend any of the in-services because "he was to busy".

Review of the Daily Staffing Schedule for November 2010 revealed MHT S13 worked the 11PM-7AM shifts of 11/12/10, 11/13/10, and 11/14/10.

Based upon reviews of medical records (#1), Patient Report of Concern form, Quality/Risk Management Report of Event form, policies/procedures, Administrative and staff interview the hospital failed to follow the established policies and procedures to monitor and report high-risk and problem prone areas as evidenced by failing to monitor and report alleged incidents of abuse and neglect (#1). Findings:

Review of patient #1's (35 year-old male), Medical Record revealed an admission date of 11/10/2010, 12:43pm, with a provisional diagnosis of depression. Patient #1 was admitted under a PEC (physician's emergency certificate) from a local acute care hospital's Emergency Department (ED) as a result of attempted suicide. Review of the PEC form revealed S20 ED physician had documented, 11/09/10, "patient attempted suicide by driving vehicle into a tree". Review of the Psychiatric Evaluation, dated 11/10/10, revealed S19 Psychiatrist documented patient #1 had "been fighting drug addiction since I was 17". Continued review of the Psychiatric Evaluation revealed S19 Psychiatrist documented patient #1 had psychiatric diagnoses of Major Depressive Disorder (MDD), R/O (rule out) Bipolar Disorder, and Polysubstance Abuse. Review of the laboratory report, dated 11/09/10, (from the local acute care hospital) revealed a Urine Drug Screen (UDS) had been completed. The UDS was positive for Benzodiazepines and Methamphetamines.

Review of the History and Physical (H&P), dated 11/11/10, revealed S21 physician documented (under a section titled) "Present Illness: Polysubstance abuse: crack, cocaine, meth (methamphetamines) and pain pills". Further review of the H&P revealed S21 physician documented patient #1 last used Meth 11/09/10, and Crack cocaine on 11/07/10; and had been arrested 08/20/10 for drug possession.

Review of Physician's Orders, 11/10/10, revealed S19 Psychiatrist documented "Librium Detox (Detoxification) #2, start loading dose tonight and start day #1 tomorrow". On 11/11/10, S19 Psychiatrist ordered "Opiates Withdrawal Protocol"; and 11/12/10 he ordered "Start working on placement in a substance abuse rehab". Patient #1 received Group Therapy, Detox protocol for opiates, and was discharged to a local Substance Abuse Facility on 11/17/10.

Review of "Tech Notes/Observation Sheet", dated 11/14/10 at 11:15pm, revealed S22 Mental Health Technician (MHT) documented patient #1 was "I (room asleep)/D (Continuous visual)".

Continued review of the Tech Notes/Observation Sheet revealed, page 1, the lower right section was titled "Code Treatment/Location". The following codes were used by S22 MHT to document patient #1's activities throughout the night shift (11/14/10 11pm through 11/15/10 7am):
11/14/10 11:30p, 11:45p I/D (room asleep/Continuous visual); 11/15/10 from 12:00midnight and every 15minutes until 1:15am I/D; 11/15/10 1:30am Q/D (Dayroom/Continuous visual); 11/15/10 1:45am and every 15 minutes until 5:30am patient #1 was H/D (Room awake/Continuous visual); 11/15/10 5:30am-and every 15 minutes to 7:00am S22 MHT documented patient #1 was Q/D (in the dayroom under continuous visual observation).

Review of patient #1's Medication Administration Record (MAR) revealed S14 Agency Licensed Practical Nurse (LPN) documented she administered Vistaril 50mg (milligrams) po (by mouth), 11/15/10 at 3:05am for anxiousness per physician's orders.

Review of "Multidisciplinary Progress Notes", 11/15/10, 4:00am, S22 MHT documented "Pt (patient) up starting of 0115 (1:15am) all through the night walking & (and) pacing room & hallway. Pt wanting to smoke and to just sit in dayroom. Pt redirected to go to room was a bit aggitated about having to be in room. Will continue to monitor for safety".

Continued review of the Multidisciplinary Progress Notes, 11/15/10, 12am through 7:00am revealed there failed to be documentation by a nurse.

Review of a form titled "Patient Report of Concern", dated 11/15/10, revealed patient #1 documented "at app. (approximately) 0230 hrs (2:30am) I walked up to get my detox meds due to waking up 0130 (1:30am) craving...The next trip up hall (name of S13 MHT) became enraged and put his hands on me... Instead of calming down he again put his hands on me forcing me back to my room. After a while the nurse apparently reviewed my chart and brought my meds. I ask that someone please review the concern and see the actions of this Tech...this man is not qualified for this job. He will end up hurting someone."

Continued review of the Patient Report of Concern, filed 11/15/10 by patient #1, revealed the form had not been completed as per hospital policy. Patient #1's documentation was the only information contained on the form. Further review revealed there were sections titled 1) "Department Director/Manager's Findings/Recommendations:" and 2) "Recommendations/Corrective Action" along with a signature line for the "Department Manager/Shift Supervisor/Director of Nurses Signature" and a separate line that read "Signature of Risk Manager"; however, these areas had not been completed.

Review of a Quality/Risk Management (QM/RM) Report of Event form revealed it was a two-sided form:
The front-side contained questions related to the event and included Who, What, and When, Description of Occurrence/Complaint, Patient's reaction to the event, Physician notification, Medical Record Documentation, the RN's assessment of the patient's physical condition.

Hospital staff completing the form were to identify the date of the event, time, and where the event occurred (department, room, or other). At the bottom, front-side of the form, the hospital staff were to print and sign in the underlined areas.

The back-side of the form contained an Occurrence Checklist and under the section titled "Complaints" hospital staff were to identify, by check mark, patient complaints related to 1) inappropriate behavior: staff, physician, patient, family, visitor; 2) complaints from patient/family: care given/not given; failure to prescribe meds; food; inattentiveness; lack of patient/family education & information; MD behavior/attitude; noise; staff behavior/attitude; breach of confidentiality; and 3) other patient care issues.

At the bottom third portion of the back-side of the form, was an area that read: FORWARD TO RISK MANAGEMENT OFFICE WITH 24 HOURS OF OCCURRENCE; and below this, in an outlined area was: RISK MANAGEGMENT USE ONLY and contained areas for a Log number to be placed, Date received, Date Reviewed, Reviewer, Notes, Actions/Date, and Status.

S6 Social Worker had documented (front-side of form) under "When": 11/15/10; and under the "Description of Occurrence/Complaint": "During morning group on Monday 11/15/10 pt. (patient) had multiple complaints. I directed pt. to the nurses station to fill out a report of concern." S6 Social Worker printed her name and placed her signature on the bottom of the front-side of the QM/RM Report of Event. Continued review of the form revealed no other portion of the form had been completed by any other hospital staff member.

Review of the Policy No. Policy #RI-00-007 titled "Identifying and Reporting Patient Abuse and Neglect", revised 10/15/10 and submitted as the one currently in use, revealed: "Responsibilities for identifying and reporting patient abuse and/or neglect which...hospitalization: A. Hospital Staff 1. Each employee...who has cause to believe that a patient has been or may be adversely affected by abuse or neglect must report the incident promptly to their supervisor and to the Administrator or his/her designee...2. The employee documents all information...on the hospital Quality/Risk Management Report of Event form...3. The employee submits...to his immediate supervisor who shall forward the report to the Director of Risk Management...B. Charge Nurse 1. Upon receipt of verbal or written complaint that alleges patient abuse or neglect, contact the Administrator or his/her designee...The staff member reported to have abused a patient will be immediately relieved of their duties...D. Quality Risk Management Coordinator/Administrator/Director of Nursing - Designee 1. Upon notification of alleged patient abuse/neglect, the administrative staff receiving this information will immediately initiate the investigation process. If after regular business hours, nights, and weekends, the Administrator, Director of Nursing/Designee, or Quality/Risk Management Coordinator/Designee will report to th e facility to initiate...interviews...2. Reports alleged or suspected cases of patient abuse or neglect in accordance with any appropriate laws, as follow: ...b. Report allegations regarding any patient to the Louisiana Department of Health and Hospitals...within 24 hours of identification of the suspected or alleged abuse/neglect... 3. ...c. A written report of findings and action taken shall be: ...(5) Result of findings and disciplinary action shall be placed in the employee's personnel file... A. Training 1. All current employees shall be oriented to the policies that define the responsibilities of reporting patient abuse and neglect... B. Notification of Reporting Procedures 1. Who to contact in the facility with a concern or complaint of any nature is posted on each unit..."

Review of the Policy No. Policy #RI-00-007 titled "Identifying and Reporting Patient Abuse and Neglect", last revised 10/15/10 and submitted as the one currently in use, revealed: "Responsibilities for identifying and reporting patient abuse and/or neglect which...hospitalization: A. Hospital Staff 1. Each employee...who has cause to believe that a patient has been or may be adversely affected by abuse or neglect must report the incident promptly to their supervisor and to the Administrator or his/her designee...2. The employee documents all information...on the hospital Quality/Risk Management Report of Event form...3. The employee submits...to his immediate supervisor who shall forward the report to the Director of Risk Management...B. Charge Nurse 1. Upon receipt of verbal or written complaint that alleges patient abuse or neglect, contact the Administrator or his/her designee...The staff member reported to have abused a patient will be immediately relieved of their duties...D. Quality Risk Management Coordinator/Administrator/Director of Nursing - Designee 1. Upon notification of alleged patient abuse/neglect, the administrative staff receiving this information will immediately initiate the investigation process. If after regular business hours, nights, and weekends, the Administrator, Director of Nursing/Designee, or Quality/Risk Management Coordinator/Designee will report to the facility to initiate...interviews...2. Reports alleged or suspected cases of patient abuse or neglect in accordance with any appropriate laws, as follow: ...b. Report allegations regarding any patient to the Louisiana Department of Health and Hospitals...within 24 hours of identification of the suspected or alleged abuse/neglect...

Review of incident reports for the time period of 11/10/10 through 11/23/10 revealed the following areas of concern documented by the hospital: possible incidents of abuse/neglect--1.

In an interview, 11/23/10 at 12:10pm S3 Quality (QA)/Risk Management Coordinator indicated the Quality/Performance Improvement plan did not include setting priorities. She indicated her main duty was to collect and compile the data sent from the departments and that since the hospital does not have PI meetings, she does not know who decides what was to be monitored as S3 stated she does not receive all of the data required.

A subsequent interview, 11/23/10 at 1:15, with S3 QA/Risk Coordinator revealed when she was questioned who was responsible for investigating and reporting complaints/incidents/grievances relative to patient abuse/neglect, S3 replied, there was no consistency in the method of investigating (i.e. nursing may or may not be involved with the process even when a patient was involved). S3 replied S1 Administrator decided who, how, and which incidents were to be investigated and reported.

Interview, 11/23/10, with S1 Administrator confirmed the alleged abuse incident that occurred with patient #1, on 11/15/10, was not reported within 24 hours to the Louisiana Department of Health and Hospitals as required per policy. S1 was questioned when she was first aware of the allegation, she replied she was aware of the alleged abuse on 11/16/10, but did not report the incident within 24 hours as the policy stated. S1 Administrator stated she e-mailed the report to the state office on 11/19/10 about 5:30pm.

Interviews, 11/23/10, with S1 Administrator, S2 Director of Nursing, S3 QA/Risk Management Coordinator, and S4 Staff Development Registered Nurse confirmed the hospital did not monitor, track and report all adverse patient events through Quality/Performance Improvement per hospital policy.

Based upon reviews of medical records (#1), Quality Management/Risk Management Report of Event forms, incident/Patient Report of Concern, policies/procedures, Administrative and staff interview the hospital failed to follow the established policies and procedures to monitor, track and report adverse patient events as evidenced by failing to monitor, track and report alleged incidents of abuse and neglect (#1). Findings:

Review of patient #1's (35 year-old male), Medical Record revealed an admission date of 11/10/2010, 12:43pm, with a provisional diagnosis of depression. Patient #1 was admitted under a PEC (physician's emergency certificate) from a local acute care hospital's Emergency Department (ED) as a result of attempted suicide. Review of the PEC form revealed S20 ED physician had documented, 11/09/10, "patient attempted suicide by driving vehicle into a tree".

Review of patient #1's Psychiatric Evaluation, dated 11/10/10, revealed S19 Psychiatrist documented "been fighting drug addiction since I was 17". Continued review of the Psychiatric Evaluation revealed S19 Psychiatrist documented patient #1 had psychiatric diagnoses of Major Depressive Disorder (MDD), R/O (rule out) Bipolar Disorder, and Polysubstance Abuse. Review of the laboratory report, dated 11/09/10, (from the local acute care hospital) revealed a Urine Drug Screen (UDS) had been completed. The UDS was positive for Benzodiazepines and Methamphetamines.

Review of the History and Physical (H&P), dated 11/11/10, revealed S21 physician documented (under a section titled) "Present Illness: Polysubstance abuse: crack, cocaine, meth (methamphetamines) and pain pills". Further review of the H&P revealed S20 physician documented patient #1 last used Meth 11/09/10, and Crack cocaine on 11/07/10; and had been arrested 08/20/10 for drug possession.

Review of Physician's Orders, 11/10/10, revealed S19 Psychiatrist documented "Librium Detox (Detoxification) #2, start loading dose tonight and start day #1 tomorrow". On 11/11/10, S19 Psychiatrist ordered "Opiates Withdrawal Protocol"; and 11/12/10 he ordered "Start working on placement in a substance abuse rehab". Patient #1 received Group Therapy, Detox protocol for opiates, and was discharged to a local Substance Abuse Facility on 11/17/10.

Review of "Tech Notes/Observation Sheet", dated 11/14/10 at 11:15pm, revealed S22 Mental Health Technician (MHT) documented patient #1 was "I (room asleep)/D (Continuous visual)".

Continued review of the Tech Notes/Observation Sheet revealed, page 1, the lower right section was titled "Code Treatment/Location". The following codes were used by S22 MHT to document patient #1's activities throughout the night shift (11/14/10 11pm through 11/15/10 7am):
11/14/10 at 11:30p,11:45p I/D (room asleep/Continuous visual); 11/15/10 from 12:00midnight and every 15minutes until 1:15am I/D; 11/15/10 1:30am Q/D (Dayroom/Continuous visual); 11/15/10 1:45am and every 15 minutes until 5:30am patient #1 was H/D (Room awake/Continuous visual); 11/15/10-- S22 MHT documented 5:30am-and every 15 minutes to 7:00am patient #1 was Q/D.

Review of patient #1's Medication Administration Record (MAR) revealed S14 Agency Licensed Practical Nurse (LPN) documented she administered Vistaril 50mg (milligrams) po (by mouth), 11/15/10 at 3:05am for anxiousness per physician's orders.

Review of "Multidisciplinary Progress Notes", 11/15/10, 4:00am, S22 MHT documented "Pt (patient) up starting of 0115 (1:15am) all through the night walking & (and) pacing room & hallway. Pt wanting to smoke and to just sit in dayroom. Pt redirected to go to room was a bit aggitated about having to be in room. Will continue to monitor for safety".

Continued review of the Multidisciplinary Progress Notes, 11/15/10, 12am through 7:00am revealed there failed to be documentation by a nurse.

There failed to be documented evidence that indicated patient #1 received an assessment by a Registered Nurse (RN) when he was allegedly physically kept from going to the nursing station to ask for his "as needed" detoxification medications on 11/15/10 (about 2:30am) per the "Patient Report of Concern" form that patient #1 filed with the hospital.

Review of a form titled "Patient Report of Concern", dated 11/15/10, revealed patient #1 documented "at app. (approximately) 0230 hrs (2:30am) I walked up to get my detox meds due to waking up 0130 (1:30am) craving...The next trip up hall (name of S13 MHT) became enraged and put his hands on me...Instead of calming down he again put his hands on me forcing me back to my room. After a while the nurse apparently reviewed my chart and brought my meds. I ask that someone please review the concern and see the actions of this Tech...this man is not qualified for this job. He will end up hurting someone."

Continued review of the Patient Report of Concern, filed 11/15/10 by patient #1, revealed the form had not been completed as per hospital policy. Patient #1's documentation was the only information contained on the form. Further review revealed there were sections titled 1) "Department Director/Manager's Findings/Recommendations:" and 2) "Recommendations/Corrective Action" along with a signature line for the "Department Manager/Shift Supervisor/Director of Nurses Signature" and a separate line that read "Signature of Risk Manager"; however, these areas had not been completed.

Review of a Quality/Risk Management (QM/RM) Report of Event form revealed it was a two-sided form:
The front contained questions related to the event and included Who, What, and When, Description of Occurrence/Complaint, Patient's reaction to the event, Physician notification, Medical Record Documentation, the RN's assessment of the patient's physical condition. Hospital staff completing the form were to identify the date of the event, time, and where the event occurred (department, room, or other). At the bottom, front-side of the form, the hospital staff were to print and sign in the underlined areas.

The back-side of the form contained an Occurrence Checklist and under the section titled "Complaints" hospital staff were to identify, by check mark, patient complaints related to 1) inappropriate behavior: staff, physician, patient, family, visitor; 2) complaints from patient/family: care given/not given; failure to prescribe meds; food; inattentiveness; lack of patient/family education & information; MD behavior/attitude; noise; staff behavior/attitude; breach of confidentiality; and 3) other patient care issues.

At the bottom third portion of the back-side of the form, was an area that read: FORWARD TO RISK MANAGEMENT OFFICE WITH 24 HOURS OF OCCURRENCE; and below this, in an outlined area was: RISK MANAGEMENT USE ONLY and contained areas for a Log number to be placed, Date received, Date Reviewed, Reviewer, Notes, Actions/Date, and Status.

S6 Social Worker had documented (front-side of form) under "When": 11/15/10; and under the "Description of Occurrence/Complaint": "During morning group on Monday 11/15/10 pt. (patient) had multiple complaints. I directed pt. to the nurses station to fill out a report of concern." S6 Social Worker printed her name and placed her signature on the bottom of the front-side of the QM/RM Report of Event. Continued review of the form revealed no other portion had been completed by any other hospital staff member.

Review of the Policy No. Policy #RI-00-007 titled "Identifying and Reporting Patient Abuse and Neglect", revised 10/15/10 and submitted as the one currently in use, revealed: "Responsibilities for identifying and reporting patient abuse and/or neglect which...hospitalization: A. Hospital Staff 1. Each employee...who has cause to believe that a patient has been or may be adversely affected by abuse or neglect must report the incident promptly to their supervisor and to the Administrator or his/her designee...2. The employee documents all information...on the hospital Quality/Risk Management Report of Event form...3. The employee submits...to his immediate supervisor who shall forward the report to the Director of Risk Management...B. Charge Nurse 1. Upon receipt of verbal or written complaint that alleges patient abuse or neglect, contact the Administrator or his/her designee...The staff member reported to have abused a patient will be immediately relieved of their duties...D. Quality Risk Management Coordinator/Administrator/Director of Nursing - Designee 1. Upon notification of alleged patient abuse/neglect, the administrative staff receiving this information will immediately initiate the investigation process. If after regular business hours, nights, and weekends, the Administrator, Director of Nursing/Designee, or Quality/Risk Management Coordinator/Designee will report to th e facility to initiate...interviews...2. Reports alleged or suspected cases of patient abuse or neglect in accordance with any appropriate laws, as follow: ...b. Report allegations regarding any patient to the Louisiana Department of Health and Hospitals...within 24 hours of identification of the suspected or alleged abuse/neglect... 3. ...c. A written report of findings and action taken shall be: ...(5) Result of findings and disciplinary action shall be placed in the employee's personnel file... A. Training 1. All current employees shall be oriented to the policies that define the responsibilities of reporting patient abuse and neglect... B. Notification of Reporting Procedures 1. Who to contact in the facility with a concern or complaint of any nature is posted on each unit..."

Review of Policy #PI-00-002 titled "Reporting and Analysis of Events", revised 11/09/10 and submitted as the current policy in use, revealed: "Purpose: In order to accurately document information relative to possible variations in patient care or untoward events, a Risk Management/Quality management Confidential Report of Events is to be completed...Procedure: A. The person discovering an unusual occurrence or event should notify the supervisor of the area involved as soon as possible. An unusual occurrence report should be prepared promptly. The report should reflect the identity of the person making the discovery and any other person involved... E. The QM/RM (Quality Management/Risk Management) Report of Event form will be forwarded to the office of the Quality/Risk Management Coordinator within 24hours of the occurrence or event... F. Reporting of An Unusual Occurrence or Event ...3. Patient--Unusual Occurrence/Event or Injury a. Any patient who is involved in an unusual occurrence or event or is injured will have a QM/RM Report of Event form completed by the person witnessing the occurrence/event/injury. The charge nurse is to be notified of any occurrence/event/injury and complete an assessment of the patient's physical/mental condition. the charge nurse will also complete the required RN assessment of the Patient's Physical Condition...The QM/RM Report of event form is to be forwarded to the Quality/Risk Management Coordinator within 24 hours of the event. b. The staff member witnessing the event should document exact information regarding the occurrence/event/injury in the patient's medical record. The charge nurse should also document their assessment of the patient's condition and interventions in the medical record...e. Any unusual occurrence or event involving a patient should be reported to the Director of Nursing/designee or after hours and on weekends or holidays to the Administrator on Call...f. All QM/RM forms involving patients will be forwarded to the Quality/Risk Management Coordinator and the original report or a copy will be forwarded to the Director of Nursing by a Risk Management staff member, for review and documentation of corrective action plan as indicated... G. The Performance Improvement Review Committee, which conducts the business of the safety committee monthly, receives a recap on unusual occurrences or events. The Quality/Risk Management Coordinator will summarize these occurrences...The committee reviews cases and/or trends to determine if any further corrective action is needed. Risk Management Trending Reports are also submitted to the Medical Staff and Governing Board."

Review of incident reports for the time period of 11/10/10 through 11/23/10 revealed the following areas of concern documented by the hospital: possible incidents of abuse/neglect--1. This occurrence was identified by S3 Quality/Risk Management Coordinator as that involving patient #1.

In an interview, 11/23/10 at 12:10pm S3 Quality (QA)/Risk Management Coordinator indicated the Quality/Performance Improvement plan did not include setting priorities. She indicated her main duty was to collect and compile the data sent from the departments and that since the hospital does not have PI meetings, she does not know who decides what was to be monitored and tracked as S3 stated she does not receive all of the data required.

A subsequent interview, 11/23/10 at 1:15, with S3 QA/Risk Coordinator revealed when questioned who was responsible for investigating and reporting complaints/incidents/grievances relative to patient abuse/neglect, S3 replied, there was no consistency in the method of investigating (i.e. nursing may or may not be involved with the process even when a patient was involved). S3 replied S1 Administrator decided who, how, and which incidents were to be investigated and reported.

Interview, 11/23/10, with S1 Administrator confirmed the alleged abuse incident (that occurred on 11/15/10 during the early morning hours, around 2:30am) with patient #1, was not reported within 24 hours to the Louisiana Department of Health and Hospitals as required per policy. S1 was questioned when she was first aware of the allegation, she replied she was aware of the alleged abuse on 11/16/10, but did not report the incident within 24 hours as the policy stated. S1 Administrator stated she e-mailed the report to the state office on 11/19/10 about 5:30pm.

Interviews, 11/23/10, with S1 Administrator, S2 Director of Nursing, S3 Quality/Risk Management Coordinator, and S4 Staff Development/Compliance Registered Nurse confirmed all events of alleged patient abuse/neglect were not tracked through the Quality/Risk Management department as required by hospital policies #PI-00-002 and RI-00-007. It was confirmed, through these interviews, that investigations and reporting was not conducted and/or reported according to these same 2 hospital policies.

Based upon reviews of 2 of 6 patient medical records (#1,#2), policies/procedures, Patient Report of Concern, Quality/Risk Management Report of Event, Administrative and staff interviews the hospital failed to ensure a Registered Nurse performed an assessment on a patient (#1) following an allegation of verbal and physical abuse by the patient (#1) and verbal abuse (#2). Findings:

Review of patient #1's medical record revealed he was admitted 11/10/10 with psychiatric diagnoses of Major Depressive Disorder, R/O (rule out) bipolar disorder, and Polysubstance abuse.

Review of "Multidisciplinary Progress Notes", 11/15/10, 4:00am, S22 MHT documented "Pt (patient) up starting of 0115 (1:15am) all through the night walking & (and) pacing room & hallway. Pt wanting to smoke and to just sit in dayroom. Pt redirected to go to room was a bit aggitated about having to be in room. Will continue to monitor for safety".

Continued review of the Multidisciplinary Progress Notes, 11/15/10, 12am through 7:00am revealed there failed to be documentation by a nurse.

There failed to be documented evidence that indicated patient #1 received an assessment by a Registered Nurse (RN) when he was allegedly physically kept from going to the nursing station to ask for his "as needed" detoxification medications on 11/15/10 (about 2:30am) per the "Patient Report of Concern" form that patient #1 filed with the hospital.

Review of a form titled "Patient Report of Concern", dated 11/15/10, revealed patient #1 documented "at app. (approximately) 0230 hrs (2:30am) I walked up to get my detox meds due to waking up 0130 (1:30am) craving...The next trip up hall (name of S13 MHT) became enraged and put his hands on me...Instead of calming down he again put his hands on me forcing me back to my room. After a while the nurse apparently reviewed my chart and brought my meds. I ask that someone please review the concern and see the actions of this Tech...this man is not qualified for this job. He will end up hurting someone."

Continued review of the Patient Report of Concern, filed 11/15/10 by patient #1, revealed the form had not been completed as per hospital policy. Patient #1's documentation was the only information contained on the form. Further review revealed there were sections titled 1) "Department Director/Manager's Findings/Recommendations:" and 2) "Recommendations/Corrective Action" along with a signature line for the "Department Manager/Shift Supervisor/Director of Nurses Signature" and a separate line that read "Signature of Risk Manager"; however, these areas had not been completed.

Review of a Quality/Risk Management (QM/RM) Report of Event form revealed it was a two-sided form:
The front contained questions related to the event and included Who, What, and When, Description of Occurrence/Complaint, Patient's reaction to the event, Physician notification, Medical Record Documentation, the RN's assessment of the patient's physical condition. Hospital staff completing the form were to identify the date of the event, time, and where the event occurred (department, room, or other). At the bottom, front-side of the form, the hospital staff were to print and sign in the underlined areas.

The back-side of the form contained an Occurrence Checklist and under the section titled "Complaints" hospital staff were to identify, by check mark, patient complaints related to 1) inappropriate behavior: staff, physician, patient, family, visitor; 2) complaints from patient/family: care given/not given; failure to prescribe meds; food; inattentiveness; lack of patient/family education & information; MD behavior/attitude; noise; staff behavior/attitude; breach of confidentiality; and 3) other patient care issues.

At the bottom third portion of the back-side of the form, was an area that read: FORWARD TO RISK MANAGEMENT OFFICE WITH 24 HOURS OF OCCURRENCE; and below this, in an outlined area was: RISK MANAGEMENT USE ONLY and contained areas for a Log number to be placed, Date received, Date Reviewed, Reviewer, Notes, Actions/Date, and Status.

S6 Social Worker had documented (front-side of form) under "When": 11/15/10; and under the "Description of Occurrence/Complaint": "During morning group on Monday 11/15/10 pt. (patient) had multiple complaints. I directed pt. to the nurses station to fill out a report of concern." S6 Social Worker printed her name and placed her signature on the bottom of the front-side of the QM/RM Report of Event. Continued review of the form revealed no other portion of the form had been completed by any hospital staff member.

Review of Policy #PI-00-002 titled "Reporting and Analysis of Events", revised 11/09/10 and submitted as the current policy in use, revealed: "Purpose: In order to accurately document information relative to possible variations in patient care or untoward events, a Risk Management/Quality management Confidential Report of Events is to be completed...Procedure: A. The person discovering an unusual occurrence or event should notify the supervisor of the area involved as soon as possible. An unusual occurrence report should be prepared promptly. The report should reflect the identity of the person making the discovery and any other person involved...The charge nurse is to be notified of any occurrence/event/injury and complete an assessment of the patient's physical/mental condition. The charge nurse will also complete the required RN assessment of the Patient's Physical Condition... The charge nurse should also document their assessment of the patient's condition and interventions in the medical record..."

Interviews, 11/23/10, with S1 Administrator and S2 Director of Nursing confirmed patient #1 had not received a physical assessment (after the alleged physical abuse) by the Registered Nurse on duty as required by hospital policy #PI-00-002.

Based upon reviews of Agency Nursing Personnel files (2 of 2), a packet titled "Orientation of Nursing Agency Personnel", Administrative and staff interview, the hospital and Director of Nursing failed to ensure Agency Nurses (S15 Registered Nurse, S14 Licensed Practical Nurse), received an orientation that included: 1) a review of the hospital's nursing policies/procedures, emergency procedures; and 2) had their skills/competencies evaluated, including verification of training in non-violent crisis intervention techniques, prior to providing direct patient care. Findings:

Review of Agency Registered Nurse (RN) S15's personnel file (maintained by the hospital) revealed the only information contained in the file was copies of her RN license, Advanced Cardiopulmonary Life Support card, and TB (tuberculosis) test results. Continued review revealed there lacked documentation S15 RN had received a skill/competencies evaluation, that included training in non-violent crisis intervention techniques, prior to providing direct patient care.

Review of Agency Licensed Practical Nurse (LPN) S14's personnel file (maintained by the hospital) revealed the information contained in the file was copies of her LPN license, CPR (Cardiopulmonary Resuscitation) card, and TB test results. Further review of S14 LPN's file revealed there lacked documented evidence she had received a skill/competencies evaluation, that included training in non-violent crisis intervention techniques, prior to providing direct patient care.

Review of the "Orientation of Nursing Agency Personnel" packet revealed the following topics: Confidentiality, Ethical Issues, Maintaining a Professional Relationship, Fire Safety and Security, Safety, Emergency Code definitions ("Code White...all available staff...report immediately to the area to assist...combative/violent patient..., Code Blue...cardiopulmonary arrest..., Code Red...used for fire drills...Code Green...patient has eloped...") Infection Control, Reporting of Unusual Occurrences, Patient Rights, Documentation ("Charting Checklist...date and time entry. Sign...name and title..."), Emergency Medical Treatment and Active Labor Act (EMTALA), Definition of Patient Abuse and Neglect, and Seclusion/Restraint protocols.

Interview, 11/24/10, with S4 Staff Development RN revealed Agency Nurses were instructed to read a packet, titled "Orientation of Nursing Agency Personnel", and then place their signatures and date on the last page to acknowledge they were educated and "acknowledge understanding of these policies and procedures and agree to adhere to them during" their presence in the hospital. Further interview of S4 RN revealed when questioned as to how the hospital ensured Agency Nurses had verification of training for non-violent crisis intervention techniques (hospital uses the "STEPS" techniques) prior to working on the inpatient units; S4 RN did not have a response.

Interviews, 11/24/10, with S2 Director of Nursing and S4 Staff Development RN confirmed the Agency Nurses (S15 RN and S14 LPN) did not have documented evidence in their personnel files that indicated they had completed an orientation program prior to providing patient care; nor was there documented evidence of either having completed a non-violent crisis intervention program.