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Based on document review, record review and interview, the hospital failed to ensure all patients or patient's representative were informed of the Patient Rights to personal privacy; to receive care in a safe setting; to be free from all forms of abuse or harassment; and to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual, for 13 of 13 patient (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) records reviewed. Failure to inform patients or their representative of all Patient Rights places the patients or representatives at risk for not knowing all of their rights and making uninformed decisions about their care and services.

Findings Include:

Review of a hospital policy titled, "Patient's Rights and Responsibilities" revised 04/2014, showed, "To provide guidelines which outline patient rights and responsibilities; to recognize and promote personal safety and dignity; and acknowledge cultural, psychosocial and spiritual values which influence patients' perception of care and illness. Patients' rights apply to persons of all ages (neonates, children, adolescents, adults, and the elderly) and irrespective of race, creed, gender, sexual orientation, national origin or disability. Each patient will be informed of his or her rights and responsibilities in a method of communication that the patient understands. The patient may appoint a representative to receive this information should he or she so desire ... ...Privacy and Confidentiality: The patient has the right, within the law, to personal and informational privacy ... ...The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned, and to be free from verbal, physical, psychological, sexual or emotional abuse or harassment ... ... The patient has the right to be informed that [Hospital] is committed to high standards of care, safety and hospitality for patients and their families.
Review of a hospital policy titled, " Abuse, Neglect, Harassment and Exploitation within the Facility" reviewed 12/2021, showed PURPOSE: Providence Medical Center (PMC) and Saint John's Hospital (SJH) maintain a work and living environment that is professional and free from threat and or occurrence of harassment, abuse (verbal, physical, mental or sexual, involuntary seclusion, misappropriation of property) neglect or exploitation.

Review of a hospital document titled, "Patient Information Guide" provided to patients or representatives on admission, showed, the "Patient Rights" failed to include the Patient Rights to personal privacy; to receive care in a safe setting; to be free from all forms of abuse or harassment; and to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual."

Review of a hospital document titled, "Information on Patient Rights, Responsibilities and Advance Directives" provided to patients or representatives on admission to the hospital, showed, the "Patient Rights" failed to include the Patient Rights to personal privacy; to receive care in a safe setting; to be free from all forms of abuse or harassment; and to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual."

Patient 1
Review of Patient 1's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 2
Review of Patient 2's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 3
Review of Patient 3's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 4
Review of Patient 4's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 5
Review of Patient 5's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 6
Review of Patient 6's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 7
Review of Patient 7's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 8
Review of Patient 8's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 9
Review of Patient 9's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 10
Review of Patient 10's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 11
Review of Patient 11's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 12
Review of Patient 12's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 13
Review of Patient 13's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.


During an interview on 04/22/22 at 9:05 AM, Staff C, Director of Risk Management, confirmed after reviewing the Patient Information Guide and Information on Patient Rights, Responsibilities and Advance Directives booklet, the right to personal privacy, the right to receive care in a safe setting; the right to be free from all forms of abuse or harassment, and the right to access the patient's medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual, were not included in the Patient Rights documents provided to the patients or their representatives on admission.

Based on document review, policy review, and interview the hospital's governing body failed to ensure the grievance committee handled the grievance process effectively including that recognizes verbal grievances, failed to ensure violations of patient's rights and other regulatory violations are processed as grievances, and failed to ensure allegations of Abuse, Neglect, and Exploitation (ANE) allegations are escalated to the grievance process for seven of ten complaints, grievances, and incidents reviewed involving nine patients (Patient 3, 4, 11, 12, 13, 14, 16, 17, and 18). The failure to recognize complaints or incident reporting as grievances and implement the grievance process has the potential to affect all patients leaving grievances unresolved and may lead to harm or other adverse outcomes.

Findings Include:

Review of the hospital's policy, "Grievance/Complaint Process," last revised 12/2021, showed, "This policy applies to alleged violations of CMS [Centers for Medicare and Medicaid Services] mandated patient rights. It is recognized that patients have other rights afforded to them through State law and hospital accreditation standards . . .Patient grievance is defined as a written or verbal concern (when verbal concern about patient care is not resolved at the time of the concern by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the facility's compliance with regulatory agencies." "All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purposes of these requirements." "When the patient requests a response from the hospital, the complaint is considered a grievance . . . The grievance review process will assure that the grievance is investigated in a timely manner."

Review of the hospital's policy, "Grievance Procedure, Alleging Discrimination," last revised 02/2021, showed, the hospital "has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. § 18116) and it's implementing regulations at 45 C.F.R. pt. 92. Section 1557 prohibits discrimination on the basis of (sic) race, color, religion, national origin, sex, gender identify, including sex stereotyping, age or disability in certain health programs and activities . . .Grievances must be submitted to the Civil Rights Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discrimination action. A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought . . . The investigation will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint . . . will issue a written decision on the grievance, based on a preponderance of the evidence, no later than 30 days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies."

1. Review of "Complaint," dated 10/11/21 showed Patient 11 went to the emergency department (ED) with abdominal pain on 10/09/21 at 9:27 PM. Patient 11 stated that she felt disrespected by the nurse practitioner that cared for her, stated that the nurse practitioner whispered to other staff in front of her, told her to change her lifestyle, and that the nurse practitioner was laughing at another patient who was trying to get a sandwich. Further review showed that Staff N, Emergency Department Director (EDD) wrote in an email to Staff C, Director of Risk Management, dated 11/10 (sic) "I investigated this incident and although we are all concerned with how the NP [Nurse Practitioner] treated the patient I am not able to properly address this without more feedback. It seems she was happy with the care received by ED nursing staff. A response requested in writing to a patient I find that a bit unusual in my experience with patient grievances and NP does not report to me. This makes it difficult for me to personally offer any evidence of remediation and I believe better handled by her direct report . . ." The complaint is dated 12/10/21 on "responder date, date of initial follow-up or contact" and on "responder dates: responder: closed date."

Further review of the complaint showed that the hospital failed to document any interviews or conversations with staff involved. The hospital failed to provide documentation that they responded to the patient with a resolution of their investigation.

During an interview on 04/22/22 at 9:05 AM Staff C, Director of Risk Management stated that the concerns about patient rights were not escalated to the grievance process. Staff C is unsure if Patient 11 was contacted with the outcome. Staff C stated that if there were supporting documentation such as interviews, they would be attached to the complaint in the reporting system.

2. Review of "Complaint," dated 10/12/21, F4, daughter to Patient 12 emailed the hospital reporting that Patient 12 was having difficulty breathing, chest pain, and a bad infection in her mouth with swelling and pain and waited in the ED waiting room for over eight hours. F4 reported that the abscess in Patient 12's mouth had burst, and Patient 12 had to manage the large amount of blood and purulent (white, yellow, or brown fluid that may be thick in texture made up of white blood cells trying to fight an infection) drainage on her own. Unknown staff stated that they were waiting for a clean room after about four hours of waiting. After another four hours of waiting, Patient 12 was told that the staff didn't know when a room would come open and if she didn't want to wait that she could leave. F4 reported that Patient 12 left the waiting room and was never seen by a physician or other provider. Further review showed that Patient 12 arrived in the ED on 10/12/21 at 4:04 PM and left the ED on 10/12/21 at 10:59 PM.

Further review of the complaint showed Staff N, ED Director, documented on 10/15/21 at 1:03 PM, "Attempted to contact [F4] at the given phone number and was told she was not available. Will reattempt contact."

The documentation does not include any interviews or other investigative measures taken on the patient's behalf or that further contact was attempted. There is no documentation showing that the patient was contacted regarding the lack of care she received when she came to the the ED seeking treatment.

During an interview on 04/22/22 at 9:05 AM, Staff C, Director of Risk Management, stated that she did not know why the incident remains uninvestigated at the time of the survey. Staff C stated that it was her responsibility to ensure complaints and grievances are completed.

3. Review of "Complaint," dated 11/19/21, showed Patient 3 was concerned that she may have been stuck by a dirty needle because she was stuck more than once. Patient 3 reported that the nurse requested her signature on a form to test her blood because she was high risk for hepatitis or HIV. Patient 3 also expressed concerns that there was someone else's blood on the sheets of the bed she was placed in.

Further review showed that Staff GG, Registered Nurse (RN), documented, "denied that any staff had been stuck with a needle which would explain request to draw patient's blood - he is unaware of any staff member being stuck."

There was no documented evidence to show further interviews were conducted, or consideration that the "dirty" needle stick might be from patient to patient. The documentation failed to determine if a needle stick had occurred or not. Further review showed that the hospital failed to investigate the infection control concerns expressed. The hospital documented, "no action necessary at this time," under interventions and actions taken.

During an interview on 04/22/22 at 9:05 AM Staff C, Director of Risk Management stated that she was unsure if cleaning logs were reviewed or if the cleaning staff were interviewed or educated regarding the blood-stained sheets. Staff C stated that she was unsure if the patient stick was investigated. Staff C stated that it was her responsibility to ensure complaints and grievances were competed.

4. Review of "Complaint," dated 01/31/22 showed that Patient 13 was seen in the ED on 10/08/21 at 10:19 AM after dropping something on his foot. Patient 13 reported that the ED told him that nothing was wrong with his foot. Patient 13 reported that he went to another ED and they informed him his foot was broken.

The hospital had no evidence that they requested Patient 13's medical record from the other ED. The hospital did not have any knowledge of the time frame between Patient's 13 ED visits. The hospital did not have any evidence that they investigated Patient 13's concerns regarding his misdiagnosis.

During an interview on 04/22/22 at 9:05 AM Staff C, Director of Risk Management, stated that further investigation and record reviews should have been conducted in order to address Patient 13's concerns. Staff C stated that it was her responsibility to ensure complaints and grievances were completed.

5. Review of "Complaint," dated 12/06/21 showed that F6 called to report the lack of care his family received on 12/2/21 or 12/3/21. F6 reported that his mother (Patient 16) and father (Patient 17) and his daughter (Patient 18) were sick and needed medical attention. F6 reports that after telling the staff that his mother had chest pains and a fever, he was informed that they were COVID-19 symptoms, whispered something to her co-worker and then informed F6 that his mother could not be seen here and that he would have to take her somewhere else. F6 stated that he believes his family was being discriminated against because they were Hispanic. F6 stated that his wife called the above-named hospital and was told that they were turned away because F6 wanted to accompany his parents while being seen. F6 reported that he requested to stay with his daughter, aged 9, who also needed to be seen.

Further review showed the staff that took the report documented, "I do not know the family's name because I didn't ask. He said we refused treatment, so I figured we don't have their names. In hindsight, I should have asked. He was quite upset, rambled, cussed and I just mostly listened. I think there is more to the story." Further review showed that the case was closed on 12/07/21, the hospital did not contact the complainant, and a notation from Staff C, Director of Risk Management showed, "unable to follow up due to patient information not provided. No complaint received from individual who was seeking treatment." Further review of the report showed that the complainant's phone number was listed in two different places. The hospital failed to provide any documentation to show that staff reached out to F6 for further information in order to conduct a thorough investigation.

The hospital did not escalate the patient right's concerns to the grievance process, nor did they follow their policy specific for grievances that included discrimination. Furthermore, the hospital failed to forward the concerns to the Civil Rights Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discrimination action. The hospital failed to provide evidence that the alleged discrimination was sent to the Civil Rights Coordinator. Further review of the report showed actions taken: "no action necessary at this time."

During an interview on 04/22/22 at 9:05 AM Staff C, Director of Risk Management, stated that she does not know if Staff L, unknown title, was interviewed regarding the incident. Staff C stated that it was not escalated to a grievance. Staff C is not sure why staff did not call the complainant back in order to get the patient's names in order to complete the investigation. Staff C stated that it was her responsibility to ensure complaints and grievances were completed.

6. Review of "Grievance," reported on 11/18/21 showed F7, daughter to Patient 14, reported that she and her siblings had several concerns about patient rights and the clinical care that their mother received during her admission between 10/12/21 to 10/25/21. The written letter outlines the following concerns from the family:

a. Patient 14 was over medicated which lead to significant decline in her health. Patient 14 was receiving 900mg (milligrams) of Dilantin (a medication used to treat seizure disorders) daily instead of her prescribed dose of 300mg daily. Lab work showed that her Dilantin level was 48, normal range should be between 10-20.
b. Patient to nurse ratio concerns due to delayed response to the call button.
c. Patient 14 was told to use an adult brief instead of being assisted to the bathroom, which is "dehumanizing" to Patient 14 who preferred not to have an accident.
d. Patient 14 was discriminated against when the family was asked, "where did she come from?"
e. The family reported concerns of health decline that was dismissed as reactions to the pain medications she was receiving.
f. The family had to request a urinary analysis to check for possible urinary tract infection and additional blood work as Patient 14 was exhibiting confusion and slurred speech.
g. Patient 14 was not spared privacy or dignity as she was told in front of visitors to use her adult brief.
h. Patient 14 requested to lay back in bed after sitting in the chair for about a half hour. Patient 14 requested to go back to bed as her back was hurting her and she requested that the nurses "please, hurry." Patient 14 still was not assisted to her bed for more than an hour after her first request to go back to bed.
i. Concerns that the nurses were not being honest regarding Patient 14's condition.
j. Concerns with the lack of medication reconciliation at discharge.

Review of "Grievance Response Letter," dated 11/30/21 showed, "In review of the medical record, the medication list was not located. Discussion with the emergency department nurse and the admitting nurse revealed that they did not have access to a copy of the current medication when the medication reconciliation occurred with the physician. The medication ordering process has many steps involved with double and triple checks in place. These steps were followed. Unfortunately, the change in dose frequency was not identified as erroneous in a timely fashion." Further review showed, "Review of the unit staffing revealed that we were staffed per the unit ratios established for the unit. The concerns with delays in call light response and staff comments that were perceived as insensitive have been addressed with all unit staff."

The hospital failed to show that they addressed all of the concerns in the response letter to Patient 14's family member. They failed to address the allegations of discrimination, breach of privacy and dignity, dismissing family concerns, not addressing Patient 14's pain in a timely manner, and concerns of the lack of medication reconciliation at discharge. The hospital failed to provide evidence that the allegations of discrimination were forwarded to Civil Rights Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discrimination action.

7. Review of "Patient Safety Event Report," showed an anonymous report dated 04/04/22 stating, "A patient (Patient 4) was being seen in ED room 22 needing a psych evaluation. Patient became hostile and became a code gray. [Staff D, Medical Doctor] ran into the room to assist with code gray. The patient had a hold of security guard's finger, to which [Staff D, MD] then began to punch the patient, with closed fist, in the abdominal region, 8 to 9 times, even after the patient let the security guards finger go. He still continued to punch the patient in the abdominal region with closed fist."

Review of the complaint/grievance log showed that the hospital did not escalate the alleged incident of patient abuse to the grievance process according to the hospital's policy.

During an interview on 04/22/22 at 9:05 AM Staff C stated that not all complaints involving patient's rights or ANE (abuse, neglect, and exploitation) go through the grievance process. Staff C stated that it was her responsibility to ensure complaints and grievances are completed. Staff C stated that complaints should be followed up within seven to 14 days and within seven days for grievances. Staff C stated that if a patient calls and say that they have a grievance they request that the patient put the grievance in writing. Staff C stated that verbal concerns are considered complaints. Staff C stated that sometimes a complaint will be escalated to a grievance. Staff C stated that she oversees the incidents and incident reports that are reported by all staff. Staff C stated that she then sends the concerns to the department head and that they have responsibility to complete the investigation and documentation. Staff C stated that the forms allow ample space to document a thorough investigation and doesn't know why staff are not being thorough in their reports.

The hospital's governing body failed to be responsible for the hospital establishing an effective process for prompt resolution of patient grievances.

Based on policy review, document review, and interview, the hospital failed to process patient concerns regarding patient's rights and other compliance issues through the grievance process leading to uninvestigated concerns, unresolved issues, and lack of response from the hospital for six of ten incidents reviewed, involving eight patients (Patient 3, 4, 11, 12, 13, 16, 17, and 18). These deficient practices have the potential to affect all patients and may lead to harm or other adverse outcomes.

Findings Include:

Review of the hospital's policy titled, "Grievance/Complaint Process," last revised 12/2021, showed, "on average, a time frame of 7 [seven] days for the response will be considered appropriate . . . If we are unable to resolve the issue on the spot, within seven (7) calendar days following the grievance receipt, the patient will be informed of this fact and of the anticipated length of the investigation. Based on the results of the investigation a decision will be rendered as to the validity of the grievance. The hospital should inform the patient or the patient's representative in writing that the hospital is still working to resolve the grievance and that the hospital will follow up with a written final response, usually within 30 days.

1. Review of "Complaint," dated 10/11/21 showed Patient 11 called the hospital on 10/11/21 at 10:00 AM to report "Staff Behavior Issues: insensitive, lack of compassion, lack of respect, not helpful, rude [and] inappropriate comments." The patient's rights concerns were not identified as a grievance and did not go through the grievance process. Review of the form showed the concern was closed on 12/10/21 and did not include documentation showing resolution was presented to the patient.

During an interview on 04/22/22 at 9:05 AM Staff C, Director of Risk Management stated that the concerns about patient rights were not escalated to the grievance process. Staff C is unsure if Patient 11 was contacted with the outcome of the investigation. Staff C stated that if there were supporting documentation such as interviews, they would be attached to the complaint in the reporting system. Staff C stated that she was responsible for ensuring the grievance process was completed.

2. Review of "Complaint," dated 10/12/21, F4, daughter to Patient 12 emailed the hospital expressing concerns of clinical care issues and delay in treatment with complaints of chest pain, difficulty breathing, and an abscessed tooth. The patient's rights concerns were not identified as a grievance and did not go through the grievance process. Review of the form showed the hospital closed the complaint on 10/15/21. A note showed, "attempted to contact [F4] at the given phone number and was told she was not available, will reattempt contact." No further documentation showing that follow up or investigation occurred.

During an interview on 04/22/22 at 9:05 AM, Staff C, Director of Risk Management, stated that she did not know why the ED log stated Patient 12 was being seen for congestion and the complaint had stated chest pain and difficulty breathing along with an abscessed tooth. Staff C does not know why the incident remains uninvestigated at the time of the survey. Staff C stated that it was her responsibility to ensure complaints and grievances are completed.

3. Review of "Complaint," dated 11/19/21, showed Patient 3 expressed in-person, verbally, clinical care and patient's rights concerns. The concerns were not identified as a grievance and did not go through the grievance process. The form showed a closed date of 11/22/21 with no indication of follow up with the patient.

During an interview on 04/22/22 at 9:05 AM Staff C, Director of Risk Management stated that she was unsure if cleaning logs were reviewed or if the cleaning staff were interviewed or educated regarding the blood-stained sheets. Staff C stated that she was unsure if patient to patient stick was investigated. Staff C stated that it was her responsibility to ensure complaints and grievances were completed.

4. Review of "Complaint," dated 01/31/22 showed that Patient 13 phoned the hospital on 01/31/22 about concerns regarding a misdiagnosis. The patient's verbal concerns were not escalated as a grievance and did not go through the grievance process. Further review showed the patient requested a follow up by the end of the week. Documentation does not indicate any follow up with the patient.

During an interview on 04/22/22 at 9:05 AM Staff C, Director of Risk Management, stated that further investigation and record reviews should have been conducted in order to address Patient 13's concerns. Staff C stated that it was her responsibility to ensure complaints and grievances were completed.

5. Review of "Complaint," dated 12/06/21 showed that on F6 called to report inadequate care, not respecting patient rights, and treatment not being provided to his parents (Patient 16 and 17) and his daughter (Patient 18). F6 believed his family was treated poorly because they were Hispanic. These patient's rights issues were not escalated to a grievance and did not go through the grievance process. Further review showed, "Unable to follow up due to patient information not provided. No complaint received from individuals seeking treatment." The hospital did not call the complainant back, even though the phone number was provided, in order to gain the information needed to investigate. The hospital failed to investigate and failed to provide a response to the complainant.

During an interview on 04/22/22 at 9:05 AM Staff C, Director of Risk Management, stated that she does not know if Staff L, unknown title, was interviewed regarding the incident. Staff C stated that it was not escalated to a grievance. Staff C is not sure why staff did not call the complainant back in order to get the patients names in order to complete the investigation. Staff C stated that it was her responsibility to ensure complaints and grievances were completed.

6. Review of "Patient Safety Event Report," dated 04/04/22, submitted by an anonymous staff member on behalf of Patient 4, alleging abuse by another staff member [Staff D, Medical Doctor]. These concerns were not escalated to a grievance and did not go through the grievance process per the hospital's policy and procedures.

During an interview on 04/22/22 at 9:05 AM Staff C stated that not all complaints involving patient's rights or ANE (abuse, neglect, and exploitation) go through the grievance process. Staff C stated that it was her responsibility to ensure complaints and grievances are completed. Staff C stated that if a patient calls and states that they have a grievance they request that the patient put the grievance in writing. Staff C stated that verbal concerns are considered complaints. Staff C stated that grievances should be reviewed and followed up on within seven days or notify the complainant that more time will be needed, no more than 30 days. Staff C stated that staff have ample space to document the investigation and notifications of outcomes on the form, and do not know why they are not being thorough.

Based on policy review, document review, and interview the hospital failed to provide patients written notice of its decision, steps taken on behalf of the patient and the results of the grievance process for eight of ten complaints, grievances, and incidents reviewed affecting nine patients (Patient 3, 10, 11, 12, 13, 14, 16, 17, and 18). These deficient practices have the potential to affect all patients by allowing grievances to go unresolved leading to harm or other adverse outcomes.

Findings Include:

Review of the hospital's policy, "Grievance/Complaint Process," last revised 12/2021, showed, The patient will be provided with a written notice of: the name and number of the hospital contact person should further information be required, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, [and] the date the investigation was completed.

1. Review of "Complaint," dated 10/11/21 showed Patient 11 went to the emergency department with abdominal pain on 10/09/21 at 9:27 PM. Patient 11 stated that she felt disrespected by the nurse practitioner that cared for her, stated that the nurse practitioner whispered to other staff in front of her, told her to change her lifestyle, and that the nurse practitioner was laughing at another patient who was trying to get a sandwich. Further review showed that Staff N, Emergency Department Director (EDD) wrote in an email to Staff C, Director of Risk Management, dated 11/10 (sic) "I investigated this incident and although we are all concerned with how the NP [Nurse Practitioner] treated the patient I am not able to properly address this without more feedback. It seems she was happy with the care received by ED nursing staff. A response requested in writing to a patient I find that a bit unusual in my experience with patient grievances and NP does not report to me. This makes it difficult for me to personally offer any evidence of remediation and I believe better handled by her direct report . . ." The complaint is dated 12/10/21 on "responder date, date of initial follow-up or contact" and on "responder dates: responder: closed date."

Further review showed the hospital failed to provide evidence that the patient was provided a written notice of its decision, steps taken on behalf of the patient and the results of the grievance.

During an interview on 04/22/22 at 9:05 AM Staff C, Director of Risk Management stated that the concerns about patient rights were not escalated to the grievance process. Staff C is unsure if Patient 11 was contacted with the outcome of the investigation. Staff C stated that if there were supporting documentation such as interviews or letters to the patient, they would be attached to the complaint in the reporting system. Staff C stated that it was her responsibility to ensure that the grievance process is completed.

2. Review of "Complaint," dated 10/12/21, F4, daughter to Patient 12 emailed the hospital reporting that Patient 12 was having difficulty breathing, chest pain, and a bad infection in her mouth with swelling and pain and waited in the ED waiting room for over eight hours. F4 reported that the abscess in Patient 12's mouth had burst, and Patient 12 had to manage the large amount of blood and purulent drainage on her own. Unknown staff stated that they were waiting on a clean room after about four hours of waiting. After another four hours of waiting, Patient 12 was told that the staff didn't know how much longer it would be and directed Patient 12 to leave if she didn't want to wait. F4 reported that Patient 12 left the waiting room, never being seen by a physician or other provider. Further review showed that Patient 12 arrived in the ED on 10/12/21 at 4:04 PM and left the ED on 10/12/21 at 10:59 PM

Further review of the complaint showed Staff N, ED Director, documented on 10/15/21 at 1:03 PM, "Attempted to contact [F4] at the given phone number and was told she was not available. Will reattempt contact."

The complaint concerning patient's rights was not escalated to the grievance process. The documentation does not include any interviews or other investigative measures taken on the patient's behalf or further contact was attempted. There is no documentation showing that the patient was contacted in writing, regarding the lack of care she received at the ED.

3. Review of "Complaint," dated 11/19/21, showed Patient 3 was concerned that she may have been stuck by a dirty needle. Patient 3 reported that the nurse requested her signature on a form to test her blood because she was high risk for hepatitis or HIV. Patient 3 also expressed concerns that there was someone else's blood on the sheets of the bed she was in.

The hospital documented, "no action necessary at this time," under interventions and actions taken. The hospital did not provide the patient with a letter of the outcome of their findings and actions taken on behalf of the patient.

4. Review of "Complaint," dated 01/31/22 showed that Patient 13 was seen in the ED on 10/08/21 at 10:19 AM after dropping something on his foot. Patient 13 reported that the ED told him that nothing was wrong with his foot. Patient 13 reported that he went to another ED and they informed him his foot was broken. Patient 13 voiced concern about the misdiagnosis.

Further review showed no evidence of documentation that the patient was contacted with the results of the investigation.

5. Review of "Complaint," dated 03/21/22, showed that F5, mother to Patient 10 called to report concerns when Patient 10 was transferred to the above-named hospital on an emergency basis for a surgery consult. F5 had expressed that after Patient 10 was admitted to the hospital at 3:00 AM for emergency surgery, nothing happened for over 9 hours. F5 found out later that the order for surgery consult failed to be written and that caused a delay. Further, F5 expressed concerns that Patient 10 was not provided a prescription for pain medication after having surgery.

Further review showed no evidence whether the patient was contacted, in writing, providing the actions taken on behalf of the patient or the results of the investigation.

6. Review of "Complaint," dated 12/06/21 showed that on F6 called to report the lack of care his family received on 12/2/21 or 12/3/21. F6 reported that his mother (Patient 16) and father (Patient 17) and his daughter (Patient 18) were sick and needed medical attention. F6 reports that after telling the staff that his mother had chest pains and a fever, he was informed that they were COVID -19 symptoms, whispered something to her co-worker and then informed F6 that his mother could not be seen here and that he would have to take her somewhere else. F6 stated that he believes his family was being discriminated against because they were Hispanic. F6 stated that his wife called the above-named hospital and was told that they were turned away because F6 wanted to accompany his parents while being seen. F6 reported that he requested to stay with his daughter, aged 9, who also needed to be seen.

Further review showed the hospital failed to provide evidence that the patient was provided a written notice of its decision, steps taken on behalf of the patient and the results of the grievance.

During an interview on 04/22/22 at 9:05 AM Staff C, Director of Risk Management, stated that she does not know if Staff L, unknown title was interviewed regarding the incident. Staff C stated that it was not escalated to a grievance. Staff C is not sure why staff did not call the complainant back in order to get the patients names in order to complete an investigation.

7. Review of "Grievance," reported on 11/18/21 showed F7, daughter to Patient 14, showed that she and her siblings had great concerns about the clinical care their mother received during their mother's admission between 10/12/21 through 10/25/21. The written letter outlines the following concerns from the family:

a. Patient 14 was over medicated which lead to significant decline in her health. Patient 14 was receiving 900mg (milligrams) of Dilantin (a medication used to treat seizure disorders) daily instead of her prescribed dose of 300mg daily. Lab work showed that her Dilantin level was 48, normal range should be between 10-20.
b. Patient to nurse ratio concerns due to delayed response to the call button.
c. Patient 14 was told to use the adult brief instead of being assisted to the bathroom, which is "dehumanizing" to Patient 14 who preferred not to have an accident.
d. Patient 14 was discriminated against when the family was asked, "where did she come from?"
e. The family reported concerns of health decline that was dismissed as reactions to the pain medications she was receiving.
f. The family had to request a urinary analysis to check for possible urinary tract infection and additional blood work as Patient 14 was exhibiting confusion and slurred speech.
g. Patient 14 was not spared privacy or dignity as she was told in front of visitors to use her adult briefs.
h. Patient 14 requested to lay back in bed after sitting in the chair for about a half hour. Patient 14 requested to go back to bed as her back was hurting her and she requested that the nurses "please, hurry." Patient 14 still was not assisted to her bed for more than an hour after her first request to go back to bed.
i. Concerns that the nurses were not being honest regarding Patient 14's condition.
j. Concerns with the lack of medication reconciliation at discharge.

Review of "Grievance Response Letter," dated 11/30/21 lacked evidence that the allegations of discrimination, breach of privacy and dignity, dismissing family concerns, not addressing Patient 14's pain in a timely manner, importance of being honest with patients, and concerns of the lack of medication reconciliation at discharge were addressed and the hospital did not provide resolution.

During an interview on 04/22/22 at 9:05 AM Staff C stated that not all complaints involving patient's rights or ANE (abuse, neglect, and exploitation) go through the grievance process. Staff C stated that it was her responsibility to ensure complaints and grievances are completed. Staff C stated that complaints should be followed up within seven to 14 days and within seven days for grievances. Staff C stated that if a patient calls and states that they have a grievance they request that the patient put the grievance in writing. Staff C stated that verbal concerns are considered complaints. Staff C stated that sometimes a complaint will be escalated to a grievance. Staff C stated that she oversees the incidents and incident reports that are reported by all staff. Staff C stated that she then sends the concerns to the department head and that they have responsibility to complete the investigation and documentation. Staff C stated that the forms allow ample space to document a thorough investigation and doesn't know why staff are not being thorough in their reports.

Based on observation, interview, and record review, the hospital failed to ensure that one of eight patients (Patient 4) who was at risk for suicide (or other forms of self-harm) and documented violent behavior that resulted in the injury of hospital staff, had appropriate safety measures in place to prevent elopement. This deficient practice has the potential to place patient(s), staff, and or/community at risk for serious harm, injury, or death.

Findings Include:

Review of Patient 4's discharged medical record showed that Patient 4 presented to the Emergency Room (ER), accompanied by his parents on 02/08/22 for altered mental status. His parents reported self-injury by hitting himself in the head with a brick and stabbing himself in the abdomen. Patient 4 was previously taken to [H2] (a psychiatric hospital) by his parents. [H2] requested patient be seen at an ER for medical clearance. Upon arrival, Patient 4 was combative and aggressive with staff for which patient was medically and physically restrained. Patient 4's history and physical showed no past medical history and no history of aggression or mental illness. Patient 4 was screened for drugs which was positive for marijuana but no other substances. Patient was placed in overnight observation (to an unlocked general medical surgical floor) with a plan to discharge to [H2] for ongoing psychiatric care. COVID-19 testing was performed and resulted positive, so patient was admitted to inpatient status. The discharge summary showed discharge diagnoses as resolving mania, probable bipolar disease, possible schizophrenia, resolving encephalopathy, and COVID-19. During the course of the hospital stay, Patient 4 required numerous Code Grays (a hospital alert of an aggressive patient or patient with escalating behaviors) due to multiple elopement attempts.

Review of the facility's investigation report, dated 04/14/22, showed, " ...On the evening of 04/04/22 an anonymous patient safety event report was submitted stating: "A Patient was being seen in ED room 22 needing a psych [psychiatric] evaluation. Patient became hostile and became a code gray (a hospital alert of an aggressive patient in need of assistance.) [Staff D, MD] ran into room to assist with code gray. The patient had a hold of security guard's finger (biting finger) ..."

Review of a document titled, "Patient Summary Report," dated 02/10/22 at 1:21 AM, showed, " ...02/02/22 at 2100 Triage Assessment ...Patient was then moved into room 22 ...Patient was placed into 4 point restraints for safety of staff and self by [Staff D, MD] ..."

Review of a policy titled, "Elopement," dated 07/2021, showed, " ...The hospital shall provide a safe, secure, legal containment for patients who are not alert and oriented and are a high risk for leaving the hospital. Precautions will be initiated on all patients who are identified at high risk for leaving the hospital ...The Charge Nurse will notify the House Supervisor and security of patients who are at high risk for elopement ...Nursing personnel shall observe for behaviors which may indicate that the patient may attempt to leave the premises; e.g., standing at doorways, in front of windows, appearing to try opening doors, changing into street clothing, pulling out IV's, tubes, etc ...High Risk Precautions may include but are not limited to the following interventions, utilizing the least restrictive measures: 1. Assigning "at risk" patient to a room near nursing station. 2. Assigning a "sitter" to the patient. 3. Placing the patient in a bed equipped with a bed alarm ...When patient is first discovered missing ...Notify primary care physician, who will determine if the patient is at risk to self or others ..."

Review of a document titled, "Providence Medical Center (PMC) Event Log," dated 02/09/22, showed, "On Wednesday, 02/09/22 at approx. 2033 (8:33 PM) hours, The S2 alarm alerted on the SE 5 floor stairwell door. Floor staff called security stating that a patient (Patient 4) eloped in the stairwell and was naked and that they needed security quickly. [Staff EE, Security] and I headed toward the stairwell and first floor. [Staff FF, Security] began to locate the pt on the CCTC (closed circuit television) system. We received a report that the patient was in numerous areas including the ED (Emergency Department) lot and Outpatient. [Staff EE, Security] and I were notified that several staff were chasing the pt through the south lot. [Staff EE, Security] and I responded in the patrol vehicle and encounter 2 ICU (Intensive Care Unit) nurses attempting to get the patient back inside. [Staff EE, Security] and I escorted the patient, who was completely naked into the hospital and back to the 5th floor. A code gray (notification of an aggressive patient or patient with escalating behaviors) was called during this above process. When we arrived at the 5th floor we escorted the patient back to his room. Several staff saw us, but we had to ask for someone to come and check on the patient. There was no response from the staff and all began to say that this patient was not theirs and they were not sure who his nurse was. Soon after the Nursing Supervisor arrived and took control of the situation. Security cleared at 2057 [8:57 PM] hours upon NS [Nursing Supervisor] approval."

Review of Patient 4's nursing note dated 02/09/22 at 2:20 AM showed, "Patient brought to 510. Is sedated with regular respirations. Accompanied by ER RN (Emergency Room Registered Nurse) and 2 security guards. SR (Side Rails) up x 4, call light in reach. Currently sedated and staff asks that he "not be wakened." Apparently, patient was quite combative and violent, bit a guard, screamed in the ED and ran across the parking lot. Physical assessment deferred at this time."

Review of Patient 4's nursing note dated 02/09/22 at 10:39 PM showed, "2000 (8:00 PM) Made rounds patient in the bed resting quietly with his eyes closed. 2030 (8:30 PM) came out of another patient room to the CNA (Certified Nurse Aide) saying that the patient was not in his room. Patient left the unit without any clothes on. Security notified as well as the nursing supervisor. Security brought the patient back to the unit. Patient unable to assess because he will not respond when talked to but he does follow commands. Was able to medicate patient with security at the bedside. Will continue to monitor and make frequent rounding." Documentation failed to show that the physician was notified of Patient 4's elopement.

During an interview on 04/28/22 at 9:00 AM, Staff JJ, Registered Nurse (RN), stated that on 02/09/22, Patient 4 did not have an order for 1:1 observation and did not have a sitter. She stated that she questioned if the patient should be on 1:1 but confirmed she did not contact the physician for an order. Staff JJ confirmed that Patient 4 was able to elope from the facility but was returned later by security.

During an interview on 04/27/22 at 10:15 AM, Staff DD, Security Officer, stated that he responded to a Code Gray and elopement call on 04/09/22 for Patient 4. He stated that the patient was located outside of the facility in the parking lot without clothes. Security was able to escort the patient back to the facility and to his room on the fifth floor.

During an interview on 04/27/22 at 1:51 PM, Staff EE, Security Officer, stated that he assisted in an elopement incident on 04/09/22 involving Patient 4. Staff EE stated the patient was located outside of the facility in the parking lot without clothes and was escorted back to the fifth floor and to his room.

During an interview on 04/28/22 at 9:20 AM, Staff A, Chief Nursing Officer (CNO) verified the hand-written admission order showed, " ...1-1 ..." and that it was interpreted to be a one on one (1:1) observation order. Staff A verified that a 1:1 observation order was not entered into the electronic medical record (EMR) until 02/10/22 at 11:13 AM (after Patient 4's elopement on 02/09/22.)

Review of Patient 4's nursing note dated 02/10/22 at 10:58 AM showed, "At 0900, this nurse was notified that the patient is agitated and walked along the hallway. He was redirected to his room by another nurse and CNA (Certified Nurse Assistant). Upon assessment, the patient was standing across his bed and staring at the wall. Few minutes later, he was pacing and made punching movements. He was visibly agitated ... The patient sat still for a few minutes then started punching the wall ..."

Review of Patient 4's nursing note dated 02/10/22 at 6:32 PM showed, "The patient is agitated again, has been pacing around the room; verbalized that he wanted to go out of the building ..."

Review of Patient 4's nursing note dated 02/11/22 at 12:08 PM showed, "Code Gray called at 1200 on patient, patient ran out of room and tried to escape ..."

Review of Patient 4's nursing note dated 02/11/22 at 2:59 PM showed, "Code Gray called on patient, when he ran towards the stairwell at 1400 ran down stairs, jumped off second floor roof. Ran down Parallel Ave (busy multiple lane street running east and west), security notified police which came and asked questions, mother notified." Documentation failed to show that physician was notified of Patient 4's elopement.

Review of a document titled "Providence Medical Center (PMC) Event Log," dated 02/11/22, showed, "On Friday 2/11/2022 at 1155 hours 5 north staff called a code gray to room 510. Patient [Patient 4] got up out of bed and ran out of his room. Patient [Patient 4] ran toward 5 south then by the visitor's elevator, Staff was able to escort patient back to his room without any problem. Staff stayed with patient until he returned to bed. The code gray was cleared at 1201 hours."

Review of a document titled, "Providence Medical Center (PMC) Event Log," dated 02/11/22, showed, "On Friday 02/11/2022 at 1410 (2:10 PM) hours a code gray was called on 5 north room 510 patient [Patient 4]. Patient had pulled past a staff member and headed down the NW stairwell. At 1408 the NW stairwell alarm sounded. At 1409 the NW roof alarm sounded at which time [security staff] who was dispatching at the time saw patient jump off the roof on the second floor and head west on Parallel (a multiple lane street running east-west on the north side of the hospital). [Security staff] then saw patient cross the street heading east on Parallel. I headed east on Parallel to try to locate patient with no luck. I had the dispatcher call K.C.K (Kansas City, Kansas) police to make a report. K.C.K Police arrived and I took them to 5 north to get the information they needed to find [Patient 4]. Code gray was cleared at 1434 hours.

During an interview on 04/26/22 at 2:42 PM, Staff W, RN stated that on 02/11/22, Patient 4 eloped from the facility by running past the CNA that was providing 1:1 observation. Patient 4 ran to the stairwell, exited the stairwell on the 2nd floor onto the roof of the Emergency Department and jumped to the ground. Patient 4 then ran across the parking lot and down the street.

During an interview on 04/26/22 at 3:18 PM, Staff BB, CNA (Certified Nurse Aide), stated that on 02/11/22, Patient 4 eloped from the hospital. Prior to the elopement, Patient 4 was attempting to change his clothes and stated that he was leaving. " ...All of a sudden he runs past me and to the stairwell exit. I yelled at the nurses to alert them, but he got in the stairwell ...He went through the door on the 2nd floor to the ER roof and jumped off the roof ..."

Based on document review, policy review, record review, and interview, the hospital failed to ensure that one of eight patients (Patient 4) was free from all forms of abuse or harassment and failed to protect all patients from the alleged perpetrator during the potential abuse investigation. This deficient practice puts any patient receiving services in this hospital as risk for serious injury, serious harm, or death.

Findings Include:

Review of the hospital's policy titled, "Abuse, Neglect, Harassment and Exploitation within the Facility," last reviewed 12/2021, showed, "Patients must not be subject to abuse by anyone, including but not limited facility staff, other patients, consultants or volunteers, staff of other agencies serving the patient, family members or legal guardians, friends, or other individuals . . . physical abuse includes, but is not limited to hitting, slapping, pinching . . . K.S.A. 39-1401 and 39-1402 mandates reporting of actual or suspected abuse, neglect, exploitation or fiduciary abuse of mentally ill, incapacitated and dependent persons . . . Procedure for Investigation . . . The supervisor will ensure that the patient is protected from harm during the investigations . . . An employee suspected of violation of these patient safety policies will be suspended pending investigation . . . if family member or visitor is suspected of violation of this policy will be reported to local law enforcement and others as appropriate."

Review of the hospital's training materials for Abuse, Neglect, and Exploitation, showed three pages of a 67-page document titled, "Annual Mandatory Training," copyright 2018. The document showed, "Patient abuse by a healthcare provider is a breach of medical ethics. Assault and abuse are also crimes." Further review showed, "Patients also may be abused outside the healthcare setting. As a healthcare provider, you are in a unique position to identify victims of abuse . . . With regard to (sic) victims of abuse and neglect, accrediting organizations require that accredited facilities: identify victims of abuse or neglect, educate healthcare staff, assess and refer victims to available resources, and report abuse and neglect."

Review of the hospital's "Medical Staff Bylaws," approved by the governing body on 03/25/21, showed "Contract Practitioners. A practitioner who is or who will be providing specified professional services pursuant to a contract with the hospital is subject to all membership qualifications, appointment, reappointment, and clinical privilege evaluations, and must meet all of the obligations of membership, just as any other applicant or staff member."


Review of Patient 4's discharged medical record showed that Patient 4 presented to the Emergency Room (ER), accompanied by his parents on 02/08/22 for altered mental status. His parents reported self-injury by hitting himself in the head with a brick and stabbing himself in the abdomen. Patient 4 was previously taken to [H2] (a psychiatric hospital) by his parents. H2 requested patient be seen at an ER for medical clearance. Upon arrival, Patient 4 was combative and aggressive with staff and so the staff used medications and physically restrained Patient 4. Patient 4's history and physical showed no past medical history and no history of aggression or mental illness. Patient was screened for drugs which was positive for marijuana but no substances. Patient was admitted for overnight observation with a plan to discharge to H2 for ongoing psychiatric care. COVID-19 testing was performed and resulted positive, so patient was admitted to inpatient status. The discharge summary showed discharge diagnoses as resolving mania, probable bipolar disease, possible schizophrenia, resolving encephalopathy, and COVID-19.

Review of the facility's investigation report, dated 04/14/22, showed, " ...On the evening of 04/04/22 an anonymous patient safety event report was submitted stating: "A Patient was being seen in ED room 22 needing a psychiatric evaluation. Patient became hostile and became a code gray (a hospital alert of an aggressive patient in need of assistance.) [Staff D, MD] ran into room to assist with code gray. The patient had a hold of security guard's finger (biting it), to which [Staff D, MD] then began to punch the patient, with closed fist, in the abdominal region, 8 to 9 times, even after the patient let the security guards finger go. He still continued to punch the patient in the abdominal region with closed fist." This alleged incident did not contain the name of the patient or the date of the event, however there had been an employee report from a security guard who was injured during an event on 02/08/22 and so they were able to identify the patient as Patient 4 and the alleged perpetrator as Staff D, MD. The hospital did not suspend Staff D during their investigation. The hospital conducted telephone interviews with identified staff (nursing and physician) involved in the incident beginning on 04/05/22 ...No one recalled or reported seeing [Staff D, MD] strike the patient with a closed fist in the abdomen at any time ... ...[Staff D, MD] denied punching the patient in the abdomen, but noted he did make contact with the patient on two occasions so that the patient would release the security guard's finger ...Based on the investigation to date, we are unable to substantiate the allegation of the physician striking the patient in the abdomen with a closed fist ..."

Review of the Ad Hoc Multispecialty Review Committee meeting minutes, dated 04/07/22, showed " ...regarding a 4/4/22 anonymous patient safety event report [Staff A, CNO] spoke to the fact that she had interviewed the staff that was involved with this patient (Patient 4) during an ED visit on 02/08/22. [Staff A, CNO] read a summary of those interviews: Staff did say that [Staff D, MD] was sitting on the patient's legs trying to get him in restraints ...
One nurse that was not in the room, but at the workstation across form [sic] the room stated that she saw [Staff D, MD] raise his hand above his head and hit patient 6-8 times in the abdomen with closed fist. [Staff A, CNO] also stated that [Staff D, MD] said that he hit the patient twice on the thigh, while the patient was biting the security guard, trying to get the patient to let go...The committee feels there was no malice involved, this was done to protect our staff and get the patient's attention. As a hospital we are mandated to report a situation of patient abuse or assault to the Department of Health, legal department wanted the meeting to determine if [Staff D, MD] should be placed on "summary suspension" or should be allowed to continue to work ..." Further review of the document showed the actions taken met the standard of care.

Review of a letter sent to [Staff D, MD] dated 04/07/22 showed that no disciplinary action would be taken towards [Staff D, MD] in the incident involving Patient 4.

Even though the hospital indicated they could not substantiate the fact that Staff D, MD struck the patient eight or nine times, there was information provided by notarized statements from various involved staff and Staff D, MD himself that provided evidence that the actions taken by Staff D, MD met the hospital policy definition of abuse.

Review of a notarized written statement on 04/13/22, Staff D, MD, wrote, " ...At that point I grabbed the patient's right thigh forcefully two or three times to stimulate him and distract him ..."

During an interview on 04/22/22 at 6:45 AM, Staff D, MD, stated, " ...I was at the foot of the bed and moved up towards leg on right side. I grabbed his right thigh two to three times to try to distract him from the biting, but it did not work ..."

Review of a notarized written statement, dated 04/12/22, Staff G, RN, wrote, " ...[Staff D, MD] came in and said, "Hey stop it, let go of his finger." I was looking to my left and saw from my right, [Staff D, MD] tap, smack patients' right leg I believe two times ..."

During an interview on 04/21/22 at 4:15 PM, Staff G, RN, stated when Patient 4 bit the security guard's finger, " ... [Staff D, MD] came in and said, "don't do that." I could see his arm movement but couldn't say if it was a slap or a punch. An incident report should have been done at the time. I have no idea if [Staff D, MD] was reported for hitting a patient but he should be for everyone's protection."

Review of notarized written statement, dated 04/21/22, Staff J, Unit Secretary, wrote, "On 02/08/22, I was seated at my desk, across from patient's room 22 when I called a code grey, assistance to ER Room 22. Shortly thereafter, I heard [Staff G, RN] yell "let go!" I looked over and saw [Staff G, RN], [Staff E, Security], a bunch of officers, in the patient's room, when [Staff D, MD] went running into the patient's room. I witnessed him punching the patient with closed fists in the patient's abdomen about 6 to 8 times ..."

During an interview on 04/21/22 at 12:12 PM, Staff J, Unit Secretary, stated that she heard [Staff G, RN] yell "let go!" and stated, " ... [Staff D, MD] ran in and [Staff D, MD] started punching the patient in the abdomen over and over. It was an over the shoulder, whole body force type of punch.

Review of a notarized written statement, dated 04/11/22, Staff M, Certified Nurse Aide (CNA), wrote, " ... [Staff D, MD] struck the patient 5-8 times in the knee ..."

During an interview on 04/21/22 at 4:37 PM, Staff M, CNA, stated, " ... [Staff D, MD] was trying to hold his legs and torso and hit the patient in his knee area five times or so. I think he was trying to inflict pain to make the patient release the security guards' finger ..."


During an interview on 04/22/22 at 9:05 AM, Staff C, Director of Risk Management, stated that Staff D, Medical Doctor (MD), continued to work during the investigation of the alleged abuse. Staff C stated if Staff D was an employee of the hospital, and not contracted staff, they would have suspended him pending the investigation. The hospital allowed the physician to continue working after reviewing the notarized statements from multiple staff and the physician himself even though he met the definition of physical abuse in the hospital's policy.

Based on policy review, interview, and record review, the hospital failed to ensure the restraints were discontinued at the earliest possible time for one of one patient reviewed wearing restraints (Patient 4). This deficient practice has the potential to place any patient at risk for serious harm, injury, or death.

Findings Include:

Review of a policy titled, "Restraints: Violent Behavior or Seclusion," revised 01/2019, showed " ...Restraint-Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or Chemical Restraint-A drug or medication that is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard of treatment or dosage for the patient's condition ...Violent Restraints-As an emergency measure reserved for those occasions when violent or self-destructive behavior place the patient or others in imminent danger ...Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time ...Restraint is discontinued by a competent Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order ...Initiation of Restraints or Seclusion - The order includes: The type of restraint; For locked Velcro restraints order must specify 4 point restraints; Duration; If a verbal order was given to initiate restraints, the physician must sign the verbal order and complete a written order which must take place within 1 hour. The patient for whom restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, is seen face-to-face as soon as possible, but no later than one (1) hour after the initiation of the intervention by a physician, or registered nurse or physician assistant ...The face-to-face is to evaluate The patient's immediate situation; The patient's reaction to the intervention; The patient's medical and behavioral condition; and The need to continue or terminate the restraint or seclusion ...If the face-to-face evaluation is conducted by a competent RN, physician assistant, or a physician who is not the attending, that person consults the attending physician or other physician who is responsible for the care of the patient as soon as possible and no later than one (1) hour after the initiation of the restrain or seclusion to: Obtain a telephone order for restraints or seclusion; Consult the physician about the patient's status; The physician reviews the information and determines if the restraint or seclusion should continue ...Staff participates in a debriefing about the restraint or seclusion episode, as soon as possible and appropriate, but no longer than 24 hours after the episode. Patient and family, as appropriate, participate in the debriefing ...Information obtained and documented from debriefings is used in performance improvement activities ...Documentation: Use available restraint flow sheets and order forms and narrative notes to document all pertinent information in the electronic medical record including but not limited to: Assessments and care provided; Alternatives attempted; Circumstances that led to use of restraint/seclusion; Physician/family notifications; Monitoring activities - include each 15 min assessment as applicable; Plan of Care/Treatment Plan - include criteria for discontinuation when applicable; Debriefing as applicable; Injuries/Deaths ..."

Review of a written email from Staff A, Chief Nursing Officer (CNO) on 04/29/22 at 2:04 PM, showed, "The physician was in the department with the patient (Patient 4) when the restraints were applied. He entered the order himself and documentation in the ED (Emergency Department) summary is consistent with a face to face."

Review of a document, "Patient Orders Detail," dated 02/14/22, showed an order for "Restraint Viol/Self age 18 or >" with a start date and time 02/08/22 at 9:20 PM and frequency every 15 minutes. The order was entered and signed by Staff D, MD on 02/08/22 at 11:37 PM. (two hours and 17 minutes after restraints were ordered.) Further review of the restraint order failed to show the type of restraint, did not specify the use of 4-point restraints, and failed to show the duration of order. The physician did not sign the restraint order within one hour as required per hospital policy.

Review of a document, "Patient Summary Report," dated 02/10/22 at 1:21 AM, showed, " ...02/08/22 at 2100 Triage Assessment ...Patient was then moved into room 22 for 1:1 ...Patient was placed into 4 point restraints for safety of staff and self by [Staff D, MD] ...

02/08/22 at 2115 Primary Nursing Assessment ...Restraints Applied ...Sitter at Bedside 2/08/22 Suicidal Precautions ...Restraints were applied after patient bit security officer ..."
02/08/22 at 2159 1:1 Observation ...Observation for HI, Manic Behavior, 4-point restraints; Assessment: Patient Status Asleep ... (signed by Staff G, RN)
02/08/22 at 2215 1:1 Observation ...Observation for HI, Manic Behavior, 4-point restraints; Assessment: Patient Status Asleep; Motor Calm ... (signed by Staff G, RN)
02/08/22 at 2230 1:1 Observation ...Observation for HI, Manic Behavior, 4-point restraints; Assessment: Patient Status Asleep; Motor Calm ... (signed by Staff G, RN)
02/08/22 at 2245 1:1 Observation ...Observation for HI, Manic Behavior, 4-point restraints; Assessment: Patient Status Asleep; Motor Calm ... (signed by Staff G, RN)
02/08/22 at 2300 1:1 Observation ...Observation for HI, Manic Behavior, 4-point restraints; Assessment: Patient Status Asleep; Motor Calm ... (signed by Staff G, RN)
02/09/22 at 0000 Nursing Note: Two ankle restraints removed from bed. Patient still has two wrist restraints. Patient is sleeping: ... (signed by Staff G, RN)
02/09/22 at 0100 Nursing Note: Restraints removed from patient. Patient sleeping nicely, lights dimmed. Warm blanket applied ... (signed by Staff G, RN)

Further review of the "Patient Summary Report," showed documentation that Patient 4 was asleep and calm at 02/08/22 at 9:59 PM. (39 minutes after restraints were applied.) Patient 4 remained asleep and calm until restraints were removed at 1:00 AM. Patient 4 remained in restraints for three hours and 40 minutes. (Patient 4 was asleep and calm for three hours with restraints in place.)

During an interview on 04/20/22 at 4:05 PM, Staff LL, Registered Nurse Manager, stated that it is the hospital's policy to remove restraints as soon as a possible if a patient is no longer exhibiting aggressive or dangerous behavior. Staff LL was asked to review the restraint/observation documentation of Patient 4's status while in restraints. Staff LL verified that the patient status was documented as asleep and calm on 02/08/22 at 9:15 PM and remained calm and asleep until restraints were removed on 02/09/22 at 1:00 AM. Staff LL stated, "Yes, the restraints should have been removed earlier."

Based on observation, interview, and document review, the hospital failed to follow the Centers for Disease Control and Prevention (CDC) guidelines for recommended routine infection prevention and control practices during the COVID-19 pandemic that included establishing a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed: 1) a positive viral test for SARS-CoV-2; 2) symptoms of COVID-19, or; 3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP)." This deficient practice has the potential to expose and spread COVID-19 to patients, other visitors, contractors, and/or employees in the hospital.

The hospital had a census of 70 patients with no COVID-19 positive patients at the time of survey entrance on 04/19/22 and four patients pending COVID-19 testing results. On 04/20/22, the hospital had two COVID-19 positive patients with two patients pending test results.

Findings Include:

Review of the hospital's COVID-19 infection control policies showed the hospital failed to have a policy or procedure in place for screening visitors. The hospital failed to ensure a process for identifying and managing visitors entering the facility for a positive SARS-CoV-2 infection, symptoms of COVID-19, or close contact with someone with SARS-CoV-2 infection.

During observation on 04/19/22 at 10:45 AM, there was no hospital staff present at the hospital entrance upon surveyor arrival. The survey team was able to enter the hospital and proceed through the hospital without being screened for COVID-19. The facility lacked any signage that stated visitors should not enter with a positive test result for COVID-19 infection, symptoms of COVID-19, or close contact with someone positive for COVID-19. During each subsequent visit, on 04/20/22, 04/21/22, 04/22/22, and 04/25/22, the survey team was not screened for COVID-19.

During observation on 04/20/22 at 8:00 AM, the hospital had no staff present at the front desk. Observation from 10:40 AM to 10:52 AM showed six unidentified visitors enter the hospital and continue through the lobby and into the hospital without COVID-19 screening.

During an interview on 04/21/22 at 11:20 AM, Staff X, Lead Infection Preventionist, stated that the hospital has never had a specific COVID-19 policy for screening visitors entering the hospital. She stated that visitor screening was discontinued in August or September of 2021. Staff X stated, " ...we just don't have the resources to screen, we are very thin right now in resources ..." Staff X confirmed that the hospital has no process in place to prevent visitors that might screen positive for COVID-19 from entering the hospital. Staff X stated that visitors discovered within the hospital would be asked to leave the hospital if facility staff recognized a visitor with COVID-19 symptoms.

During an interview on 04/20/22 at 10:50 AM, Staff Y, Volunteer, stated that the hospital is not requiring COVID-19 screening for visitors. Staff Y stated she was not certain when they stopped screening visitors, but that it had been, " ...a long time ago."

During an interview on 04/26/22 at 242 PM, Staff AA, Registered Nurse (RN) stated that COVID-19 screening for visitors to the hospital "stopped a long while ago."

During an interview on 04/26/22 at 3:45 PM, Staff CC, RN Supervisor, stated, "We used to have door greeters for a period of time. After we ended that, we simply have to ensure that visitors are wearing masks. It's probably been several months since we stopped the door greeters."

Based on document review, policy review, medical record review and interview, the hospital failed to ensure that discharge planning included the patient's likely need for appropriate psychiatric care, non-healthcare services related to her intellectual and developmental disabilities, community-based care providers, or the determination of the availability of the services that meet the patient's needs for a safe discharge. These deficient practices affected one of eight patients reviewed (Patient 1) and resulted in an unsafe discharge, additional contact with other hospitals leading to an additional admission, and unsafe behaviors leading to additional contact with law enforcement which potentially can lead to harm or other adverse outcomes with the potential to affect all patients with dual diagnoses with an axis II (long-standing conditions of clinical significance) diagnosis of Intellectual and Developmental Disabilities (ID/DD).

Findings Include:

Review of the hospital's policy titled, "Discharge Planning," last revised 12/2018, showed "Even though discharge planning is provided for all patients, additional requests for intervention can be initiated by the physician, staff, patient, or patient family . . . The objectives of discharge planning are: coordinate interdisciplinary team and community resources for comprehensive systematic discharge planning . . . assure high quality of departmental practice of discharge planning as an essential component of continuum of care . . . patients at risk for discharge planning barriers or with the potential for extended lengths of stay related to inadequate resources, alternatives or support systems . . . certain high risk populations may suffer adverse health consequences upon discharge if there is not additional discharge planning. High-risk patients may be defined as any person with combined age, health, and/or social factors which may negatively impact their post-hospital care."

Review of Patient 1's discharged medical record showed that Patient 1 was a 39-year-old female, admitted 03/31/22 for medical clearance in order to be transferred to a psychiatric unit. Patient 1's history and physical showed that she had diagnoses of agitation, hypertension (elevated blood pressure), Post Traumatic Stress Disorder (PTSD) (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), Intellectual and Developmental Disabilities (ID/DD), Borderline Personality Disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships), anxiety, and depression.

Review of "Assessment Center Screening Form," dated 03/31/22, untimed, completed by Staff T, Social Worker with the Psychiatric Assessment Team (PAT), showed "Pt [patient] presents to ED [Emergency Department] by [City Police Department] after lighting her group home on fire. Pt reports she was blacked out when she used a match to light her bedroom on fire. Pt reports she did not want to hurt anyone, but she wanted to get away. Pt reported the group home is abusive to her as the reason behind lighting the house on fire. [Police Department] reports the pt left the house after she lit the fire and called 911 from down the street. 5 [sic][Five] other people were in the home at the time the fire was set, [Police Department] said the fire was severe enough to be put out by fire department."

Review of "Emergency Department History/Physical Information," dated 03/31/22 at 11:37 PM, showed Staff U, Advanced Practicing Registered Nurse (APRN) wrote, "Patient is a 39-year-old female with history of mental retardation (sic), PTSD, bipolar, borderline personality, who presents to the ED today for medical clearance. Patient resides in a group home with other residents and group home employees. Arrives in the ED with two police officers. They state this patient went to the gas station, bought a matchstick and came back to the group home and light her room on fire, she ran out and called 911 to report the fire. Patient states they are abusing her at the group home . . ."

Review of "Triage Assessment," dated 03/31/22 at 7:04 PM, completed by Staff V, Registered Nurse (RN), showed, "Patient presents to the ER [emergency room] accompanied by [police officers] for medical clearance. The officers state the patient lives in a group home, and she set the house on fire with people in the home. Patient has mental disabilities per pd [police department]. Patient states, 'I set the house on fire because they are physically and mentally abusing me.' Patient alert. Patient given meal tray."

Review of "Addendum to Assessment Screening Form," dated 04/02/22 at 8:30 AM to 10:00 AM, completed by Staff S, SW with PAT showed, "The pt [patient] states she was upset with her group home and feels she is being abused . . . Pt reports not feeling safe with others."

Review of "Assessment Center Screening Form," dated 04/07/22 at 12:30 PM, completed by Staff R, Social Worker with PAT, showed, "Pt [patient] arrived [above-named hospital] on 03/31/22 for medical clearance after starting a fire in her room at her group home. Pt reports she did not intend to harm anyone but became angry after staff was "mean" and did not [let her]get her way. Pt has hx [history] of bipolar, borderline, PTSD, and mild MR [sic] [intellectual disability]. Pt denies SI-HI [Suicidal - Homicidal Ideation]. States she feels better in a structured environment but feels she is being mistreated at current group home." Further review showed recommendations: "to return to [group home] and will continue to seek alternative long-term housing and care, pt to be monitored by staff and med (sic) (medication) eval . . . Group home to monitor behaviors . . . Group home report they will monitor pt for safety and continue to seek alternative long-term housing."

Review of Patient 1's "Safety Plan," completed 04/07/22 showed "warning signs: anxiety, depression, and self-harm thoughts . . . internal coping strategies . . . smoking. Music. Tv . . . people and social settings that provide distractions [F2, DPOA], park, mall . . . people I can ask for help: case manager, group home staff, guardian . . . professionals or agencies I can contact: group home, guardian, suicide prevention lifeline [number omitted], [above-named hospital] ED . . . making the environment safe: staff [group home] monitor pt and behavior and pt to follow coping skills discussed." Further review showed that Patient 1's safety plan depended a lot upon the group home and group home staff that Patient 1 had alleged abuse and did not include a safety plan for continued abuse or mistreatment.

Review of Patient 1's discharge summary showed "Date of Discharge: Apr (sic) 7, 2022. Admission diagnosis: SI [suicidal ideation]. Discharge diagnosis: same . . . Brief psychotic disorder - still wants to burn her group home down, does not want to return . . . when asked if she has any suicidal or homicidal ideation she states no but she notes that she feels she was being physically and emotionally abused at her group home and tells me if she returned to her group home she would burn it down . . . Patient denied from every facility that has been tried. Really no other option at this point other than to send back to group home. Discharge back there today."

Review of Patient 1's discharged medical record from a second hospital, H2, showed that Patient 1 was brought to H2 by the local police department for "running naked in streets," and admitted on 04/09/22 at 7:53 PM. Review of Patient 1's History & Physical showed, "39 F (female) with history of cognitive impairment presents to the emergency department for evaluation after being found running around the street naked, trying to get into cars. Initial details limited due to patient's mental status. PD (police department) was able to find patient's address which is a boarding home, [name of group home]. The manager, [name omitted] called and informed that this is the third time patient has run away this week. She was seen at [above-named hospital] Monday then [H3] Tuesday. I spoke with patient's guardian [F2] [phone number omitted] who states she does not feel safe with patient's discharge back to the group home because she keeps running away."

Further review showed that Patient 1 arrived agitated, continued to remove her clothing, kicking her legs in the air and screaming. She was unable to be redirected and required 5 mg (milligrams) midazolam HCl (a sedative) at 8:26 PM and a second dose at 9:04 PM. She also received a dose of Haldol (antipsychotic medication) at 8:23 PM.

Review of provider noted dated 04/10/22 at 6:23 AM showed, "Patient has been assessed, plan to discharge back to group home; however, assessor has been unable to reach anyone at the group home despite leaving multiple messages . . . will continue 1:1 psych watch."

Review of provider note dated 04/10/22 at 11:24 AM showed, "The patient has been cleared medically and psychiatrically for discharge . . . Patient's group home has been contacted and is now here to pick up the patient. The patient will be discharged back to her group home."

Review of behavioral health note dated 04/10/22 at 2:00 AM showed, "Pt (patient) is a 39-year-old Caucasian female presenting for bizarre behavior after allegedly running from her facility and turning up naked on [street] far from her facility. Pt is in a four-person group home with four staff. Pt was dc (discharged) from a state institution for 10 years and that her mental capacity has decreased since her discharge. Pt's speech is childlike, and her IQ is estimated below 70. Pt has been leaving her facility during her 10-minute cigarette time. Pt will walk down the street. She will get into a car and will end up far away from her facility. Pt will be grandiose with her behaviors for example saying she drinks when in reality she does not. There is no current reason per report that pt continues to run from her treatment. Writer discussed with guardian and has left msg (message) with group home. Pt will be discharged back to her group home."

During an interview on 04/20/22 at 11:11 AM, F1, Registered Nurse (RN), with Patient 1's state insurance plan, stated that she was reading through clinical notes and noted that Patient 1 had alleged physical and mental abuse occurring at the group home in which she resides. F1 stated that she was concerned that Patient 1 was discharged back to the group home where the alleged abuse is occurring and still expressing that she will burn the group home down if she is returned. F1 stated that it also places the other individuals and staff at the group home at risk, as well as placing Patient 1 back into a potentially abusive situation. F1 stated that she reached out to the above-named hospital and spoke with the Utilization Review (UR) department to ensure that the allegations of abuse were reported to the appropriate authorities. The UR department referred her to social work. F1 stated that she attempted to reach out to the assigned social worker and the supervisor leaving messages for both staff every day, for four days, with no return calls. F1 stated that she wanted to ensure that the concerns were reported to the appropriate agencies.

During an interview on 04/20/22 at 10:52 AM, F2, Durable Power of Attorney (DPOA) to Patient 1, stated that Patient 1 requires a more structured and secure setting in which to be cared for long term. F2 stated that Patient 1 has a long history of being in the state hospitals and struggles with permanent placement in the community. F2 stated that even right at the moment of this interview, Patient 1 is out running the streets. F2 stated that Patient 1 refused to go to day program and instead ran off to spend the day with her new boyfriend. F2 stated that since being discharged from [the above-named Hospital] she's been to two other hospitals trying to get help with stabilization. F2 stated that Patient 1 had been raped in the past, that she is trusting of people, accepting rides, and is at risk in the community.

During an interview on 04/20/22 at 3:10 PM, Staff P, Social Worker, stated that Patient 1 was assessed by the psychiatric assessment team who determined she required inpatient psychiatric services. Staff P stated that the district attorney for the county refused the case once it was identified that Patient 1 has intellectual and developmental disabilities and denied admittance to a state hospital. Staff P stated that Patient 1 never disclosed any allegations of abuse to her directly but was aware of some comments from the staff caring for her. Staff P stated that she was not aware if anyone reported the alleged abuse.

During an interview on 04/21/22, at 9:43 AM, Staff R, Social Worker, stated that Patient 1 did express that she wanted to burn the group home down. Staff R stated that Patient 1 said she was mistreated at the group home and explained that the group home staff would not allow her to get cigarettes and would lock her out of the home. Staff R stated that she wasn't abused, just not treated well. Staff R stated that he did not report the allegations of mistreatment. Staff R stated that he did speak to the staff at the group home and they had informed him that she says things like that when she doesn't get her way. Staff R stated that she was not displaying any suicidal ideation at the time of the discharge, so they discharged her back to the group home. Staff R stated that Patient 1 was clever about what she says and that she knows exactly what to say, because she's been through the system. Staff R stated that he could not recall if Patient 1 was referred to outpatient psychiatric services once psychiatric placement could not be found. Staff R stated that he would have to review the safety plan that was developed for Patient 1.

During an interview on 04/21/22 at 2:45 PM, Staff T, Social Worker, stated that Patient 1 told her that the group home would limit access to alcohol and that she wanted matches. Staff T stated that Patient 1 reported she was being verbally abused at the group home. Staff T stated due to context and history, and her experience working with family services, she did not report the alleged abuse.

During an interview on 04/21/22 at 3:15 PM, Staff S, Social Worker, stated that after the previous screener screened Patient 1, she screened Patient 1. Staff S stated that Patient 1 reported that she started a fire and started a previous fire before that. Staff S stated that Patient 1 alleged being verbally abused. Staff S stated that she did not report the alleged abuse because she inherited the screen and came in to find placement for her.

During an interview on 04/21/22 at 3:24 PM, Staff V, Registered Nurse (RN), stated that Patient 1 did report that she was being physically and mentally abused at the group home and that she did not report the alleged abuse and acknowledged that she should have. Staff V stated that she understands that she has an obligation to call and report abuse and feels that she may not have done that because of the presence of the Police Department.

During an interview on 04/20/22 at 2:00 PM Staff Q, Director of Social Work and Case Management, stated that when a patient makes an allegation of abuse or domestic violence, he expects his staff to immediately make a report to the age-related agency. Staff Q stated that staff can help the patient with making a police report for those that are crime victims. Staff Q stated that he is responsible for reviewing social work notes but does not recall seeing any notes that Patient 1 had alleged abuse at her group home or any staff members reporting the alleged abuse, acknowledging the allegations of abuse presents an unsafe discharge for Patient 1.