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Based on observation, interview, and record review, the hospital failed to ensure that the Patient Rights Condition of Participation was met by failing to:

1. Inform each patient or patient's representative (as allowed under state law) of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.
(See A 117)

2. Provide information regarding advance directives to patient's and have hospital staff and practitioners comply with these directives.
(See A 132)

3. Provide personal privacy on 2 hospital units.
(See A 143)

4. Keep a patient free from all forms of abuse or harassment.
(See A 145)

The cumulative effect of these systemic practices resulted in the hospital's inability to deliver care in compliance with the Condition of Participation for Patient Rights.

Based on interview and record review, the facility failed to provide consent for services on admission when Patient's B, C, D, and G's admission consents, including patient's rights were not signed.

This failure had the potential for Patient's B, C, D, and G not to be informed of their rights as hospital patients, and could affect their ability to make decisions about care and treatment.

Findings:

1. During a review of admission record, Patient B was admitted to the facility on 4/6/21 with admitting diagnoses which included right sided weakness and hypertension (high blood pressure). Record review revealed, Patient B's consent for admission services including patient's rights, dated 4/9/21 indicated "Pt medically unable to sign."

During an interview with Admitting Staff 1 (AS 1) on 4/30/21, at 2:01 PM, AS 1 stated he was working on 4/9/21 and went to Patient B's room and was unable to get a signature. AS 1 failed to provide documented evidence of attempts or follow up made to obtain Patient B's signature.

2. During a review of admission record, Patient C was admitted to the facility on 4/15/21 with admitting diagnoses which included hypertension and atrial fibrillation (irregular heartbeat). The admission condition of service forms including Patient Rights dated 4/15/21, indicated "medically unable to sign." There was no documented evidence of attempts or follow up made to obtain Patient C's signature.

During an interview with Admission Director (AD) on 4/30/21, at 2:15 PM, AD stated the admission staff should have made attempts to ensure the admission forms were signed.

3. During a review of admission record, Patient D was admitted to the facility on 4/19/21 with admitting diagnosis which included Obstructive Jaundice (specific type of jaundice (a medical condition with yellowing of the skin) where symptoms develop due to liver problem). Condition for admission forms including Patient's Rights were signed on 4/22/21, four (4) days after Patient D was admitted to the facility.

During an interview with Admitting Staff 2 (AS 2) on 4/30/21, at 1:50 AM, AS 2 stated "I obtained Patient D's signature after checking the end of the day shift report on 4/22/21." AS 2 confirmed there was no documented evidence Patient D's condition for admission consent forms were signed.

During a concurrent interview, the AD stated all staff in her department were expected to follow up throughout and document indication/reason why the forms were not signed on the day of admission. The AD confirmed the Admission Department had the overall responsibility of ensuring patient's consent for service forms were signed upon admission.

A review of the facility's policy and procedure titled, "General Admitting Policy", dated 2/27/19, indicated each patient shall sign documents on admission.

A review of the facility's policy and procedure titled, "Registration, Process, Patient", dated 2/27/19, indicated at the time of admission, the patient or the legal representative shall sign conditions of service consent forms.



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4. During a review of the clinical record for Patient G, the face sheet (a summary of important patient information) indicated Patient G was admitted to the facility from a skilled nursing facility, on 4/17/21 at 12:42 PM. The admitting diagnosis was left hip fracture. The document indicated a family member as Patient G's emergency contact.

The admission Conditions of Services, Notice of Patients' Rights, Advance Directive Acknowledgment and Declaration of Financial Responsibility forms, dated 4/17/21, indicated "medically unable to sign."

A review of the nursing admission assessment, dated 4/17/21 at 3 PM, completed by a Registered Nurse, revealed Patient G was confused, disoriented, and had cognitive limitations.

On 4/30/21 at 8:30 AM, an interview and concurrent electronic record review was conducted with Admissions Staff 1 (AS 1).

AS 1 stated when a patient was unable to sign the admission consent forms, "We're supposed to call the emergency contact. If we tried to make contact with the emergency contact, we would document that in the admitting notes."

In a concurrent review of Patient G's electronic record, there was no documented evidence that there was follow up to obtain Patient G's signature, or Patient G's legal representative's signature.

On 4/30/21 at 1:53 PM, an interview was conducted with the Admission Director (AD). The AD stated upon admission, admitting staff will obtain signatures from the patients. The AD stated, "The expectation is to document that they made an attempt, and follow up. We are a 24 hours operation so continue to endorse the chart until it is complete."

A review of the facility's policy and procedure (P&P) titled, "Registration Process, Patient," dated 2/27/19, the P&P indicated, "At the time of registration and/or admission, the patient or the patient's legal representative shall sign the following consent forms: a. Conditions of Service b. Advanced Directive Screening Form (if applicable) c. An Important Message from Medicare (if applicable) d. Notice of Privacy Practice Acknowledgment Form... e. Opt out Acknowledgment Form..."

Based on observation, interview, and record review, the facility failed to ensure its policy and procedure titled, "Advance Health Care Directives (AHCD, legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves)," dated 8/28/19, was followed for two patients (Patient's E and F) when:

1. Patient E's Advance Directive Acknowledgement (ADA) form was not completed upon admission. This failure had the potential to violate Patient E's right to formulate an AHCD.

2. Patient F's Advance Directive Acknowledgement form was not in Patient F's hard chart. This failure resulted in Patient F's ADA form not to be readily available to staff.

Findings:

1. During tour of unit 10 West on 4/29/21 at 11:20 AM, with the Director of Medical-Surgical (DMS), Patient E was observed lying on her bed watching the television.

In a concurrent interview with Patient E, she stated she was a transfer patient from another hospital. Patient E stated she had been in her room for 14.5 hours. Patient E stated she had not been asked if she had an AHCD.

During a review of Patient E's clinical record the face sheet (a summary of important patient information) indicated Patient E was admitted to the facility on 4/28/21 at 10:53 PM with a diagnosis of rectal bleeding. At the bottom of the face sheet was an area that indicated, "ADV (Advance) DIRECTIVES." Typed into the area were the words, "NOT APPLICABLE."

In a concurrent interview with DMS, DMS confirmed Patient E's clinical record did not contain an ADA form. DMS stated the ADA was to document whether a patient had an AHCD or did not have one. DMS stated the ADA form was completed by the Admitting staff, and a copy was supposed to be placed in the patient's clinical record.

During an interview with Admitting Staff 1 (AS 1), on 4/30/21 at 8:30 AM, AS 1 stated when a patient arrived on the unit for admission, the nurse's station would inform him. AS 1 stated he would type into the system the date and time of the patient's arrival and generate a patient identification wrist band, patient stickers, face sheet and consent forms.

AS 1 further stated he would go to the patient's bedside as soon as possible upon arrival, and place the patient's identification wrist band on the patient. AS 1 stated he would also ask the patient about an AHCD. AS 1 stated, "If they don't have one, will use the [ADA] form. The original goes to the nurse's station."

During a concurrent electronic review of Patient E's admission information, it was revealed an ADA form was signed by Patient E on 4/29/21 at 4:30 PM.

The "ADV DIRECTIVES" area at the bottom of the face sheet indicated, "NOT APPLICABLE." AS1 stated the "NOT APPLICABLE" should have been removed and the area updated to whatever the ADA form indicated.

On 4/30/21 at 1:53 PM, an interview was conducted with the Admissions Director (AD). The AD stated upon admission the ADA form was to be completed. The AD stated the original signed copy of the ADA form would go to the nurse on the unit.

2. During tour of unit 10 East on 4/29/21 at 11:45 AM, with the Director of Medical-Surgical (DMS), Patient E's clinical record was reviewed.

The face sheet (a summary of important patient information) for Patient F indicated the patient was admitted to the facility on 4/10/21 at 1:14 AM, with a diagnosis of thrombocytopenia (a low blood platelet count, the blood cells that help blood clot).

A review of the nursing admission assessment dated 4/10/21 at 5:54 AM, indicated that in the "Advance Directives" section of the assessment, the Registered Nurse who had completed the assessment documented, "None, refused further information."

In a concurrent interview, the DMS stated the ADA form was completed by the Admitting staff, and was responsible to document whether a patient had an AHCD or did not have one. The DMS stated the signed ADA was supposed to be kept with consents in the patient's hard chart. The DMS confirmed Patient F's hard chart did not contain an ADA form.

During an interview with the Admitting Staff 1 (AS 1), on 4/30/21 at 8:30 AM, AS1 stated when a patient arrived on the unit for admission, the nurse's stations would inform him. AS 1 stated he would type into the system the date and time of the patient's arrival and generate a patient identification wrist band, patient stickers, face sheet and consent forms.

AS 1 stated he would go to the patient's bedside as soon as possible upon arrival, and place the patient's identification wrist band on the patient. AS 1 stated he would also ask the patient about an AHCD. AS 1 stated, "If they don't have one, will use the [ADA] form. The original goes to the nurse's station."

In a concurrent review of Patient F's electronic clinical record, the record revealed an ADA had been signed by Patient F on 4/21/21 at 1:21 AM. AS 1 stated the ADA form was scanned into Patient F's clinical record by Admitting staff, but the original copy would have been left on the unit with the nurse to place in Patient F's hard chart.

On 4/30/21 at 1:53 PM, an interview was conducted with the Admissions Director (AD). AD stated upon admission the Advance Directive Acknowledgement form was to be completed. AD stated the original signed copy of the ADA form would go to the nurse on the unit.

A review of the facility's policy and procedure (P&P) titled, "Advance Health Care Directives," dated 8/28/19, the P&P indicated, "Health Information Management shall identify the medical record of the patient with an advance directive for easy document retrieval. The Health Information Management Department will place the AD in the front of the patient's chart with the face sheet and Conditions of Admission (COA)... Procedure: Upon admission to [name of facility] either through the Admitting Department or the Emergency Department, the admitting person will ask the adult patient if s/he has an advance directive or if s/he wants information regarding advance directives... If the adult patient has not completed an AD, admitting staff will ask the patient if s/he wants information regarding advance directives and will complete Section A of the "Does the Patient have an Advance Directive?" form to document the following: 1. An Advance Directive Pamphlet was given to the patient. 2. Patient wishes to obtain more information and/or complete a new AD. 3. An Advance Directive Pamphlet was not given to the patient; and staff will note the reason (e.g., patient refused information, patient unable to receive information due to condition). The Advance Directive screening form will be provided to pastoral care for those patients that are interested in additional information."

Based on observation, interview, and record review, the facility failed to ensure white boards were not placed in areas where they could be viewed by the public. This failure resulted in a violation of patients' right to privacy.

Findings:

During a tour of the patient care unit 10 East and 10 West, on 4/29/21 at 11:15 AM, escorted by the Medical-Surgical Director (MSD), a large white board approximately five feet by four feet was observed on the wall inside the nurse's station. The white board contained the last name and first initial of patients with their room numbers. To the right of each name was written healthcare treatments the patient was receiving. The white board was within view of the public entering the unit.

During a tour of the patient care unit 9 East and 9 West, on 4/29/21 at 12:25 PM, escorted by the MSD, a large white board approximately five feet by four feet was observed on the wall inside the nurse's station. The white board contained the last name and first initial of patients with their room numbers. To the right of each name was written healthcare treatments the patient was receiving. The white board was within view of the public entering the unit.

On 4/29/21 at 11:35 AM, an interview was conducted with the MSD. The MSD stated, "The white boards have the patient names. It's used to facilitate communication for the healthcare team. Originally we only put initials of the patient, but we are now writing last name and first initial by the room number."

On 4/30/21 at 9:41 AM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated he thought a patient's name should be confidential because it was one way that was used to identify a patient. CNO stated that sharing a patient's name in addition to other patient information would make it easy to know who the patient was. CNO stated, "I wouldn't want to be sharing names with people who don't have the right to know. I don't think I'd want my name with the activities I was getting."

A review of the facility's policy and procedure (P&P) titled, "Use and Disclosure Requiring Authorization," dated 2/27/19, the P&P indicated, "Purpose: Identifies when the Medical Center may use and disclose PHI (Protected health information, individually identifiable health information) of patients pursuant to an Authorization... Definitions... Individually identifiable means that the medical information includes or contains any element of personal identifying information sufficient to allow identification of the individual, such as the patient's name, address, electronic mail address, telephone number, or social security number, or other information that, alone or in combination with other publicly available information, reveals the individuals' identity... Except as otherwise permitted or required by policy or is required by law, the Medical Center may not use or disclose PHI without an authorization that is valid under this Policy..."

Based on interview and record review, the facility failed to ensure the following:

1. Registered Nurse 1's (RN 1) criminal background and verification from previous employment was conducted prior to employment to the facility.

2. After the physical abuse to Patient A occurred, the facility allowed the Registered Nurse to continue working until the end of her shift. RN 1 initially punched Patient A in the chest, then returned later and hit Patient A in the knees with a flashlight.

As a result, Patient A received substantial physical abuse from RN 1 during care, which had the potential to place all other patients safety at risk.

Findings:

On 4/29/20, at 9:30 AM, complaint validation survey was conducted at the facility.

1. On 4/30/21, RN 1's employee file was reviewed. RN 1 was hired as a Registered Nurse on 2008.

On 4/30/21, at 3:13 PM, an interview with Senior Human Resources Business Partner (SRHRBP) and Executive Assistant (EA) was conducted. SRHRBP and EA confirmed RN 1's criminal background and verification of previous employment information was not in their computer system.

On 4/30/21, at 5:30 PM, Vice President Quality Management 1 (VPQ 1) confirmed no documented evidence showed criminal background check and verification from previous employment were conducted prior to RN 1's employment.

Further review of RN 1's employee file, the facility substantiated RN 1's physical abuse towards Patient A on 11/25/20 and RN 1 was terminated on 12/1/20.

A review of the facility policy and procedure titled "Requirements for Employees/Outsourced/Contracted/Volunteer Staff", dated 12/4/13, indicated [facility name] will require the pre-employment criminal background check including screening through the listing of individuals barred from doing business with federal agencies.

A review of facility's policy and procedure titled, "Pre-Employment Background Screening", dated 5/27/20, indicated the facility will conduct background checks on all prospective employees in order to verify their identity, qualifications, ability and character to work in the health care environment.



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2. During a review of Patient A's "History and Physical" (H&P), dated 11/22/2020, the H&P indicated, Patient A was hospitalized on 11/22/2020, due to a fall that occurred outside of the facility that led to a subdural hematoma (A traumatic brain injury with bleeding).

During a review of the Daily Assignment Sheet, dated 4/25/2020, from 7PM - 7AM, the Assignment Sheet indicated, RN 1 was assigned to work on the Surgical Intensive Care Unit (SICU).

During a review of the Registered Nurse's (RN 1) Time Card, dated 4/25/2020 - 4/26/2020, the Time Card shows RN 1 clocked in for work at 6:41 PM on 4/25/2020 and clocked out of work on 4/26/2020, at 7:15 AM.

During an interview on 4/30/2021, at 6:55 AM, with RN 2, RN 2 stated, while trying to reposition Patient A in his bed, Patient A became combative and kicked RN 1 in the head. RN 1 began punching Patient A in the chest and told Patient A she would kill him. RN 2 further stated, she told RN 1 to stop and get away from the patient, but when she returned from a break she saw RN 1 next to Patient A hitting him in his knees with a flashlight.

During an interview on 4/30/2021, at 4:20 PM, with the Chief Nursing Officer (CNO), CNO stated, that RN 1 should have been sent home after the first incident of abuse occurred, but staff working the night the incident occurred decided to let her stay or they would have been short staffed.

During a review of the facility's policy and procedure (P&P) titled, "Abuse: Prevention, Identification, Investigation, and Protection" dated, August 2019, indicated, "[Facility] is committed to assuring that the facility is doing all that is within its control to prevent occurrences of abuse ... [Facility] shall have evidence that all alleged violations are immediately and thoroughly investigated, and shall prevent further potential abuse while the investigation is in progress ... The employee may be removed from the patient care area immediately."

Based on interview and record review, the hospital failed to ensure that the Quality Assessment and Performance Improvement (QAPI) Program was in compliance when they failed to:

1.Provide documentation of education to staff members and set clear expectations for patient safety after an adverse event occurred.
( See A-0286)

2.Was accountable for providing hospital-wide quality assessment and performance improvement efforts for improved quality of care and patient safety regarding staff to patient abuse. (See A-0309)

The cumulative effect of these systemic practices contributed to hospital staff and management not knowing what to do when staff to patient abuse was witnessed, which allowed an abusive staff member to continue working her shift after abusing a patient (Patient A).

The hospital was unable to comply with it's mandated Condition of Participation for Quality Assessment and Performance Improvement Program.

Based on interview and record review, the hospital failed to ensure that the Quality Assessment and Performance Improvement Program (QAPI):

1. Provided documentation of education to staff members and set clear expectations for patient safety and/or tracking after an adverse event occurred and failed to ensure hospital-wide staff training was completed.

Findings:

During an interview on 4/30/2021, at 9:45 AM, with the Director of ICU (DICU), DICU stated, she could not provide documentation of education provided to staff regarding staff to patient abuse.

During an interview on 4/30/21, at 9:04 AM, the Director of Education (DE), when asked if she had knowledge of the abuse incident that occurred on 11/26/20, the DE stated, that incident was specific to the SICU Department and would be shared in their bi-weekly huddle. DE further stated, they usually collaborate between departments. If they have a need, the department manager can come to us, if something pops up, it is that department that handles the education. DE further stated, she did not collaborate with SICU Director about the abuse incident or any learning needs.

During an interview on 4/30/2021, at 3:45 PM, with the DE, DE stated, she was unable to provide evidence of house-wide abuse training provided to staff related to staff to patient abuse.

During an interview on 4/30/2021, at 6:10 PM, with the Vice President for Quality Improvement (VPQI), the VPQI stated, no specific training regarding staff to patient abuse could be provided.

During an interview on 4/30/2021, at 6:25 PM, with the Chief Nursing Officer (CNO), the CNO stated, he was not sure why the Charge Nurse and House Supervisor allowed the Registered Nurse (RN 1) to complete her shift after she had abused a patient.

During a review of the facility's policy and procedure (P&P) titled, "Quality Assurance/Performance Improvement Plan (QAPI)" dated 2020, the P&P indicated, "Effective Quality Assurance and Performance Improvement (QAPI) is mission critical to our organization's goals to improve the quality of care for individuals and improve health for our community and patient populations ...The Quality Assurance and Performance Improvement (QAPI) Plan that follows is designed to underpin a continuous and systematic, integrated approach used to plan, design, measure, assess, and improve our care and operational delivery models in order to better serve our patients, ...The QAPI plan includes, but is not limited to, an ongoing program that shows measurable improvement in identified quantitative indicators for which there is evidence that it will improve health outcomes ..."

Based on interview and record review, the hospital failed to ensure that the Quality Assessment and Performance Improvement Program (QAPI):

1. Was accountable for providing hospital-wide quality assessment and performance improvement efforts for improved quality of care and patient safety regarding staff to patient abuse resulting in the facility failing to: track an adverse events that involved staff to patient abuse, failing to ensure that hospital-wide staff training was completed after the staff to patient abuse occurred and failing to ensure that expectations for patient safety regarding staff to patient abuse were established.

Findings:

During an interview on 4/30/2021, at 9:45 AM, with the Director of ICU (DICU), DICU stated, she could not provide documentation of education provided to staff regarding staff to patient abuse.

During an interview on 4/30/2021, at 3:45 PM, with the Director of Education (DE), DE stated, she was unable to provide evidence of house-wide abuse training provided to staff related to staff to patient abuse.

During an interview on 4/30/2021, at 6:10 PM, with the Vice President for Quality Improvement (VPQI), the VPQI stated, no specific training regarding staff to patient abuse could be provided. VPQI further stated, when asked if an in-service was done regarding staff to patient abuse, VPQI stated, "It doesn't appear I have that." VPQI stated, she could not recall if the patient to abuse incident was discussed in the QAPI meeting and failed to provide documented evidence.

During a concurrent interview on 4/30/2021, at 6:25 PM, with the Chief Nursing Officer (CNO) and the VPQI, the CNO stated, he was not sure why the Charge Nurse and House Supervisor allowed the Registered Nurse (RN 1) to complete her shift after she had abused a patient. VPQI stated, no one knows who made the decision to let the nurse stay to complete her shift.

During a review of the facility's policy and procedure (P&P) titled, "Quality Assurance/Performance Improvement Plan (QAPI)" dated 2020, the P&P indicated, "Effective Quality Assurance and Performance Improvement (QAPI) is mission critical to our organization's goals to improve the quality of care for individuals and improve health for our community and patient populations ...The Quality Assurance and Performance Improvement (QAPI) Plan that follows is designed to underpin a continuous and systematic, integrated approach used to plan, design, measure, assess, and improve our care and operational delivery models in order to better serve our patients, ...The QAPI plan includes, but is not limited to, an ongoing program that shows measurable improvement in identified quantitative indicators for which there is evidence that it will improve health outcomes ..."