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Based on document review and interview it was determined, for 1 of 1 clinical record reviewed (Pt. #1) of a patient who sustained injury without a subsequent physician assessment, and 3 of 10 records (Pt. #1, 3, 4) of patients who failed to receive patient rights information, the hospital failed to ensure care in a safe environment.

The cumulative effects of these systemic practices resulted in the Hospital's inability to ensure patient safety was maintained. As a result, 42 CFR 482.13 Condition of Participation Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to ensure Patients Rights information was provided to all patients upon admission in accordance with policy. See deficiency at A117.

2 The hospital failed to ensure physician notification and inform the patient of the consequence of leaving AMA as required by policy. See deficiency at A130.

3. The Hospital failed to ensure prevention of a patient assault by a staff member. See deficiency at A144(A).

4. The Hospital failed to ensure a physician provide a documented physical assessment for a patient injury. See deficiency at A144(B).

5. The hospital failed to ensure an incident report was completed for a patient injury in accordance with policy. See deficiency at A144(C).

Based on document review and interview it was determined for 3 of 10 (Pts. #1, 3 and 4) patient medical records reviewed, the Hospital failed to ensure Patients Rights information was provided to all patients upon admission in accordance with policy.

Findings include:

1. On 6/11/14 the Hospital's policy titled "Administrative Policy Patient Rights" (revised 11/2014) included, "...Procedure: 1. In order to ensure patients understand their rights, each patient will receive a copy of their rights at the time of admission to the hospital for care and treatment..."

2. On 6/11/15 at approximately 9:40 AM the medical record of Pt. #1 was reviewed. Pt. #1 was a 50 year old female admitted on 6/4/15 with a diagnosis of Atypical Chest Pain, Anxiety, and Seizure. The medical record lacked documentation that Pt. #1 received Patient Rights information.

3. On 6/11/15 at approximately 9:30 AM the medical record of Pt. #3 was reviewed. Pt. #3 was a 65 year old male admitted with a diagnosis of Congestive Heart Failure. The medical record lacked documentation that Pt. #3 received Patient Rights information.

4. On 6/11/15 at approximately 9:30 AM the medical record of Pt. #4 was reviewed. Pt. #4 was a 57 year old male admitted on 6/4/15 with diagnoses of Coronary Artery Disease (CAD) and Hypertension (HTN). The medical record lacked documentation that Pt. #4 received Patient Rights information.

5. On 6/11/15 at approximately 10:00 AM during record review, the Telemetry Nurse Manager (E #2) verified the medical records lack documentation of Patient's Rights.

Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) record reviewed of a patient who left against medical advise (AMA), the hospital failed to ensure physician notification and inform the patient of the consequence of leaving AMA as required by policy.

Findings include:

1. The Hospital policy titled "Patient Leaving Against Medical Advice" (revised 4/2014) required, "Whenever a patient wishes to leave the Hospital without a physician's discharge order, the "Release of Responsibility for Discharge" form should be signed by the patient and the nurse. Procedure: Notify the physician that the patient wants to go home AMA. Have the patient ...sign release of responsibility Discharge form...The attending physician and consultation physicians must be notified that the patient is leaving AMA. The Nurse taking care of the patient and/ or Nurse Manager/Nursing Supervisor are responsible for telling the patient how the leave will effect his/her health. An AMA incident report must be completed and given to Nursing Office. ...If a patient...refuses to sign "Release from Responsibility for Discharge" the nurse must document this in the progress notes and on the AMA Incident report."

2. On 6/11/15 at approximately 9:40 AM the medical record of Pt. #1 was reviewed. Pt. #1, a 50 year old female, was admitted to the telemetry unit on 6/4/15 with diagnoses of Atypical Chest Pain, Anxiety, and Seizure. The record contained a nursing note dated 6/10/15 at 6:31 PM that Pt. #1 left AMA with a family member. The clinical record lacked physician notification; a signed "Release from Responsibility for Discharge" form or progress note acknowledging that Pt. #1 was informed of the risk involved in leaving AMA.

3. The above finding was discussed with the Telemetry Unit Nurse Manager during an interview on 6/12/15, who stated a signed AMA form should have been signed by the patient and witnessed by staff.

A. Based on document review and interviews, it was determined that for 1 of 10 (Pt. #1) patient records reviewed, the Hospital failed to ensure prevention of a patient assault by a staff member.

Findings include:

1. The Hospital policy titled, " Patient's Bill of Rights" (effective 2014), required, "Patient Rights: The right to receive care in a safe setting."

2. The Hospital policy titled, "Administrative Policy and Procedure" (revised 03/2015), required, "...It is expected that employees will provide appropriate care to our patients at all times and under all circumstances."

3. The clinical record for Pt. #1 was reviewed on 6/11/15. Pt. #1 was a 50 year old female admitted on 6/4/15 with diagnoses of atypical chest pain and seizures. Nursing documentation included observations of patient tremors and seizure. The Attending physician ordered a sitter for safety reasons on 6/6/15 at 9:53 AM. Nursing notes indicated a sitter was at bedside. However, on 6/9/15 at 6:30 PM, nursing documented, "Patient family requesting to see house doctor regarding laceration on nose that won't stop bleeding." The clinical record did not include any nursing assessment or identification of an injury or nasal bleeding.

4. An interview with Pt. #1's sitter (E #5) was conducted on 6/11/15. E #5 stated that on 06/09/15 she witnessed Pt. #1 grab a blood pressure machine and threw it towards E #1. E#5 stated, " The patient (Pt #1) got hold of Ms...(E #1) by the collar and ripped the shirt down. Ms...(E #1) started punching the patient; the patient was not able to punch back because I grabbed the patient by the arm, and other people were grabbing Ms...(E #1), pulling them apart. Ms...(E #1) just kept flinging her arm, punching the lady (Pt. #1) and me (on the shoulder)."

5. An interview with Pt. #1's nurse (E #4) was conducted on 6/11/15. E #4 stated that on 6/9/15, Pt. #1 accused a CNA (Certified Nurse Assistant) E #1 of stealing money. E #4 stated that as Pt. #1 was being escorted to her room, Pt. #1 grabbed a blood pressure (BP) machine and ran after E #1. E #4 stated, "I saw the patient (Pt. #1) and Miss...(E #1) battling... I didn't see her actually give her a lick, more of a tussle."

6. The above findings were discussed with the Chief Nurse Executive (CNE) during an interview on 6/11/15 who stated that he was aware of the incident after being informed by a supervisor. The CNE also stated that he was informed by Pt. #1's sister, who was concerned about the CNA's assault on the patient. The CNE was unable to produce a nursing incident report, or medical record documentation of the altercation and patient injury.

B. Based on document review and interview, it was determined for 1 of 1 (Pt #1) record reviewed of a patient who sustained injury during hospitalization, the Hospital failed to ensure a physician provide a documented physical assessment for a patient injury.

Findings include:

1. The Hospital policy titled, "Code White (Disruptive Patient/Visitor)" (created 6/2014) required, "(...disruptive patients Nursing Responsibilities...Complete and incident report as soon as possible), ...Physician responsibilities: Perform a thorough physical assessment (including mental condition) and document in the medical record by the attending physician of record."


2. The clinical record for Pt. #1 was reviewed on 6/11/15. Pt. #1 was a 50 year old female admitted on 6/4/15 to the telemetry unit with diagnoses of atypical chest pain and seizures. On 6/9/15 at 6:30 PM, nursing documented, "Patient family requesting to see house doctor regarding laceration on nose that won't stop bleeding." The clinical record did not include any documentation when and how Pt. #1 sustained the injury. The nursing documented on 6/09/15 at 6:45 PM," House doctor came to evaluate patient, stated to place steri strip on laceration and if it continues to bleed, send to ER for stitches." The physician failed to enter a progress note for a description of the laceration and/or nasal bleeding.

3. An interview with Pt. #1's sitter (E #5) was conducted on 6/11/15. E #5 stated that on 06/09/15 she witnessed Pt. #1 grab a blood pressure machine and threw it towards E #1. E#5 stated, " the patient (Pt #1) got hold of Ms...(E #1) by the collar and ripped the shirt down. Ms...(E #1) started punching the patient; the patient was not able to punch back because I grabbed the patient by the arm, and other people were grabbing Ms...(E #1), pulling them apart. Ms...(E #1) just kept flinging her arm, punching the lady (Pt. #1) and me (on the shoulder)."


C. Based on document review and interview, it was determined that for 1 of 1 record of a patient who sustained injury after assaulting staff, the hospital failed to ensure an incident report was completed for a patient injury in accordance with policy.

Findings include:

1. The Hospital policy titled, "Code White (Disruptive Patient/Visitor)" (created 6/2014) required, "(...disruptive patients Nursing Responsibilities...Complete and incident report as soon as possible),

1. The Hospital policy titled, "Identifying, Communicating and Reporting Adverse Events" (rev. 5/14), required, "Purpose: to provide guidelines for identifying adverse events resulting from medical care; and also, for recording/documenting, investigating and conducting a risk-prevention analysis, and communicating and reporting of adverse events.....Adverse Events: An injury that was caused by medical management rather than the patient's underlying disease...Medical Management refers to all aspects of health care, not just the actions or decisions of physicians or nurses. ...Potential criminal events...C...assault on a patent or staff member within or on the grounds of a healthcare setting. ...All staff members are expected to report occurrences that might be adverse events... Interventions will be provided as soon as possible to ensure the safety of any patients or staff involved."

2. E #2 stated she was rounding on another unit when she heard a code white (Security assistance) on 6/9/15 at about 10:00 or 11:00 AM, for the Telemetry unit. E #2 stated she came down to respond to the call however the incident was "finished" and patient was already escorted to her room by security, though "still yelling and wanted to hurt more people." The incident was not documented in the clinical record nor was an incident report available for review when requested. E #2 stated an incident report is expected to be completed in such events.

3. An interview with Pt. #1's nurse (E #4) was conducted on 6/11/15. E #4 stated that on 6/9/15 Pt. #1 had an outburst accusing a CNA (Certified Nurse Assistant, E #1) of stealing her money. E #4 stated that as Pt. #1 was being escorted to her room when Pt. #1 grabbed a blood pressure (BP) machine and ran after E #1. E #4 stated "I saw Pt. #1 and Miss...(E #1) battling... I didn't see her actually give her a lick, more tussling." E #4 stated she didn't see a laceration on Pt. #1. E #4 did not assess Pt #1 because after she was knocked down she was no longer functional and went home early. E #4 did not complete an incident report.

4. The charge nurse (E #6) who was on duty on 6/9/15 was interviewed on 6/12/15. E #6 stated that altercation between E #1 and Pt. #1 started at the nursing station with Pt. #1 yelling at E #1 about stolen money. E #6 stated she directed staff to call a code white and told E #1 to leave. E #6 stated she witnessed Pt. #1 grabbed a blood pressure machine, who then followed E #1. E #6 further stated that Pt. #1 grabbed E #1's shirt, the nurse (E #4) assigned to Pt. #1 grabbed the patient, and as the patient flung her arms; E #4 fell to the ground. E #6 stated that as Pt. #1 hit E #1's face and E #1 yelled "get off me and punched the patient back." E #6 stated she did not know who assessed Pt. #1 because after the patient was taken back her room E #6 responded to rapid response call elsewhere. E #1 stated did not write an incident report expecting the patient's nurse would complete one.

5. The above findings were discussed with the Chief Nursing Executive during an interview on 06/11/15.