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Based on medical record review, document review and interview, it was determined that the facility failed to fully implement the Plan of Correction. Consequently, the Condition of Participation for Patient's Rights remain out of compliance.

This failure placed patients at risk for harm.


Findings include:

(1) The facility failed to investigate an allegation of patient abuse.

See Tag A 120.

(2) The facility failed to obtain physician order for patient seclusion and failed to monitor and assess a patient who was in seclusion.

See Tag A 168 & Tag A 175.

Based on medical record review, document review and interview, it was determined that the facility failed to investigate an allegation of patient abuse as per facility's policy and procedure. This was evident in one (1) one (1) medical record reviewed. (Patient #1).


Findings include:

Review of the medical record for Patient #1 identified, on 7/26/17 at 4:15 PM, Staff Q, Emergency Room RN, documented that Patient #1 sustained an injury to her right eye, while in the emergency room area of the hospital.
On 7/27/17, there is documentation that the patient complained to three different staff that she was "punched in the face 5 times" by a security officer.


On 8/8/17, a review of the facility's Grievance Reports for 6/2017 through 8/7/2017, showed no documented evidence of the patient's grievance.

On 8/9/17, Staff R, Regulatory Affairs Manager, presented the surveyors, documents of a Grievance Report and a letter to the patient. The Grievance Report documented that the patient filed a grievance on 7/27/17. There is no documented evidence of a grievance investigation.
The letter to the patient, dated 8/8/17, stated it is their "goal to investigate and respond within 7 days following receipt of your claim, unfortunately, it has not been possible in this instance, and I apologize."

Review of the facility's Policy and Procedure titled, "Patient Complaint and Grievance," last reviewed 10/16 states that allegation of abuse is a grievance. Grievances investigation will conclude within 5 calendar days and the results of the investigation will be sent to the patient in 7 days.

The facility failed to follow P&P and did not investigate the patient's allegation


During interview on 8/10/17 at 2:00 PM, Staff R acknowledged the findings.

Based on document review, medical record review, and interview, the facility did not ensure that physician's order is written for a patient in seclusion. This was evident in one (1) of one (1) medical record reviewed. (Patient #1).


Findings include:

Review of the medical record for Patient #1 revealed, a 36-year-old female who had a scheduled appointment in the Outpatient Psychiatric Department (OPD) on 7/26/17. During the visit, she became "aggressive and assaultive" and at 3:12 PM, four (4) security officers and a physician removed her from the OPD to the emergency room.
The triage documentation note indicated that the patient was alert and oriented and had no homicidal or suicidal ideation.

A progress note on 7/26/17 at 3:34 PM, written by Staff Q, Emergency Room RN, noted that at 3:00 PM seclusion was started, and was discontinued at 4:45 PM. There is no documented evidence that a Physician's order for seclusion was obtained prior to, or immediately after the patient was placed on seclusion.


The Facility's Policy and Procedure titled, "Restraint or Seclusion, Care of the Patient Requiring," last revised 8/17, states that an order must be obtained either during the emergency application of the seclusion or immediately within few minutes after the seclusion.

The facility failed to implement its policy.

Based on medical record review, document review and interview, it was determined the facility failed to appropriately monitor a patient for safety, during seclusion. This was evident in one (1) of five (5) medical records reviewed. (Patient #1).


Findings include:

Review of the medical record for Patient #1 revealed that on 7/26/2017, the patient went to the Outpatient Psychiatric Clinic (OPD) for a scheduled appointment. She has a history of schizoaffective and bipolar disorder. During examination by the Psychiatrist, she became agitated and combative, and four (4) security officers and a physician removed her from the OPD to the Emergency Department (ED) for further evaluation, at approximately 3:12 PM.

Nursing staff in the ED, documented on 7/26/17 at 3:34 PM, that patient was placed in seclusion room at 3:00 PM due to aggressive and combative behavior.
At 4:15 PM, the nurse noted that the patient alleged that she was struck in the face by a security officer, no injury was noted at that time. The patient was examined by the physician at 4:15 PM for swelling of the right eye, and an X-ray of the orbit was ordered. The nursing documentation noted that seclusion was discontinued at 4:45 PM, and which time "a small area of swelling was noted on the right side of patient's eyebrow, no open area or bleeding or brushing noted."
An X-ray was completed on 7/27/17, which showed "Traumatic hematoma of orbit."


The Facility's Policy and Procedure Titled, "Restrain or Seclusion, Care of the Patient Requiring," last revised 8/17, states "While in seclusion the patient is cautiously observed via visual monitoring." The policy also states, "The Patient must be supervised and assessed at least every 15 minutes."


There was no documented evidence that this patient was monitored or assessed while she was kept in seclusion.