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Based on interview and record review, the hospital failed to ensure staff were appropriately educated in the grievance process. This resulted in staff unaware of the written process for submitting a grievance according to the hospital's policy and procedure.

Findings:

During an interview with the Quality of Assurance Officer (QAO), on 11/15/11 at 9:05 AM, he indicated he was responsible for handling grievances at both hospital campuses. During a subsequent interview, he indicated that patient complaints should be resolved at "point of care." But if they were not, the nurses were responsible for completing the patient complaint form, which would, in turn, come to him.

The hospital policy and procedure titled, "PATIENT COMPLAINT/GRIEVANCE PROCESS," last revised 3/04, was reviewed on 11/15/11. Under the 'purpose' subheading it read in part, "The hospital has developed and implemented a mechanism by which complaints are identified..." Under the 'procedure' subheading it read in part, "All complaints received from a patient or representative...will be documented on a Patient Complaint Form by the person receiving the complaint and forwarded to the Department Manager."

During an interview with Registered Nurse (RN) B, on 11/15/11 at 10:45 AM, she was asked the process staff followed when a patient complaint/grievance came in. RN B indicated, the patients were provided the telephone number of the Chief Nursing Officer and the Nurse Manager of the unit, and they would complete the occurrence report form.

During an interview with the Nurse Manager (NM) of the medical surgical floor, on 11/15/11 at 10:55 AM, he was asked the process the staff follow when a patient complaint/grievance comes in. He stated, they tried to "handle it at this level", otherwise it would go to the QAO. He was unaware of any patient complaint forms he was required to complete.

2. The clinical record for Patient 24 was reviewed on 11/14/11 at 2:30 PM. The Restraint/ Seclusion Order Form indicated Patient 24 had been physically restrained and placed in seclusion on 10/23/11 at 9 PM.

The hospital policy and procedure titled, "Use of Seclusion and Restraint," indicated, "A physician or other licensed independent practitioner must see the patient and evaluate the need for restraint or seclusion within one hour after the initiation of this intervention."

During an interview with the Quality Assurance Officer (QAO) on 11/15/11 at 1:55 PM, he reviewed the clinical record and was unable to find documentation that Patient 24 had a face- to-face with a physician within 1 hour after being placed in seclusion. The QAO stated, "The doctor didn't come in within the one hour to see the patient according to the policy."



27926

Based on interview and record review, the hospital failed to ensure restraint and seclusion policies and procedures were consistent which had the potential to result in unsafe restraint and seclusion use putting patients at risk for harm. The hospital also failed to ensure one of 30 patients (24) was seen by a physician within 1 hour after being placed in seclusion which had the potential to result in unmet care needs and harm.

Findings:

1. The hospital policy and procedure titled "Restraint, Seclusion and Immobilization Policy", dated 3/04, indicated "There must be a face-to-face assessment by a physician within four hours of patient being put into restraints for emergency behavior management, for patients 18 years old and above"

The hospital policy and procedure titled "Use of Seclusion and Restraint", dated 9/08, indicated; "Seclusion and restraint for behavior management: A physician or other licensed independent practitioner must see the patient and evaluate the need for restraint or seclusion within one hour after the initiation of this intervention."

The hospital policy and procedure titled "Restraint, Seclusion, and Immobilization", dated 6/10, indicated; "When restraint 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, the patient must be seen face-to-face within 1 hour after the initiation of the restraints."

During an interview with the Chief Nursing Officer on 11/15/11 at 2 PM, he reviewed the different policies and procedures for restraint and seclusion and noted the discrepancies in the existing policies.

3. The employee file for the Nurse Manager was reviewed on 11/16/11 at 2:05 PM. The file indicated the Nurse Manager completed the restraint and seclusion competency evaluation in 11/3/09. No restraint and seclusion competency evaluation was found for 2010.

During an interview with the Chief Nursing Officer on 11/16/11 at 2:15 PM, he reviewed the personnel file for RN C and stated he was unable to locate documentation of restraint training being completed in 2010.

The hospital policy and procedure titled, "Restraint, Seclusion and Immobilization Policy," dated 06/20/10, indicated under the heading for Training and Competency of Staff, "2. Staff must complete restraint training during orientation and at least once a year thereafter."



27926

Based on interview and record review, the hospital failed to ensure three of six sampled staff were trained in restraint and seclusion usage on an annual basis which had the potential to result in harm towards patients by improper application and use.

Findings:

1. The employee file for Mental Health Worker (MHW) A was reviewed on 11/15/11. The file indicated MHW A completed ProAct (Professional Assault Crisis Training) training, which included training on restraint and seclusion, in 2009 and 2011. There was no documentation of restraint and seclusion training for 2010 found in the employee file.

During an interview with the Chief Nursing Officer on 11/16/11 at 1:50 PM, he reviewed the file and was unable to find documentation of completion of the restraint and seclusion competency for 2010.

2. The employee file for Registered Nurse (RN) B was reviewed on 11/16/11. The file indicated RN B completed the restraint and seclusion competency evaluation in 2009. No restraint and seclusion competency evaluation was found for 2010.

During an interview with the Chief Nursing Officer on 11/16/11 at 1:50 PM, he reviewed the file and was unable to find documentation of completion of the restraint and seclusion competency for 2010.

2. The clinical record for Patient 24 was reviewed on 11/15/11 at 1 PM. The Physician Orders dated 10/23/11 at 9:10 PM indicated, "1:1 for AWOL (Absence without leave)." Review of the Intensive Observation/Treatment Record dated 10/23/11 indicated Patient 24 was to be on every 15 minute checks.

During an interview with the Quality Assurance Officer (QAO) on 11/15/11 at 1:30 PM, he reviewed the clinical record and was unable to find documentation of Patient 24 ever being placed on one-to one observation. The QAO stated, "I can't find anything where he (Patient 24) was placed on one-to one observation."



21905

Based on observation, interview, and record review, the hospital failed to ensure the registered nurse appropriately supervised the staff for two of 30 sampled patients (9 and 24). Patient 9 had "line of sight (LOS)" observation ordered by the physician, and the staff were not conducting the line of site observations according to the hospital's policy and procedure. For Patient 24, staff did not follow a 1:1 observation as ordered by the physician. This had the potential for the patients to harm themselves due to being unsupervised.

Findings:

1. During an interview with Registered Nurse (RN) D, on 11/15/11 at 2:10 PM, she was asked the meaning of "LOS observation". RN D replied, the staff should be able to see the patient at all times when they are LOS observation.

The clinical record for Patient 9 was reviewed on 11/16/11 at 9:45 AM. The patient was admitted due to being a danger to self; therefore, the physician ordered the patient to be LOS observation. The patient's "Suicide/Homicide/Self-Harm Assessment Tool" listed the room requirements for the LOS supervision. The list included maintaining an "open door".

During an observation of Unit 6 on 11/16/11 at 10:05 AM with the Director of Psychiatric Services (DPS), there were two mental health workers (MHW) in the hallway of the unit. Patient 9 was behind a closed door in his room, not visible to either MHW. During an interview at this time with one of the MHWs (MHW B), he was asked what type of observation Patient 9 was receiving. MHW B indicated they were checking on Patient 9 every 15 minutes.

The hospital's policy and procedure titled, "SUICIDE PRECAUTIONS," dated 9/08, was reviewed on 11/16/11. Under the policy statement it read, "To ensure the safety of each individual, all patients admitted to the Psychiatric and Mental Health Unit will be considered high-risk potential for suicide until assessed by the RN." Under the 'procedure' subheading it read in part, "All patients placed on suicide precautions will be assigned an acuity level based upon the severity of the suicidal thoughts, plan, or behavior. The levels are as follows...Line of sight observation...Staff must be within visual contact at all times with the exception of toileitng and showering during which times staff shall be present outside a door left ajar but will remain in audible contact with the patient..."

8. The clinical record for Patient 29 was reviewed on 11/16/11. The physician orders dated 11/15/11 at 3:30 PM, indicated the Clinical Institute Withdrawal Assessment (CIWA: a drug withdrawal assessment tool) was to be assessed every four hours for 48 hours, then every eight hours for 24 hours, then every 12 hours. The CIWA assessment was documented 11/15/11 at 3:30 PM and 8:20 PM.

During an interview with Registered Nurse A on 11/16/11 at 10:05 AM, she reviewed the clinical record and was unable to find documentation of a CIWA assessment completed since 11/15/11 at 8:20 PM.

9. The clinical record for Patient 30 was reviewed on 11/16/11. The physician orders, dated 10/26/11 at 5:55 PM, indicated the Clinical Institute Withdrawal Assessment (CIWA: a drug withdrawal assessment tool) was to be assessed every four hours for 48 hours, then every eight hours for 24 hours, then every 12 hours. The CIWA assessment was documented being done at 7:55 AM, 7 PM and 11 PM on 10/27/11, and at 7:45 AM and 8 PM on 10/28/11.

During an interview with the QAO (Quality Assurance Officer) on 11/16/11 at 11:20 AM, he reviewed the clinical record and was unable to find documentation that the CIWA had been done every 4 hours X 48 hours as ordered by the physician.



21905

7. The clinical record for Patient 10 was reviewed on 11/16/11 at 10:30 AM. According to the physician's history and physical (H & P), dated 11/9/11, the patient had throat discomfort and therefore was ordered throat lozenges every 4 hours as needed for throat pain for 3 days. On 11/10/11 the H & P indicated the patient had a diagnosis of asthma, allergic rhinitis (runny nose), and an upper respiratory infection. On 11/11/11 the physician ordered Levaquin (antibiotic medication) 500 milligrams daily by mouth for 7 days. A review of the care plans was conducted and there were no care plans developed for the asthma, allergic rhinitis and upper respiratory infection.

During an interview with the Quality Assurance Officer (QAO), on 11/16/11 at 11:15 AM, after reviewing the clinical record for Patient 10, no care plan could be found. The QAO acknowledged there should be care plans developed for identified medical problems.



27926

Based on interview and record review, the hospital failed to develop patient care plans based on assessment and evaluate and assess patients based on the medical plan of care for nine of 30 sampled patients.

For Patients 11, 13, and 18, the hospital failed to develop care plans for pain management which had the potential to result in ineffective pain management. For Patient 10 the hospital failed to develop a care plan for identified medical issues which had the potential to result in unmet care needs.

For Patients 14, 21, 22, 29 and 30 the hospital failed to assess and evaluate drug withdrawal symptoms as ordered by the physician which had the potential to result in unidentified and unmet care needs.

Findings:

1. The clinical record for Patient 11 was reviewed on 11/15/11. The Nursing Admission Assessment, dated 11/13/11 at 6:45 PM, indicated Patient 11 was experiencing pain rated 8 of 10, on a scale of 0-10 with 10 being the most intense, all over her body. There was no care plan addressing pain management found in the clinical record.

During an interview with the Chief Nursing Officer on 11/15/11 at 1:55 PM, he reviewed the clinical record and was unable to find documentation of a plan of care for pain management.

2. The clinical record for Patient 13 was reviewed on 11/15/11. The Nursing Admission Assessment, dated 10/10/11 at 5:45 PM, indicated Patient 13 was experiencing pain rated 6 of 10, on a scale of 0-10 with 10 being the most intense, that was caused by a toothache. There was no care plan addressing pain management found in the clinical record.

During an interview with the Chief Nursing Officer on 11/15/11 at 1:55 PM, he reviewed the clinical record and was unable to find documentation of a plan of care for pain management.

3. The clinical record for Patient 18 was reviewed on 11/15/11. The Nursing Admission Assessment, dated 11/7/11 at 3:05 PM, indicated Patient 18 was experiencing pain rated 6 of 10, on a scale of 0-10 with 10 being the most intense, that was all over her body. There was no care plan addressing pain management found in the clinical record.

During an interview with the Chief Nursing Officer on 11/15/11 at 1:55 PM, he reviewed the clinical record and was unable to find documentation of a plan of care for pain management.

The hospital policy and procedure titled "Management of Patient Pain", dated 9/08, indicated "Management of the patient's pain is an interdisciplinary process and is to be included on the interdisciplinary plan of patient care. Inclusion of this component of the patient's care process will alert and educate all members of the healthcare team regarding the patient's pain experience."

4. The clinical record for Patient 14 was reviewed on 11/16/11. The physician orders dated 11/15/11 indicated the Clinical Opiate Withdrawal Scale (COWS: a drug withdrawal assessment tool) was to be assessed every four hours for 48 hours, then every eight hours for 24 hours, then every 12 hours. The COWS assessment was documented on 11/15/11 at 2 PM and 7:15 PM and 11/16/11 at 8 AM.

During an interview with the Chief Nursing Officer on 11/16/11 at 9:30 AM, he reviewed the clinical records and was unable to find documentation of any other COWS assessment. He stated there were two assessments missing.

5. The clinical record for Patient 21 was reviewed on 11/16/11. The physician orders dated 11/15/11 at 11:30 AM, indicated the Clinical Institute Withdrawal Assessment (CIWA: a drug withdrawal assessment tool) was to be assessed every four hours for 48 hours, then every eight hours for 24 hours, then every 12 hours. The CIWA assessment was documented 11/15/11 at 4 PM and 8:25 PM.

During an interview with Registered Nurse A on 11/16/11 at 10 AM, she reviewed the clinical record and was unable to find documentation of a CIWA assessment completed since 11/15/11 at 8:25 PM.

6. The clinical record for Patient 22 was reviewed on 11/16/11. The physician orders dated 11/12/11 at 7:25 PM indicated the COWS was to be assessed every four hours for 48 hours, then every eight hours for 24 hours, then every 12 hours. The COWS assessment was documented on 11/12/11 at 8 PM, 11/13/11 at 8:25 AM and 7:30 PM, 11/14/11 AM (not timed), and 7:30 PM, and 11/15/11 at 11 AM and 8 PM.

During an interview with the Chief Nursing Officer on 11/16/11 at 10:50 AM, he reviewed the clinical record and was unable to find documentation of the COWS performed as ordered by the physician.