HospitalInspections.org

Based on a review of policies and procedures, hospital documents, medical records, and interviews, it was determined the Governing Body failed to ensure the hospital's systems and processes were identified and implemented to provide safe care and protect the patient's rights as evidenced by the following deficient practices.

Findings include:

The Condition level deficiency is the result of the Condition level and Standard deficiencies found under the Conditions of Patient's Rights and Quality Assessment and Performance Improvement Program in the following tags:

(0115): Condition of Participation: Patient's Rights: The hospital failed to ensure the rights for each patient were protected and promoted as evidenced by the hospital ' s:

(A0123): Failure to communicate or provide any information to the patient regarding the grievance investigation, including assisting the patient with contacting law enforcement.

(A0131): Failure to provide and/or obtain a consent to treat for 19 out of 26 patients presenting to the hospital for treatment.

(A0144): Failure to remove a staff member from the work schedule while an abuse allegation was being investigated.

(0263): Condition of Participation: Quality Assessment and Performance Improvement Program: The hospital failed to follow policies and procedures in identifying adverse events, and perform follow-up activities of adverse events to improve patient health and safety as evidenced by the hospital ' s:

(0286):
1. Failure to ensure that a grievance was created regarding a patient allegation of abuse from an employee.
2. Failure to ensure that a Root Cause Analysis (RCA) was performed, including once additional information was discovered.
3. Failure to ensure the Governing Body was informed of an adverse event.

The cumulative effect of these systemic failures has resulted in the hospital being out of compliance with the condition of the Governing Body that demonstrated lack of responsibility for the operation of the facility resulting in adverse patient outcomes.

Based on review of the hospital policies and procedures, documents, medical records, and interviews, it was determined that the facility failed to follow policies and procedures as evidenced by:

(A0123) Communicate or provide any information to the patient regarding the grievance investigation, including assisting the patient with contacting law enforcement.

(A0131) Provide and/or obtain a consent to treat for 19 out of 26 patients presenting to the hospital for treatment.

(A0144) Remove a staff member from the work schedule while an abuse allegation was being investigated.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient's Rights, which poses a potential risk to the health and safety of patients when a safe environment is not provided that protects the patient(s) from potential harm.

Based on review of policies and procedures, hospital documents, medical records, and interviews, it was determined that the hospital failed to communicate or provide any information to the patient regarding the grievance investigation, including assisting the patient with contacting law enforcement.

Findings include:

Policy titled "Customer Service/Concern/Grievance Policy and Procedure" revealed: "...YRMC expects all staff to address and attempt to resolve patient /family concerns at point of service...YRMC will solicit feedback about the patient's experience with services provided...Grievance: If a concern cannot be resolved by staff present and is postponed for later resolution, is referred to other staff for later resolution, requires investigation, is received in writing and/or requires further action for resolution it becomes a grievance...Grievances require a written acknowledgement to the patient or the patient's representative, that the grievance has been received. The initial written response for the received grievance will be sent within an average of seven workdays...The response must include the name of the person handling the grievance and the steps taken on behalf of the patient to investigate the grievance. If the results of the grievance process cannot be conducted within seven workdays the date of completion should be included in the initial letter...The follow-up letter must include the results of the process and completion date as listed above...."

Policy titled "Patient Abuse and Reporting Policy" revealed: " ...Purpose: To provide...safe, non-threatening care...and appropriate interventions in cases of suspected abuse...II. Policy: Suspected or actual cases of...sexual assault or sexual abuse are considered reportable events. The services of Yuma Regional Medical Center (YRMC) are intended to assure that an individual is safe in their environment...D. Sexual Assault or Sexual Abuse...In cases of sexual assaults involving only adults, offer assistance and support in notifying the appropriate law enforcement agency. The law is notified only with the patient's knowledge and consent ...E. Suspected or Actual Abuse Occurring on YRMC Property...Abuse occurring on YRMC property will be reported to Yuma Police Department (YPD) as appropriate...Abuse to the patient: f) Remove staff member involved from work schedule until investigation is completed...h) Yuma Police Department (YPD) will notified as appropriate by HR. Risk or CNO .... "

Hospital document titled "Patient & Family Guide" revealed: "...Concern & Grievance Policy & Procedure: ...If you are dissatisfied with any of our services, please discuss your concerns with the nurse providing your care. If your nurse is unable to resolve your concerns, ask to speak with the Resource Coordinator, Unit Director or Administrative Hospital Supervisor. If your concern cannot be or is not resolved by our staff, then it becomes a grievance...We will acknowledge your grievance in writing within 7 work days of receipt. After our investigation, we will let you know what actions we took on your behalf to resolve your grievance ...."

Hospital document - grievance for Patient #1 was requested on 10/21/2021, and none was provided.

Medical Record Patient #1 revealed on 07/17/2021, entry made by Employee #4-Director of Risk, "...Allegations reviewed and investigation complete. Informed Care Advocacy that patient can file complaint with police if desired ...."

Employee #4-Director of Risk Management confirmed in an interview on 10/18/2021, that Risk Management received Patient #1's complaint on 07/05/2021. It was determined there was not enough evidence to pursue the investigation and no further steps were taken. The case was closed after the interview with Employee #17 RN-ED on 07/12/2021. Employee #4-Director of Risk Management confirmed that his/her office did not sent out any letters to Patient #1. Patient Experience sends out the grievance letters. On 10/20/2021, Employee #4-Director of Risk Management revealed that s/he did not speak to the patient regarding the allegation or subsequent investigation, however made a recommendation for Patient Experience/Patient Advocate to speak with the patient and to see if s/he wanted to contact the police. Patient Experience was going to speak to the patient.

Employee #29-Director of Patient Experience and Care Advocacy confirmed during an interview conducted on 10/21/2021, that there was no grievance done regarding the complaint/allegations made by Patient #1. Employee #29 further stated that her/his department had no further contact with Patient #1 after the initial complaint was received and handed over to Risk Management. Employee #29 stated s/he was unaware of recommendation to contact Patient #1 in regards to assisting with police report if Patient #1 wanted to pursue the allegation.

Based on review of policies and procedures, hospital documents, medical records, and interviews, it was determined that the hospital failed to provide and/or obtain a consent to treat for 19 out of 26 patients presenting to the hospital for treatment.

Findings include:

Policy titled "Patient Rights and Responsibilities" revealed: "...Purpose...Your Rights and Responsibilities as a Yuma Regional Medical Center (YRMC) Patient, informs each patient or patient ' s representative of the patients ' rights in advance of providing or discontinuing care. II. Documentation...The Conditions of Admission is offered to patients and signed by patients or their representative each time they present to the YRMC Emergency Department, or are in an Inpatient, Observation, and Surgical or Procedural unit of the hospital. The Authorization and Service Terms is offered to patients and signed by patients or their representative once annually ...."

Hospital document titled "Authorizations and Service Terms" revealed: "...Authorization for Treatment: I consent to the rendering of medical care which may include routine diagnostic procedures and such medical treatment as my attending physician(s) or other Yuma Regional Medical Center (YRMC) medical staff consider to be necessary. I may be offered medical services via telemedicine systems that involve the delivery of health care by electronic communication with a provider who is at a different physical location, and I consent to such services. YRMC participates in training programs for physicians and other health care personnel. I understand that my medical care and treatment may be provided by physicians, including fellows and residents, medical and allied students, nurses, and other health care providers. I have read and understand this Authorization for Treatment and understand that no guarantee or assurance has been made as to the results that may be obtained...This is a legal document. Changes will not be accepted on this form. Requests for alterations can be made by calling...By signing, I agree that I agree and understand the terms of this form. I understand I have the right to revoke the authorizations on this form at any time by notifying YRMC in writing, except to the extent that YRMC has already taken action in reliance on them. These authorizations will remain valid until I revoke them in writing ...."

Hospital document titled "Conditions of Admission" revealed: "...All patients are provided a copy of the hospital ' s statement of Patient Rights and Responsibilities in their admission packet ..." and the patient signs the form. There is no consent to treat located on the form.

Hospital document titled "Patient Rights and Responsibilities" revealed: "...We are honored to partner with you in your care. As a patient at Yuma Regional Medical Center, you have many rights...You have the right to...Consent to or refuse treatment, as permitted by law, throughout your stay ...."

Medical records were reviewed for Patient #1 through Patient #30. Nineteen (19) patient's did not have a consent to treat signed the day of the patient's Emergency Department visit/admission to the hospital. Patient #1 and Patient #3 did not have any consent to treat signed, including the Authorization and Service Terms form.

Employee #16 confirmed during an interview conducted on 10/19/2021, that the Authorization and Service Terms is for all services including outpatient, clinic, or admissions and it is obtained once a year. The Condition of Admissions lists the patient's rights. The patient would not sign an additional consent for treatment if the patient has a current Authorization and Service Term that had been signed within the last year.

Employee #1-Corporate Compliance Officer confirmed during an interview conducted on 10/20/2021, that the hospital's policy states the Authorization and Service Term is signed by the patient or patient representative once a year, however s/he believes it should be signed for every admission.

Based on review of policies and procedures, hospital documents, medical records, and interviews, it was determined that the hospital failed to remove a staff member from the work schedule while an abuse allegation was being investigated.

Findings include:

Policy titled "Patient Abuse and Reporting Policy" revealed: "...Purpose: To provide...safe. non-threatening care...and appropriate interventions in cases of suspected abuse...II. Policy: Suspected or actual cases of...sexual assault or sexual abuse are considered reportable events. The services of Yuma Regional Medical Center (YRMC) are intended to assure that an individual is safe in their environment...D. Sexual Assault or Sexual Abuse...In cases of sexual assaults involving only adults, offer assistance and support in notifying the appropriate law enforcement agency. The law is notified only with the patient ' s knowledge and consent ...E. Suspected or Actual Abuse Occurring on YRMC Property...Abuse occurring on YRMC property will be reported to Yuma Police Department (YPD) as appropriate...Abuse to the patient: f) Remove staff member involved from work schedule until investigation is completed...h) Yuma Police Department (YPD) will notified as appropriate by HR. Risk or CNO ...."

Review of Employee #17 RN-ED's timecard for July, revealed the employee worked 07/06/2021, 11.80 hours from 6:51 pm until 7:07 am, 07/07/2021, 11.78 hours from 6:52 pm until 7:11 am, 07/08/2021, 12.3 hours from 6:50 pm until 7:06 am.

Medical record for Patient #1 revealed on 07/02/2021, that Patient #1 disclosed that "...when [he] was first admitted to the Emergency department a man in light blue scrubs and cap came in to start IV. Patient was told that they would need a urine sample. Patient says [he] apologized to employee...that [he] had been outside and probably smelled. [He] said that employee told [him] that [he] would wash [him] to make sure [he] was clean for urine sample. Patient declined, yet said that employee proceeded to "uncomfortably {sic} and "too" thoroughly for comfort clean patient's groin area. Patient at the time said [he] figured this must be protocol. Patient said [he] fell asleep and woke up to same employee removing his socks. Patient "asked employee what [he] was doing." [He] said employee offered to sponge bathe {sic} [him] and change clothes. Patient said that [he] again declined yet employee proceeded to remove clothes and wash patient. [He] stated that entire body including between butt cheeks was washed and dried. Per patient [he] felt even more uncomfortable given the dialogue being used. Patient expressed that while washing the patient the employee was asking if patient was sexually active and inquiring about sexuality {sic} preferences. During disclosure patient was crying. Two family members were at bedside during disclosure...asked patient if perhaps timing was off and this was before procedure ...[He] said that is was before procedure when [he] first came to ED...asked patient if [he] would like me to share with appropriate staff RE: charge nurse and patient experience. [He] said [he] did not want to cause trouble but that [he] "did not want this to happen to anyone else."...."Further review of Patient #1 medical record revealed on 07/17/2021, entry made by Employee #4-Director of Risk, "...Allegations reviewed and investigation complete. Informed Care Advocacy that patient can file complaint with police if desired ...."

Employee #4-Director of Risk confirmed during an interview conducted on 10/18/2021, patient reported incident on 07/02/2021, and the investigation was closed on 07/12/2021. On 10/20/2021, Employee #4-Director of Risk revealed that s/he did not speak to the patient, however made a recommendation for Patient Experience/Patient Advocate to speak with the patient and to see if s/he wanted to contact the police. Patient Experience was going to speak to the patient. On 10/21/2021, Employee #4-Director of Risk confirmed that Employee #17 RN-ED was not removed from the work schedule during the investigation, as instructed by YRMC's general counsel.

Employee #2-Chief Nursing Officer confirmed during the Exit Conference on 10/21/2021, that s/he had instructed Employee #3-Administrative Director of Emergency Department to remove Employee #17 RN-ED from the work schedule until the investigation was completed.

Based on review of policies and procedures, hospital documents, medical records, and interviews, it was determined that the hospital failed to:

(0286)
1. Ensure that a grievance was created regarding a patient allegation of abuse from an employee.
2. Ensure that a Root Cause Analysis (RCA) was performed, including once additional information was discovered.
3. Ensure the Governing Body was informed of an adverse event.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Quality Assessment and Performance Improvement Program, which poses a potential risk to the health and safety of patients when quality of care standards are not monitored or tracked.

Based on review of policies and procedures, hospital documents, medical records, and interviews, it was determined that the hospital failed to:

1. Ensure that a grievance was created regarding a patient allegation of abuse from an employee.
2. Ensure that a Root Cause Analysis (RCA) was performed, including once additional information was discovered.
3. Ensure the Governing Body was informed of an adverse event.

Findings include:

Medical record for Patient #1 revealed on 07/02/2021, that Patient #1 disclosed to Employee #31-RN an allgation of abuse by Employee #17 RN-ED. Patient #1 revealed that while in the ED, Employee #17 RN-ED was inappropriate with touching and dialogue.

Medical Record Patient #1 revealed on 07/17/2021, entry made by Employee #4-Director of Risk, "...Allegations reviewed and investigation complete...."

1.
Policy titled "Customer Service/Concern/Grievance Policy and Procedure" revealed: "...YRMC expects all staff to address and attempt to resolve patient /family concerns at point of service...YRMC will solicit feedback about the patient's experience with services provided...Grievance: If a concern cannot be resolved by staff present and is postponed for later resolution, is referred to other staff for later resolution, requires investigation, is received in writing and/or requires further action for resolution it becomes a grievance...Grievances require a written acknowledgement to the patient or the patient's representative, that the grievance has been received. The initial written response for the received grievance will be sent within an average of seven workdays...The response must include the name of the person handling the grievance and the steps taken on behalf of the patient to investigate the grievance. If the results of the grievance process cannot be conducted within seven workdays the date of completion should be included in the initial letter...The follow-up letter must include the results of the process and completion date as listed above...."

Hospital document titled "Patient & Family Guide" revealed: "...Concern & Grievance Policy & Procedure: ...If you are dissatisfied with any of our services, please discuss your concerns with the nurse providing your care. If your nurse is unable to resolve your concerns, ask to speak with the Resource Coordinator, Unit Director or Administrative Hospital Supervisor. If your concern cannot be or is not resolved by our staff, then it becomes a grievance...We will acknowledge your grievance in writing within 7 work days of receipt. After our investigation, we will let you know what actions we took on your behalf to resolve your grievance ...."

Hospital document - grievance for Patient #1 was requested on 10/21/2021, and none was provided.

Employee #4-Director of Risk Management confirmed in an interview on 10/18/2021, that Risk Management received the Patient #1's complaint on 07/05/2021. An interview with Employee #17 RN-ED was conducted on 07/01/2021, and her/his explanation was deemed plausible. It was determined there was not enough evidence to pursue the investigation and no further steps were taken. The case was closed after the interview with Employee #17 RN-ED.

Employee #29-Director of Patient Experience and Care Advocacy confirmed during an interview conducted on 10/21/2021, that there was no grievance done regarding the complaint/allegations made by Patient #1.

2.
Policy titled "Adverse Events" revealed: "...Purpose: To provide a systematic and comprehensive mechanism for identifying, reporting, and analyzing any unexpected adverse or sentinel event; to provide a process for improving performance by preventing a future similar occurrence...Adverse Event: serious incidents...or other adverse occurrences directly associated with care or services provided ...Debrief: a process to get all parties who were involved in an occurrence together for a few minutes after the event to discuss in a non-threatening manner what the team did right and to identify those areas where the team needs to improve...Root Cause Analysis (RCA): are processes for identifying the basic or contributing casual factors that underlie variations in performance associated with adverse events...The primary objective is to improve and implement system support to ensure that such events will be less likely to happen in the future...Policy...Yuma Regional Medical Center (YRMC) has a procedure for the...investigation and follow-up of adverse events...that may occur at any YRMC patient care locations...National Quality Forum...Serious Reportable Events...Potential Criminal Events...7C. Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting ...."

Hospital document dated "07/02/2021" revealed an addendum note by Employee #4-Director of Risk dated 07/12/2021, in which an interview was conducted by Employee #4-Director of Risk Management and Employee #1-Corporate Compliance Officer with Employee #17 RN-ED regarding the incident reported by Patient #1 on 07/02/2021. Employee #17 RN-ED denied any inappropriate behavior. Employee #17 RN-ED acknowledged s/he remembered Patient #1 and felt sorry for her/him, revealing s/he was unbathed, diaphoretic and not clean. Employee #17 RN-ED revealed that s/he provided bathing supplies to the patient however, the patient kept falling asleep so s/he assisted with the bath. Employee #17 RN-ED revealed that the nursing units get upset if patients are transferred from the ED dirty and not in a hospital gown. Employee #17 RN-ED revealed s/he had to obtain urine samples from the urethral catheter and nephrostomy tube. Employee #17 acknowledged it was necessary to clean both areas to ensure clean samples were obtained. Employee #17 RN-ED revealed it is part of the nursing assessment to ask questions regarding sexual activity.

Employee #4-Director of Risk Management confirmed during an interview conducted on 10/21/2021, that s/he did not do any debriefing and s/he was not sure who s/he would debrief. The investigation included contacting the Emergency Department Director and Human Resources to check if Employee #17 RN-ED had any past behavior problems or if the employee's file had anything related to incidents, and there was none. The only person interviewed was Employee #17 RN-ED and his/her story seemed plausible. The medical record was not reviewed, the staff member that took the complaint was not interviewed, and the patient was not interviewed.

Employee #2-Chief Nursing Officer confirmed during an interview conducted on 10/20/2021, that no RCA was completed, including after a staff member was arrested. Initially the investigation was turned over to risk to complete an investigation. When the staff member was arrested, it was then a criminal investigation at that point.

3.
Review of Governing Body meeting minutes from January 2021, to present were requested. Governing Body meeting minute agendas from 07/2021, to present were provided and there was no evidence of the incident/adverse event in July 2021, or the arrest of an employee in August 2021.

Employee #12 confirmed during an interview conducted on 10/19/2021, that the incident/adverse event and arrest of a staff member had not been presented to the board. Employee #12 was directed by legal counsel to show the surveyors only agendas of the Governing Body meeting minutes. If the agenda was not sufficient, Employee #12 would need to speak to legal counsel.

Employee #2-Chief Nursing Officer confirmed during an interview conducted on 10/20/2021, that the Governing Body had not been made aware of allegations against Employee #17 RN-ED or of Employee #17 RN-ED arrest. The incident/adverse event will go to the board this month or next month.