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Based on record review, policy review and interview it was determined the facility failed to ensure patient's complaints regarding quality of care were reported, investigated and provided a resolution for 1 of 3 sampled patients (Patient # 5).


The findings included:


Review of the Grievance logs dated 12/2016 thru 03/2017 revealed no entries related to Patient # 5.

Clinical record review of Patient # 5 conducted on 03/16/2017 revealed the patient's son had verbalized concerns related to the quality of care, the facility environment and physician's communication.

Pertinent entries in the record revealed the following:

Nurses Notes dated 02/04/2017 at 9:45 AM documents "Spoke with patient's son this morning. Son upset no one called him last evening when the patient acted out and why patient was given Ativan. Reported that patient had acted out and the actions taken and that I would discuss again with the assistant clinical manager. Son also upset that Medical Doctor (MD) has not called him regarding patient's care and plan."
Nurses Notes dated 02/04/2017 at 9:50 AM documents "Spoke to Dr. . gave him patient's son number and explained that he is upset and wants to speak with MD regarding care and plan of care."
Nurses Notes dated 02/04/2017 at 5 PM documents "son in to see patient and upset that the MD did not call him".
Nurses Notes dated 02/05/2017 at 1:59 PM documents "Patient and son given discharge instructions. Son verbalized understanding and has no further questions at this time. Son given prescription for the patient. Had multiple complaints regarding the hospital but was pleasant towards me."


Phone Interview with Staff A conducted on 03/17/2017 at 11 AM revealed the staff recollection of an incident related to Patient # 5. Staff A explained the patient's son came out of the room very upset, stating the patient was not receiving acceptable care and complained the room was not clean. The Charge Nurse went in the room to address the issues.


Interview with the Nursing Supervisor on 03/17/2017 at 11:20 AM revealed the charge nurse made him aware Patient # 5's son had complained regarding the cleanliness of the room and was the subject of an incident. The supervisor explained due to his busy schedule he was not able to speak to the patient the day the complaints were reported. The next day, he was following up and received report from the night supervisor the patient's son was alleging the use of chemical restraints. He met with the patient's son and the conversation was related to the incident (needle stick). Emergency room services were offered and declined. The supervisor has no knowledge of follow up on the complaint alleging chemical restraints and explained environmental services was contacted at the time to address the cleanliness of the room.

Phone interview with Staff A on 03/20/2017 at 8:36 AM revealed Patient # 5's son had a concern regarding the physician and had requested the physician calls him regarding his mother's care. Staff A forwarded the request to the physician during rounds and the son did not want the physician to see the patient until they had spoken. Staff A explained she had relayed the message and has no control over the physician's actions.

Interview with The Patient Advocate on 03/17/2017 at 12:33 PM revealed there are no grievances related to Patient # 5.

Interview with The Director of Quality Improvement on 03/17/2017 at 12:44 PM revealed the patient advocate was not able to locate a complaint related to Patient # 5.


Facility policy titled "Grievance Policy" approved 10/02/2014 documents "A patient grievance is a formalized or informal written or verbal complaint that is initiated by the patient/family following discharge. A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patients' care (when the complaint is not resolved at the time of the complaint by staff present). A record of the complaint/grievance shall be maintained in the system to determine closure and for the purpose of identifying performance trends. Hospitalized patient complaints will be addressed by the patient advocate in conjunction with the department director and risk management. The Department Director is accountable for responding to the substance of the complaint and identifying, investigating and resolving any problem".

Based on record review and interview it was determined the facility failed to honor patient/patient representative's right to participate in the implementation of the inpatient treatment plan for 1 of 5 sampled patients (Patient # 5) as evidenced by failure to notify responsible party of changes in behavioral condition as requested by the patient's representative.

The findings included:


Clinical record review conducted on 03/17/2017 revealed Patient # 5 was admitted to the facility on 02/01/2017 with diagnoses of abdominal pain.

Nursing History dated 02/02/2017 documents the patient's son is the health care surrogate, is the person to disclose information to and is the responsible party.

Admission orders dated 02/02/2017 included the following medications; Xanax 0.5 mg every twelve hours as needed for anxiety, Ativan 1 mg/0.5 milliliters intravenously every four hours as needed for agitation, Seroquel 25 mg one tab two times a day as needed and Namenda 28 mg extended release daily.


Phone interview with Staff C, a Registered Nurse, conducted on 03/20/2017 at 2:03 PM revealed the nurse took care of Patient # 2 on 02/02/2017. Staff C recalls the patient arrived to the unit yelling and was very restless attempting to get out of the bed. The son requested to be called whenever the patient exhibited behaviors, as he took care of her at home and was able to calm her down. The son told her he was available "twenty- four/seven" if they needed him. Staff C stated the information was passed along to the next shift during report.

Pertinent entries in the clinical record revealed the following:
Nurses Notes dated 02/02/2017 at 9:15 PM documents "Patient yells and screams ...agitated, complaining and restless".
Nurses Notes dated 02/03/2017 at 9:20 PM documents "Behavior agitated, complaining and demanding".
Nurses Notes dated 02/04/2017 at 9:45 AM documents "Spoke with patient's son this morning. Son upset no one called him last evening when the patient acted out and why patient was given Ativan. Reported that patient had acted out and the actions taken and that I would discuss again with the assistant clinical manager."

Further review of the record revealed Patient # 5 received the following medications due to behaviors:
Ativan 1 mg for agitation on 02/02/2017 at 11:36 PM
Ativan 0.5 mg for agitation on 02/03/2017 at 11:42 PM (half dose)
Ativan 1.0 mg. for agitation on 02/04/2017 at 3:39 AM.
Xanax 0.5 mg on 02/03/2017 at 9:20 PM for Anxiety
Seroquel on 02/03/2017 at 10:53 PM.

Further review of the record failed to provide evidence the patient's son was contacted when the patient was exhibiting behaviors requiring the use of these medications.

Phone interview with Staff D, a Registered Nurse on 03/17/17 at 8: 37 AM revealed the nurse cared for Patient # 5 on 02/03/2017, night shift. Staff D heard the patient's son was upset because no one called him when the mother received Ativan during her shift. The preceding shift had reported the patient had received Ativan the prior night with good relief, so she administered the drug due to the patient's behavior, yelling and trying to get out of the bed, it was administered for her safety. Staff D confirmed the patient was medicated four times during her shift for behaviors and first stated she could not remember if the son was called; then stated she did call the son, but was not sure if it was documented. Staff D was not able to provide any other details such as when and how many calls were attempted or the outcome of the calls.

Based on record review and interview it was determined the facility infection control program failed to ensure the maintenance of a sanitary environment in 1 of 6 patient care units (4th floor) as evidenced by failure to properly dispose of sharps resulting in a visitor needle stick.


The findings included:



Facility policy titled "Blood Borne Pathogens Exposure Control Plan" approved 01/31/2017 documents:
"Immediately after use, all needles and sharps shall be placed in appropriate containers. These containers will be puncture resistant, labeled, color- coded and leak proof.
Regulated waste shall be contained and disposed of in accordance with Federal, State and Municipal regulations.
Regulated Waste: means liquid or semi liquid or semi liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials. If compressed, items are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.
Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are: Closable, Puncture resistant, Leak proof and Labeled".

Facility policy titled "Incident Reports" approved 12/14/2017 documents "It is the responsibility of the team member in charge or his/her designee to assess the patient or the situation. Visitors: if an injury is involved, the visitor should be routinely taken to the occupational health clinic/emergency room (ER) and assessed by the ER physician."


Facility document dated 02/04/2017 documents a visitor sustained a needle stick, "needle exposed and no safety covering".

Phone interview conducted with the Staff B, a Charge Nurse, conducted on 03/17/2017 at 10:28 AM revealed details related to an incident involving Patient # 5' son. The patient's son was very upset, stating the room was disgusting, he was venting and going on about the room not being clean and started to pick items from the floor. He picked up an intravenous needle with no cap and stated he got stuck with the needle. The injury was a small prick with visible blood. Staff B does not recall offering emergency room services to the patient's son after the incident and believes the primary nurse took care of injury.


Phone Interview with Staff A, a Registered Nurse, conducted on 03/17/2017 at 11 AM revealed the staff recollection of an incident related to Patient # 5. Staff A explained the patient's son came out of the room very upset, stating the patient was not receiving acceptable care; the son complained the room was not clean, and went around the room putting papers away and picking up stuff from the floor. The patient's son went around the bed, by the window and picked up something from the floor and verbalized it was a needle and he was stuck with it. The charge nurse who was in the room took the needle and placed it in the sharps container. Staff A does not recall offering emergency services after the needle stick; she believed they gave him a Band-Aid. The son then stated," great now I am going to get MRSA" (methicillin resistant staphylococcus aureus) and grabbed the garbage can, looking for the needle. Staff A explained to him the facility would not discard the needle in the garbage and that it was discarded in the sharps container. Staff A verbalized she did not do an intravenous (IV) start on this patient, she had a power glide (PICC line, a peripheral intravenous central catheter) line due to unsuccessful IV start on the previous day. Staff A was not aware how or who left the needle on the floor.


Interview with The Nursing Supervisor on 03/20/2017 at 11:20 AM revealed he was made aware of the incident related to Patient # 5's son. The day of the incident was a weekend; he was very busy and was handling all administrative issues at the facility. The Supervisor was not able to talk to the patient's son on that day but a follow up was done the next day, to offer emergency room services.


Interview with The Director of Quality Improvement on 03/17/2017 at 12:12 PM revealed the facility has a blood borne pathogens exposure control plan, this policy only applies to team members, contractors, ancillary support, independent practitioners and volunteers. If a visitor is subject to any injury, the facility practice is to offer emergency room services for further assessment of the injury.