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Based on medical record review, document review and interview, the facility did not implement its policy and procedure to ensure that all Medicare beneficiaries or their representatives received the Important Message from Medicare (IMM) notice that explains the beneficiary's right as a hospital patient. This finding was evident in four (4) of six (6) medical records reviewed (Patient #s 13, 15, 16, and 17 ).

Findings include:

Review of the facility's policy titled "Discharge Notice and Appeals Rights as related to Medicare Beneficiaries for Acute Inpatient Hospitalizations" last reviewed 3/16/17 notes, "The Important Message from Medicare (IMM), a statutorily required notice that explains the beneficiary's rights as a hospital patient, including discharge appeal rights ... will be issued upon admission or up to two days after admission. Signature of the beneficiary or representative is obtained and a copy of the IMM notice is provided to the beneficiary/designee at that time. if the patient and/or designee is unable to sign at point of entry the Case Manager/Social Worker is to be notified and the Case Manager/Social Worker makes three attempts to contact the beneficiary/designee to explain the Important Message from Medicare (IMM) and appeal rights. Documentation of all outreach attempts including date and time of the outreach as well as person with whom the conversation occurred are written on the IMM with an indication that patient is unable to sign and outcome of discussion."

Review of medical record for Patient #13 during tour of a Medical Unit (5 Uris) on 10/25/17 at approximately 11:15 AM identified an 86 year-old female who was admitted to the facility on 10/20/2017. A copy of the IMM notice was not signed by the patient or her representative.

At interview with Patient #13 on 10/25/17 at approximately 11:30 AM, she stated that she had not received the document and knew nothing about it.

Similar findings were noted in medical records for Medicare beneficiaries Patient #s 15, 16, and 17 whose IMM notices indicated they were unable sign. However, there was no documented evidence of Case Manager/Social Worker's attempts to furnish the IMM notice to patients' representatives.

On 10/25/17 at 2:10 PM, during interview with Staff I, Assistant Director Case Management and Staff J, Assistant Director of Social Work, they acknowledged these findings.

Based on medical record review, document review, and interview, the facility failed to implement its policies and procedures to ensure a comprehensive investigation of allegations of abuse and neglect/mistreatment of patients. This deficiency was noted in one (1) of three (3) grievance files reviewed (Patient #2).

Findings include:

Review of hospital policy titled "Abuse and Neglect/Mistreatment of Patient" dated 5/26/17, states, "Allegations against employees or other Healthcare Providers regarding patient abuse must be immediately escalated to the employee's Healthcare Provider's supervisor or manager ... The department supervisor or manager, in conjunction with Quality department and Human Resources, will begin an immediate and comprehensive investigation."


Review of medical record for Patient #2 identified this 24-year-old male who was admitted on 4/29/17 for psychiatric evaluation and stabilization. The patient's past medical/psychiatric history included schizophrenia, autism-spectrum and chronic rectal prolapse.

Progress Note, dated 9/8/17 at 9:00 PM, authored by Staff # 9, Assistant Nurse Manager indicated that he was informed by a staff nurse that Patient #2 reported an allegation of abuse by Staff O, Mental Health Technician on the evening of 9/7/17.

Review of Occurrence/investigation report, dated 09/08/17, noted Patient #2 stated "Staff O escorted him to the bathroom yesterday evening (9/7/17), shoved him twice against the wall between the toilet, and the sink, then closed the door, and punched him in the left shoulder." On 9/8/17, the physician on call evaluated the patient and noted "no injury or complaint." The attending physician also noted that the patient had no complaint.

The investigation report did not include evidence of a complete investigation by the facility and there was no documentation of the outcome of the investigation.

In addition, there was no documented evidence that the case was forwarded to the Human Resources Department or escalated to Quality Management for further review and investigation as prescribed by the policy.

During interview with Staff K, Nurse Manager and Staff S, Social Worker on 10/24/17 at approximately 12:30 PM, they reported that the investigation of alleged abuse of the patient was discontinued when the patient retracted his complaint on 9/11/17, two days after he lodged the complaint.

On 10/24/17 at 12:30 PM during interview with Patient #2, in the presence of Staff K, Staff S, and Staff M, Director of Inpatient Psychiatric Services, the patient restated his allegation and denied that he retracted the complaint regarding abuse/maltreatment by Staff O.

Based on medical record review and interview, the facility failed to notify the patient and or his representative the outcome of a complaint investigation as required by the hospital policy and procedure on the management of patient complaint and grievances. This deficiency was noted in one (1) of sixteen (16) grievance files reviewed (Patient #2).

Findings:

Review of facility's policy and procedure titled, "Management of Patient Complaint and Grievances" dated 1/21/16 states, " Every effort will be made to respond to all grievances within seven days indicating, the contact person at the site, the steps taken to investigate the grievance, the results of the grievance process and the date of completion."

Review of Occurrence report dated 9/8/17 indicated that Patient #2 reported an allegation of abuse/assault by a Mental Health Technician on 9/7/17.

Review of the investigation report on 10/25/17 noted there was no documented evidence that the patient was provided with the outcome of the investigation, seven weeks after the grievance was reported.

During interview with Staff K, Nurse Manager on 10/25/17 at 2:30 PM, she reported that the patient retracted the complaint on 9/11/17 but acknowledged that the facility's grievance process that includes response to all grievances within a specified timeframe was not implemented.