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Based on interview, and review of the facility's grievance policy and log, it was determined the facility failed to implement their grievance policy regarding notification time frames for one (1) of two (2) sampled patients (out of total sample of 21) chosen from the facility's grievance log. Patient #19 came to the hospital on 05/30/12 to voice a concern regarding the care the patient received in the facility's Emergency Department (ED) on 05/19/12. The facility did not provide a response to the grievance until 06/25/12. The facility's grievance policy indicated a response should be provided to a patient within a time period not to exceed seven (7) working days.

In addition, the facility failed to provide a written response of resolution to the patient until 08/22/12.

The findings include:

Review of the facility's Patient Complaint Resolution and Grievance Process policy, reviewed on February 2012, revealed a grievance is a written or verbal complaint voiced by the patient, or patient's representative regarding patient care or abuse/neglect issues. The policy stated each patient has the right to voice complaints regarding care and to have those complaints reviewed and promptly resolved whenever possible. A response or update must be provided to the patient within a time period not to exceed seven (7) working days. The patient is notified of the status of the process and when resolution is anticipated. In addition, the policy stated the facility would send a letter, within thirty (30) days of receiving the complaint/grievance, to acknowledge the conversation, apologize for the problems, affirm their commitment for resolution, and detail specific actions taken to resolve the concerns.

Two Grievance complaint forms were reviewed during the survey.

Review of Patient #19's complaint/grievance form revealed the facility received the patient's concerns on 05/30/12 at 4:30 PM. Through interview between facility staff and the patient it was revealed the patient came to the hospital and verbalized those concerns in person. The patient voiced concern with care received in the ED on 05/19/12. Those complaints included: (1) did not receive pain medication for pain, (2) fall from a bed while in the ED, (3) staff was rude to the patient in radiology, (4) a nurse (in the ED) pushed the patient in the chest and told the patient all he/she wanted was pain medications and the patient was mad because he/she could not get the pain medications. The report stated the patient told the facility he/she was groggy at the time, upset with the staff, and did not like staff physically touching him/her. This form was signed on 06/25/12. The form stated the complaint was not resolved on that date and stated the patient would come in to discuss the complaint issues again. There was no evidence a written response, with specific actions the facility had taken, was provided to the patient according to their policy.

Interview with the Quality Risk Manager (QRM), on 10/24/12 at approximately 4:00 PM, revealed Patient #19 came to the hospital on 05/30/12 and spoke with her. She stated she spoke with the departments involved (ED and Radiology) and found the staff denied the allegations. However, she could not provide any documented evidence of an investigation. She stated she had not provided written response of actions taken by the facility to the patient because she was waiting for the patient to return to the hospital to discuss the concerns. She stated she called the patient in July and the patient stated he/she was coming to the hospital. She told the patient to stop at her office; however when the patient discovered she was the same person the patient had discussed the concerns with in May 2012, the patient said, "No", he/she did not want to talk to the QRM, the patient requested to speak with the ED Director.

Continued review of the patient complaint form revealed the ED Director called the patient on 06/25/12 to discuss the complaint. The patient told the ED Director the QRM's report was wrong and the ED Director requested the patient to come back to the hospital to discuss the patient's concerns. The QRM called the patient on 07/17/12 to set up an appointment. Documentation revealed the patient refused to speak with the QRM and requested to speak with the ED Director.

Interview with the ED Director, on 10/24/12 at 6:45 PM, revealed she had been on medical leave when the complaint was received. She stated she called the patient on 06/25/12 to discuss the patient's complaints. She said the patient told her the QRM report was wrong and became upset. She could not understand the patient's complaints and requested the patient to come back to the hospital to discuss the concerns. The patient agreed to come back to the hospital. She stated the meeting was scheduled for 07/17/12. She revealed the patient came in on 07/17/12 and refused to speak with the QRM but did talk with the ED Director. She gave the patient another complaint form to fill out. The patient brought a written letter to the hospital on 08/14/12 stating the same concerns as the patient told the QRM in May 2012.

Review of the written letter, dated 08/14/12, revealed the patient again alleged a nurse had pushed him/her in the ED. The patient wrote he/she refused to sign discharge papers. The nurse told the patient he/she could leave after they signed the papers. The patient wrote he/she told the nurse, "I'm leaving." The nurse put her hands on the patient's chest and pushed. "I told her don't touch me." The patient attempted to walk around the nurse and walked into the ED hallway. The patient wrote the nurse ran in front of him/her and pushed "forcefully-enough to make me lose my balance and almost fall." Refer to A-0145

Review of the clinical record revealed Patient #19 presented to the ED, on 05/19/12 at 12:09 PM, with symptoms of left rib pain with movement and respirations. The patient also complained of nausea. The patient was diagnosed with Pleurisy with abnormal chest x-ray. Review of the patient's home medications revealed the patient had phenergan 25 mg ordered every four (4) hours as needed. In addition, the patient had pain medications ordered as needed. The clinical record revealed the patient refused to sign discharge papers.

Interview with the Chief Nursing Officer (CNO), on 10/24/12 at 5:25 PM, revealed the QRM was responsible for conducting complaint/grievance investigations. She stated the patient came to the QRM's office for the first time on 05/30/12. It was the process to forward those concerns to the department where the complaint originated. When the ED Director returned to work, she called the patient to discuss the patient's complaints. The patient was not satisfied with the facility's actions so the facility conducted another investigation in August 2012. However, the CNO revealed the patient's complaints from May 2012 had not been addressed promptly according to facility policy. She stated a written response was not provided to the patient until August 22, 2012. She acknowledged there was no documentation an investigation of the patient's complaints had been conducted.

Based on interview and review of the facility's abuse policy, it was determined the facility failed to investigate a reported allegation of physical abuse for one (1) sampled resident (#19) out of total sample of twenty-one (21). Patient #19 alleged a nurse pushed the patient in the chest causing her/him to lose their balance and almost fall.

The findings include:

Review of the facility's abuse policy, reviewed February 2012, revealed patients have the right to be free from all forms of abuse. In protecting the patients from abuse, the hospital shall adhere to the following: Prevention, screening, identification: maintenance of a proactive approach to identify events or occurrences that may constitute or contribute to abuse or neglect. Investigation: an objective investigation is performed in a thorough and timely manner. Report/respond: all incidents of abuse, neglect, or harassment are reported and analyzed, followed by the appropriate corrective, remedial or disciplinary actions in accordance with applicable local, state, or federal laws or regulations.

Review of Patient #19's clinical record revealed the patient presented to the Emergency Department (ED), on 05/19/12 at 12:09 PM, with symptoms of left rib pain upon movement and respirations. The patient also complained of nausea. The patient was diagnosed with Pleurisy. In addition, the patient had pain medications ordered as needed. The patient was discharged from the ED at 2:28 PM; however, the clinical record revealed the patient refused to sign the discharge papers.

Review of the facility's grievance log revealed Patient #19's filed a complaint/grievance, on 05/30/12 at 4:30 PM. Through interview it was revealed the patient came to the hospital and verbalized those concerns in person. Review of the grievance report form revealed the patient voiced concern regarding care received in the ED on 05/19/12. Those complaints included: (1) did not receive pain medication for pain, (2) fall from a bed while in the ED, (3) staff was rude to the patient in radiology, (4) a nurse (in the ED) pushed the patient in the chest and told the patient all she/he wanted was pain medications and the patient was mad because she/he could not get the pain medications. The report stated the patient told the facility she/he was groggy at the time, upset with the staff, and did not like staff physically touching her/him. The Quality Risk Manager (QRM) received the report and stated the department manager would follow up. On 06/25/12, the ED Director called the patient at home to discuss the patient's concerns. The form stated the complaint was not resolved at that time. The ED Director requested the patient to come to the hospital to discuss the complaint issues again.

Interview with the Quality Risk Manager (QRM), on 10/24/12 at approximately 4:00 PM, revealed Patient #19 came to the hospital on 05/30/12 and spoke with her. She stated she spoke with the departments involved (ED and Radiology) and found the staff denied the allegations. However, she could not provide any documented evidence of an investigation.

Interview with the ED Director, on 10/24/12 at 6:45 PM, revealed she had been on medical leave when the complaint was received. She stated she called the patient on 06/25/12 to discuss the patient's complaints. She said the patient told her the QRM report was wrong and became upset. She could not understand the patient's complaints and requested the patient to come back to the hospital to discuss the concerns and the patient agreed. She revealed the patient came to the hospital on 07/17/12 and the ED Director gave the patient another complaint form to fill out. The patient brought a written letter to the hospital on 08/14/12 stating the same concerns as the patient told the QRM in May 2012.

Review of the written letter from Patient #19, dated 08/14/12, revealed the patient again alleged a nurse had pushed her/him in the ED. The patient wrote he/she refused to sign discharge papers. The nurse told the patient he/she could leave after they signed the papers. The patient wrote he/she told the nurse, "I'm leaving." The nurse put her hands on the patient's chest and pushed. "I told her don't touch me." The patient attempted to walk around the nurse and walked into the ED hallway. The patient wrote the nurse ran in front of him/her and pushed "forcefully-enough to make me lose my balance and almost fall." The patient stated this was witnessed by the patient's sister. In addition, the patient provided written documentation regarding the phone conversation with the ED Director on 06/25/12. The patient documented he/she received a call from the ED Director asking the patient about the complaint. The patient documented the ED Director told the patient in all the years she had worked, she had never known a nurse to push anyone. The patient told the ED Director it did occur and was witnessed by the patient's sister. The patient stated the nurse pushed with enough force to cause the patient to lose his/her balance and almost fall. "I told her I have no reason to lie." The ED Director told the patient she would have to do more checking and someone would get back with him/her.

Review of the patient's sister's written documentation of the incident revealed the nurse came in for the patient to sign release papers. The discharge papers had a prescription for Phenergan and the patient told the nurse he/she already had this medication at home and didn't need another. The patient asked the nurse to take the medication order off. The nurse told the patient she would if the patient would sign the discharge papers. The patient refused and attempted to leave. The sister wrote the nurse stood in front of the patient and pushed on the patient's shoulders, trying to make him/her sign. The patient refused again. The nurse again got in front of the patient and this time pushed hard, causing the patient to lose balance, and almost fall. The patient told the nurse not to put her hands on him/her again. Continued review of the sister's letter revealed another worker appeared and yelled, "No," "No", "I'll sign him/her out." The sister wrote she overheard the nurse tell the other worker,"Oh," "he/she is just mad because they could not get no pain pills." The sister documented she thought the patient was going to die before the patient was seen by his/her primary physician.

Continued interview with the ED Director, on 10/24/12 at 6:45 PM, revealed she did not review the complaint as a possible allegation of abuse. She stated staff had been interviewed and the nurse denied pushing the patient. However, the nurse admitted standing in front of the patient attempting to get the patient to sign the discharge papers. The ED Director revealed she had investigated allegations of abuse before and had knowledge of reporting requirements. Normally, she would interview all staff present, any witnesses, and interview the patient. However, since she was not here when the incident occurred, she had not considered to do that.

Interview with the Chief Nursing Officer (CNO), on 10/24/12 at 5:25 PM, revealed the QRM was responsible for conducting complaint/grievance investigations. She revealed there was no documentation of the investigation of the patient's complaints. She stated the allegation of physical abuse was not identified, investigated, nor reported. She had failed to consider the patient's complaint to be an allegation of abuse and did not investigate nor report according to facility policy and state law. She stated staff was provided education on abuse and how to report. Although the patient alleged a nurse had physically pushed him/her on several occasions including written letter, the facility failed to investigate and report the allegation.

Based on observation, interview and record review it was determined the Condition of Participation: Physical Environment was not met. The facility failed to maintain the physical environment to ensure the safety and well-being of patients.

A Life Safety Code survey was initiated on 10/23/12 and concluded on 10/24/12. Life Safety Code deficiencies were cited that determined the Condition for Participation for Physical Environment at 42 CFR 482.41 was not met under A710.

Refer to LSC tags: K025, K027, K045, K046, K050, K056, K069, K070, K072, K075, and K147.

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Based on observation, interview and record review, it was determined the facility failed to maintain the physical environment to ensure the safety and well-being of patients.

A Life Safety Code survey was initiated on 10/23/12 and concluded on 10/24/12. Life Safety Code deficiencies were cited at 42 CFR 482.11.

Refer to LSC tags: K025, K027, K045, K046, K050, K056, K069, K070, K072, K075, and K147.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to follow their policy related to obtaining Cardio-Pulmonary Resuscitation (CPR) and Advanced Cardiac Life Support (ACLS) certifications for one (1) of six (6) personnel files reviewed.

The findings include:

Review of the facility's policy and procedure (Lippincott's Nursing Procedures and Skills) revised 03/05/10, revealed all employees are required to receive annual education in specified area. Some departments have also established department specific education requirement. The Emergency department requires CPR every two years (all staff) and ACLS every two years (RN).

Review of the personnel file for RN #1, on 10/24/12 at 3:50 PM, revealed the last CPR and ACLS training was completed in September of 2009.

Interview with the Human Resources Director, on 10/24/12 at 4:00 PM, revealed she did not have the CPR or ACLS verification, and stated she had been trying to get the proof from the facility that provided the course. She stated the certification would have expired one (1) year ago.

Interview with the Staff Development Nurse, on 10/24/12 at 4:35 PM, revealed all nurses are responsible for completing CPR and ACLS for Emergency Room, which was where this nurse usually worked, and should have been put on administrative leave until the information was produced.

Interview with the Chief Nursing Officer (CNO), on 10/24/12 at 5:45 PM, revealed clinical bedside care providers are required to have CPR every two years. The CNO stated the staff member should have been put on administrative leave, and not allowed to work during that time; if after the 30 days the information was not provided, the employee would be terminated. The CNO stated the employee was put on administrative leave today, or approximately one (1) year after the certifications were due, which was not consistent with the policy.