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Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to meet the Medicare Conditions of Participation for Acute Care Hospitals 42 CFR 482.13 Patients Rights as evidenced by failure to:

1. to identify and investigate all grievances; See A tags 0118 and 0119

2. respond to grievances in writing, to include all information as required by federal regulations; see A tag 0123

3. establish a grievance process in which all grievances are reviewed through governing body or a committee appointed by the governing body and information obtained from the review is used to improve organizational performance. A0118 ,122,123

4. develop and enforce an abuse and neglect policy that clearly defined:
a. The steps the hospital would take to protect the patient and staff;
b. The procedure the hospital would follow to investigate the allegation.
c. The steps the hospital would take to remove the staff from patient care when allegations of abuse are made.
d. The steps the hospital would take to educate and remediate staff regarding abuse and neglect. A0144, A145,

5. Ensure all staff were appropriately trained in abuse and neglect procedures .
6. Ensure all staff were appropriately trained in the hospital grievance process.

Based on review of the hospital's policies, handouts and meeting minutes, and interviews with hospital staff, the hospital failed to establish a process for prompt resolution of patient grievances.
1. The hospital failed to correctly identify grievances.
2. The hospital failed to identify whom to contact to file a grievance.
3. There is no documentation the hospital ensures grievance data is used to improve patient care.

Findings:

Recognition of Grievances:
1. The hospital's grievance documents do not identify grievances according to CMS (Centers for Medicare and Medicaid Services) guidelines. CMS defines a grievance as "a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient 's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation."

2. Nursing notes for Patient #1 documented on 05/27/2012, the patient's representative voiced concerns about the patient's care. These concerns, if they had been addressed, would not have been able to be addressed without investigation. A grievance form was not completed and the hospital had no documentation of investigation into the concerns expressed.

3. Hospital documents and policy document the patient or patient's representative must complete and sign a written grievance form. CMS does not require this.

4. Policy #200.2.1, "Inpatient Grievances for Youth", Section VI, K, documents "In order to be processed for action and resolution, a grievance must be filed within 15 working day of the date of the incident, decision, act or omission complained about in the grievance."

Contact to file grievance:
1. The surveyors requested the patient rights handouts and grievance policies.
2. The grievance process forms that had the Patient Rights attached, only listed the accrediting agency for outside contact for complaints. It did not give contact information for the State agencies.
3. The grievance process forms that had the Notice of Privacy Practices, listed the State agencies, but did not list the accrediting agency. Although this form required a patient/patient representative signature, staff told the surveyors that a copy was only given to the individual if it was requested.
4. Staff B told the surveyors on 12/18/2012 that Staff O was the local grievance coordinator (LGC/patient advocate), but grievances and hospital documents did not list this staff or give contact information.
5. Six of six Pt#10, 11,12,13, 14, 15)grievances reviewed did not have evidence the facility investigated all of the allegations, with all parties involved, removed staff accused of abuse from patient care, and informed the patient of the grievance decision in writing.

6. Meeting minutes for the Governing Body and Quality Assessment and Performance Improvement did not reflect the Governing Body had designated a committee to be responsible for the grievance process.

7. Meeting minutes for the Governing Body and Quality Assessment and Performance Improvement did not reflect grievance and complaint data is reviewed, analyzed and action taken to improve patient care and safety.

Based on policy and procedure review, record review and staff interview, it was determined the hospital failed to ensure grievances were reviewed, analyzed and trended, and failed to ensure the results of the analysis were reported to the
QAPI committee and recommendations and actions were taken. All grievances identified in patient records were not included in the hospital's grievance log. All grievances were not resolved according to the hospital's process.

1. A grievance identified on Patient # 1's record was not identified by the hospital as such and with an investigation and a written response made to the complainant.

2. Nursing notes documented a grievance alleging poor patient care and abuse, this was not identified and processed by the hospital's grievance process.

3. According to a grievance filed by Patient #10, Staff G told the patient to "get the hell in there or I will kick your ass". The documentation also included an allegation of a staff member hitting Pt#10 on the side and shoulder and taking the patient to time out. Patient #10 also wrote in the grievance another patient witnessed the interaction. The grievance documentation included a statement from the other patient corroborating Patient #10's grievance and included a statement Staff G whispered to the patient later "patient #10 is a bitch". The grievance documentation did not include investigation of all allegations. There was no documentation of interviews of the other patient. There was no documentation all parties involved or all witnesses were interviewed.

Grievance documentation indicated the staff member involved was counseled regarding multiple complaints of non professional communication, a grievance filed regarding threatening comments, multiple complaints from other patients stating the staff member was mean and rude. The counseling form included the unit manager signature and the employee signature. A space was included for the Human Resources Department to sign off. This space was blank. There was no documentation all of the allegations were reviewed with human resources. There was no documentation the facility removed the staff member from patient care during the investigation. There was no documentation the patient had received written documentation regarding the grievance decision.

4. Pt #13 wrote a grievance indicating Staff H pushed him into the shower. Pt#13 further indicated there was a staff member who witnessed the incident and saw Pt#13 was soaking wet in his clothes. Pt #13 stated he was "afraid to shower". The grievance documentation included "referred to DHS hotline". There was no documentation of the investigation or if all parties present during the incident were interviewed. There was no documentation the facility removed the staff member from patient care during the investigation. There was no documentation the patient had received written documentation regarding the grievance decision.

5. Pt #12 and Pt# 15 wrote grievances indicating the same staff member called them names like "punk and wimp". Pt#12 indicated the same staff member allowed patients to pick on him and another patient to "hit me really hard".
There was no documentation of the investigation or if all parties present during the incident were interviewed. There was no documentation the facility removed the staff member from patient care during the investigation. There was no documentation the patient had received written documentation regarding the grievance decision. Documentation on one of the grievances indicated the local grievance coordinator allowed the staff involved in the incident to discuss the incident with the patient and the "patient rescinded the grievance".

6. Pt#14 wrote a grievance indicating Staff I "raised my arm up and almost broke my ay arm...Staff I should not be so forceful. The patient also indicated the staff members called him names. There was no documentation of the investigation or if all parties present during the incident were interviewed. There was no documentation the facility removed the staff member from patient care during the investigation. There was no documentation the patient had received written documentation regarding the grievance decision

7. Grievances are reported in the hospital's PIC (Performance Improvement Council). The type of grievance is documented, but the analysis and action taken is not documented. Not all grievances listed on the grievance log 2012 were documented and reviewed in the PIC meeting minutes.

Based on review of the hospital's policies, handouts and meeting minutes, and interviews with hospital staff, the hospital failed to establish a process for prompt resolution of patient grievances.

Findings:


1. The hospital's grievance documents do not identify grievances according to CMS (Centers for Medicare and Medicaid Services) guidelines. CMS defines a grievance as "a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient 's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation."

2. There is no documentation in six of six grievances the facility addressed the grievances with all of the required elements and within prompt timeframe.

3. Six of six grievances reviewed did not have a written response to the complainant.

Based on policy and procedure review, document review and staff interview, it was determined the hospital failed to ensure a written notice of the hospital's determination of the grievance investigation was provided to the complainant. Findings:

1. The hospital grievance policy was reviewed. The policy did not document how a patient grievance should be addressed in writing.

2. Six patient grievances were reviewed. None of the grievances included written responses by the hospital to the complainant.

3. These findings were reviewed at the exit conference. No other documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that patients receive care in a safe setting. The hospital failed to review, analyze, and trend incidents, grievances, and complaints in order to develop plans to improve patient safety and clinical performance.

Findings:

1. Review of Quality Assurance and Performance Improvement Committee Meeting minutes for 2012, Governing Body Meeting Minutes, and Medical Staff Meeting Minutes did not include analysis of all grievances, and complaints to identify patterns which might impair patient safety. There was no analysis to develop plans of correction to improve patient safety.

2. Six of six grievances reviewed where allegations of physical abuse occurred did not have documentation the grievances had been taken through the grievance process. None of the grievances reviewed included any written documentation to the complainant. There was no documentation the allegations of abuse were reviewed through human resources or adminstration. None of the grievances included any removal of staff from patient care duties while allegations of physical abuse were investigated.

3. Surveyors reviewed personnel files on 12/18/2012. There was no documentation the employees were educated on the current grievance policy/process. Training files for the employees reviewed did not include any remediation although scores were below passing levels. Some of the files contained tests which were not complete. There was no documentation the education files and training plans were updated and reviewed with employees to insure competency.

4. This finding was discussed at the exit conference. No further documentation was provided.

Based on review of hospital policies and documents and interviews with hospital staff, the hospital failed to:
1. Develop and enforce an abuse and neglect policy that clearly defined:
a. The steps the hospital would take to protect the patient and staff;
b. The procedure the hospital would follow to investigate the allegation.

2. Ensure all staff were appropriately trained. Seven of seven personnel training files reviewed did not demonstrate staff competency to prevent, identify, report and protect patients from abuse, harassment and neglect.

Findings:

1. The surveyors requested to review the abuse policy. Two policies were provided. The hospital's policy, Patient Abuse or Neglect, #200.3 with a revision date of 06/22/2011, stipulates that all staff are "expected to report facts they suspect to be possible abuse, mistreatment, neglect and/or exploitation of a patient." The policy, "Qualification, Competencies and Privileges Progressive Discipline", #900.18 with a revision date of 12/21/07, only describes what would occur it the allegation was substantiated.
a. The policies do not instruct staff what steps are needed to immediately protect the patient and the staff, against whom the allegation was made and to continue while the allegation is investigated.
b. The policy does not stipulate the hospital will be responsible for investigation, in addition to notifying authorities, or how this will occur.

2. Education files reviewed did not show staff the hospital ensured staff were trained and prepared to recognize, report and take steps to protect patients from abuse.
a. For two of seven staff files (Staff C and D) reviewed, the "education fair" for 2012, that contained abuse and neglect section, the competencies were not scored.
b. For the remaining five files (Staff E, F, G, H and I), the file did not show remediation had occurred.

3. Staff C related a situation of reported alleged abuse. She stated she reassigned the staff so that he was not taking care of the patient. The staff was not removed from patient care responsibilities while the allegation was investigated.

4. Six of six grievances reviewed did not have documentation of investigation, steps taken on behalf of the patient, written grievance decision to the complainant, and review of all required elements.
a. According to a grievance filed by Patient #10, Staff G told the patient to "get the hell in there or I will kick your ass". The documentation also included an allegation of a staff member hitting Pt#10 on the side and shoulder and taking the patient to time out. Patient #10 also wrote in the grievance another patient witnessed the interaction. The grievance documentation included a statement from the other patient corroborating Patient #10's grievance and included a statement Staff G whispered to the patient later "patient #10 is a bitch". The grievance documentation did not include investigation of all allegations. There was no documentation of interviews of the other patient. There was no documentation all parties involved or all witnesses were interviewed.

Grievance documentation indicated the staff member involved was counseled regarding multiple complaints of non professional communication, a grievance filed regarding threatening comments, multiple complaints from other patients stating the staff member was mean and rude. The counseling form included the unit manager signature and the employee signature. A space was included for the Human Resources Department to sign off. This space was blank. There was no documentation all of the allegations were reviewed with human resources. There was no documentation the facility removed the staff member from patient care during the investigation. There was no documentation the patient had received written documentation regarding the grievance decision.

b. Pt #13 wrote a grievance indicating Staff H pushed him into the shower. Pt#13 further indicated there was a staff member who witnessed the incident and saw Pt#13 was soaking wet in his clothes. Pt #13 stated he was "afraid to shower". The grievance documentation included "referred to DHS hotline". There was no documentation of the investigation or if all parties present during the incident were interviewed. There was no documentation the facility removed the staff member from patient care during the investigation. There was no documentation the patient had received written documentation regarding the grievance decision.

c. Pt #12 and Pt# 15 wrote grievances indicating the same staff member called them names like "punk and wimp". Pt#12 indicated the same staff member allowed patients to pick on him and another patient to "hit me really hard".
There was no documentation of the investigation or if all parties present during the incident were interviewed. There was no documentation the facility removed the staff member from patient care during the investigation. There was no documentation the patient had received written documentation regarding the grievance decision. Documentation on one of the grievances indicated the local grievance coordinator allowed the staff involved in the incident to discuss the incident with the patient and the "patient rescinded the grievance".

d. Pt#14 wrote a grievance indicating Staff I "raised my arm up and almost broke my ay arm...Staff I should not be so forceful. The patient also indicated the staff members called him names. There was no documentation of the investigation or if all parties present during the incident were interviewed. There was no documentation the facility removed the staff member from patient care during the investigation.

Based on review of hospital policies and procedures, documents and personnel files and interviews with staff, the hospital failed to ensure all staff were able to demonstrate competency before being on the unit.

Findings:

1. The surveyors were told the facility approved method for handling aggressive patients was "Handle with Care."

2. State Licensure Chapter 667 Hospital Standards, Subchapter 33, 310:667-33-2(b)(2), stipulates, "All staff providing active treatment or monitoring patients shall be trained in facility methods approved to physically hold or restrain patients before patient care responsibilities are assigned. These staff members shall be reoriented regarding these policies annually or when policies are revised."

3. Staff C was assigned to the Children's Unit before completing the hospital's "Handle with Care" training course. This finding was reviewed and confirmed with Staff B on the evening of 12/18/2012.

4. Four of four staff (D,G, H, and I) named in patient grievances where restraint or hold was applied did not have complete training in their files. Some of the documents were not graded. Some of the documents included failing scores without any documentation of remediation. There was no documentation staff were educated, trained, and oriented in techniques to prevent escalation of symptoms and reduce the need for restraint.

5. Restraint training hours did not match the hours required by the hospital policy. Some of the staff members did not have dates of training documented.

6. These findings were reviewed with administration at the time of the exit conference. No further documentation was provided.

Based on review of hospital documents and personnel files and interviews with staff, the hospital failed to ensure patient care staff had training and demonstrated knowledge on techniques to identify behavior and factors that might trigger the use of restraint or seclusion and to use nonphysical intervention skills.

Findings:

1. Hospital staff told the surveyors that "Handle with Care" was the hospital's approved method to handle aggressive patients. The manual contained methods for recognizing situations that could escalate to require the use of restraints and/or seclusion; use of nonphysical interventions; specified physical holds and transport; and methods to escape holds.

2. Review of seven of seven personnel files (Staff C, D, E, F, G, H, and I) did not demonstrate competency except to demonstrate physical holds and methods to escape holds. Tests for competency were either not scored or showed not retraining to ensure competency.

3. Four of four staff (D,G, H, and I) named in patient grievances where restraint or hold was applied did not have complete training in their files. Some of the documents were not graded. Some of the documents included failing scores without any documentation of remediation. There was no documentation staff were educated, trained, and oriented in techniques to prevent escalation of symptoms and reduce the need for restraint.

4. The above findings were reviewed with administration at the time of the exit conference. No further documentation was provided.

Based on review of hospital documents personnel files, and medical records and interviews with hospital staff, the hospital failed to ensure staff are adequately trained, oriented and have demonstrated skills competency for their assigned care areas and are competent to provide care to meet the needs of the patients.

Findings:

1. The surveyors were told the facility approved method for handling aggressive patients was "Handle with Care."

2. State Licensure Chapter 667 Hospital Standards, Subchapter 33, 310:667-33-2(b)(2), stipulates, "All staff providing active treatment or monitoring patients shall be trained in facility methods approved to physically hold or restrain patients before patient care responsibilities are assigned. These staff members shall be reoriented regarding these policies annually or when policies are revised."

3. Staff C was assigned to the Children's Unit before completing the hospital's "Handle with Care" training course. This finding was reviewed and confirmed with Staff B on the evening of 12/18/2012.

4. Four of four staff (D,G, H, and I) named in patient grievances where restraint or hold was applied did not have complete training in their files. Some of the documents were not graded. Some of the documents included failing scores without any documentation of remediation. There was no documentation staff were educated, trained, and oriented in techniques to prevent escalation of symptoms and reduce the need for restraint.

5. Restraint training hours did not match the hours required by the hospital policy. Some of the staff members did not have dates of training documented.

6. These findings were reviewed with administration at the time of the exit conference. No further documentation was provided.



1. The hospital is an acute care hospital that cares for patients of all ages in the emergency, surgical and inpatient settings.

2. Review of eight of eight nursing staff (Staff F, G, H, I, N, Q, R, and S) and two of two paramedics (Staff O and P), who provide nursing care and whose personnel files were reviewed, did not have current age-specific competencies. The most current training/competency verification was 2009.

3. Staff I, who had recently been promoted to medical/surgical manager had not been provided orientation and training for this position.

4. Staff L, who also worked as the pharmacy tech/drug room staff, did not have orientation and training to the drug room by the pharmacist and the last medication competency was 04/2009.

5. Surgical staff F, G and H did not have orientation, training and competencies for their duties in the surgical and endoscopy areas.