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Based on record reviews, policy reviews, observations, and interviews, the hospital failed to protect and promote patient rights for notification of grievance outcome for one of ten sampled patients (Patient 4), care in a safe setting for the three psychiatric inpatients (Patient 1, 6 and 7), and being free from restraints for one of seven sampled patients (Patient 5).

The cumulative effects of this deficient practice violate patients' rights to be notified of grievance outcomes, care in a safe setting, and be free from restraints potentially place patients at risk for harm and unresolved grievances.

Findings Include:

1. The hospital failed to provide one of ten sampled patients (Patient 4), with written notice of its grievance decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. (Refer to A-0123)

2. The hospital failed to ensure patients received care in a safe setting by failing to ensure 15-minute checks were completed in accordance with hospital policy for one of three psychiatric inpatients (Patient 7), failed to ensure hand sanitizer was not accessible to the three psychiatric inpatients (Patient 1, 6 and 7) and failed to ensure plastic pillow coverings were in good condition without tears in two observed patient rooms (Room 402 and 408). (Refer to A-0144)

3. The hospital failed to identify that a physical hold employed when giving an intramuscular injection (IM) to a patient who refused an oral medication was a restraint for one of seven sampled patients (Patient 5). (Refer to A-0159)

Based on policy review, medical record review, interview and review of a hospital grievance/complaint document, the hospital failed to provide one of ten sampled patients (Patient 4), with written notice of its grievance decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This failure has the potential to prevent any future patient or caregiver who submitted a grievance to receive notification of the outcome of the grievance investigation.

Findings Include:

Review of the policy titled, "Patient Complaint and Grievance Process," revised 10/02/20, showed, " ... patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, or issues related to the hospital's compliance with the CMS [Centers for Medicare and Medicaid Services] Hospital Conditions of Participation (CoP) or accrediting organization standards, or a Medicare beneficiary billing complaint related to rights and limitations. . . After thorough research has been conducted, the Director of Social Services or designee will work in tandem with staff identified as key individuals critical to problem resolution for the specific identified concern. . . The patient or patient's representative will be provided with written notice of: The name of the hospital contact person. The steps taken to investigate and resolve the grievance. The results of the grievance process. The date of completion. . ."

Review of a "Patient & Family Grievance Form," provided by Staff A, Administrator, showed Patient 4 ...reported that a male patient repeatedly came into her room throughout the nighttime over the weekend. She reported concerns about a female patient sitting at the table and the male staff named was very rude to her. . . Also, she reported that a female patient had blood all over her hands the whole weekend and they didn't wash her hands. She reported that on Saturday night, a nurse came to her room and told her "Don't come out here, it's pretty violent." The form showed that, "She said that the nurse scared her that there are violent males and that it was a violent night. She reported that at 4:21 AM, the male patient came into her room and when she went to the Nurse's station, all three female Nurses were sleeping .... ."

Review of the "Plan for resolution," documented on the above "Patient & Family Grievance Form," showed that the Chief Executive Officer (CEO) spoke with former Patient 4, an investigation was opened, and a report was sent to KDADS [Kansas Department of Aging and Disability Services]. Review of the document also showed that video from a security camera was reviewed, a staff person was suspended, and nursing staff attended education completed by Staff D, Assistant Director of Nursing (ADON).

There was no other documented information of the outcome of the investigation.

There was no documented evidence that a written notice was sent to Patient 4 upon completion of the investigation that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, or the date of completion.

During an interview on 12/29/20 at 1:35 PM with Staff A, Administrator and Staff D, ADON present, Staff A, stated that he viewed the video recording of the night stated in the grievance. He stated staff were supervising the station but were not paying attention to the patients. Staff A further stated that Staff E, Registered Nurse (RN) had her head down but "was not sleeping." When asked how he knew Staff E, RN, wasn't sleeping, Staff A, Administrator, stated "It wasn't a long enough time period of having her head down and she was seen moving." He stated he did see on the video that Patient 4 walked out of her room and looked into the station when one nurse had her head down. He stated the other nurse in the nursing station didn't have her head down. He stated Patient 4 then went back into her room. Staff A, Administrator confirmed that the written documentation of the investigation did not include the outcome of the investigation. He stated that a written notice of the decision had not been sent to Patient 4.

Based on observation, policy review, document review, and interviews, the hospital failed to ensure patients received care in a safe setting by failing to ensure 15-minute checks were completed in accordance with hospital policy for one of three psychiatric inpatients (Patient 7), failed to ensure hand sanitizer was not accessible to the three psychiatric inpatients (Patient 1, 6 and 7) and failed to ensure plastic pillow coverings were in good condition without tears in two observed patient rooms (Room 402 and 408). These failures have the potential to place the health and safety of the three inpatients (Patient 1, Patient 6, Patient 7) and any future patient admitted to the hospital at risk for injury or harm.


Findings Include:


Review of the hospital policy titled "Assessment for Suicidal Ideation/Precautions," originated 03/26/18 and revised 03/06/19, showed ". . . All patients admitted to St. Anthony's Hospital will be placed on Low precautions with monitoring by Nursing staff every 15 minutes unless indicated or patient needs a higher level of observation. . ."

1. Review of Patient 7's "Initial Psychiatric Evaluation," located in the medical record under "H&P," [history and physical], showed she was admitted on 12/24/20 with diagnoses of major depressive disorder, anxiety, and frontotemporal dementia (memory loss). The evaluation also showed Patient 7 had no "suicide risk/thoughts."

Review of Patient 7's physician orders, showed no physician order for an increased level of observation (therefore she was to be observed every 15 minutes in accordance with hospital policy).

Review of Patient 7's "Behavioral Mapping," the form used by nursing staff to document patients' location, behavior, and staff initials at the frequency ordered or at a minimum of every 15 minutes, showed Staff F, Registered Nurse (RN), documented Patient 7 was in her room "sleeping/resting" from 12:00 AM through 6:45 AM on 12/29/20.

Review of a hospital-provided video recording dated 12/29/20 at 8:45 AM, in the presence of Staff A, Administrator, of Patient 7's room, Room 402, on 12/29/20 from 12:45 AM through 6:34 AM, showed the following observations made:

12:45 AM Staff F, RN, and Staff G, RN, walked in Patient 7's room;
1:17 AM Staff F, RN walked into Patient 7's room (32 minutes since the previous observation);
2:43 AM Staff F, RN, walked into Patient 7's room (1 hour 26 minutes since the previous observation);
4:00 AM Staff F, RN walked into Patient 7's room (1 hour 17 minutes since the previous observation);
4:53 AM Staff G, RN, walked into Patient 7's room (53 minutes since the previous observation);
6:34 AM Staff F, RN, and Staff G, RN, entered Patient 7's room (1 hour 41 minutes since the previous observation).

The video recording showed no other staff member entered Patient 7's room during this time.

During an interview on 12/29/20 at 8:51 AM, Staff A, Administrator stated the video recording showed Patient 7 was observed by the nursing staff as written above. He stated he "can only say if staff went in it didn't trigger the camera." He stated the video recording is "motion activated" (meaning it records when motion is detected).

During an interview on 12/29/20 at 9:45 AM, Staff C, Psychiatrist, stated when the RN does his/her preliminary patient admission assessment, the RN would call her if the assessment indicated a need for a higher level of care/observation. She stated if a higher level of observation is not needed, the patient would be observed every 15 minutes in accordance with the hospital's policy. She stated the reason for every 15 minutes observation is to assure the patient doesn't harm themselves or others. She stated Patient 7 should have been observed every 15 minutes.


Review of the hospital policy titled "Patient Rights and Responsibilities," originated 03/26/18 and revised 10/28/20, showed patients had the right to ". . . Considerate, dignified and respectful care, provided in a safe environment. . ."

2. Observation during the tour of the psychiatric unit on 12/28/20 at 9:40 AM, with Staff A, Administrator, and Staff B, Director of Nursing (DON), present, showed hand sanitizer was mounted on the wall in various locations of the psychiatric unit that were accessible to patients.

Review of the insert of the "ECOLAB Foam Hand Sanitizer," presented by Staff A, Administrator, showed the active ingredient was Ethyl alcohol 62%. Review of the "Warnings" on the label showed "For external use only. . . Flammable, keep away from fire or flame, heat, sparks and sources of static discharge Do not use in eyes . . . If swallowed, get medical help or contact a Poison Control Center right away."

Review of the "Initial Psychiatric Evaluation" or the "Psychiatric Progress Note" for Patient 1, Patient 6, and Patient 7, all patients currently on the psychiatric unit at the time of the tour, showed each was evaluated by the psychiatrist as having poor judgement (inability to make appropriate decisions) and poor insight (deficit of the capacity of judgment).

During an interview on 12/28/20 at 10:20 AM, Staff A, Administrator, stated that the hand sanitizer that is mounted on the walls in the common area of the psychiatric unit was "ECOLAB Foam Hand Sanitizer." He stated it is accessible to all psychiatric patients on the unit.


3. Observation during the tour of the psychiatric unit on 12/28/20 at 9:40 AM, showed a pillow on the bed of Patient 7 in Room 402 had a tear in the plastic covering with the foam protruding from the tear. Observation showed a pillow on the bed in Room 408 (no patient was currently admitted to the room) had a tear in the plastic covering with the foam protruding out the covering. The presence of tears in the pillow covering presented a risk of suffocation and potential injury to psychiatric patients.

During an interview on 12/28/20 at 9:40 AM, Staff A, Administrator, stated the torn pillow coverings presented the potential for the pillow covering to be a risk of suffocation, and injury for psychiatric patients.

Based on record review, policy review, and interviews, the hospital failed to identify that a physical hold employed when giving an intramuscular injection (IM) to a patient who refused an oral medication was a restraint for one of seven sampled patients (Patient 5). This failure had the potential to place the welfare and safety of the three current inpatients and any future patient admitted to the hospital at risk for serious injury or serious harm when a physical hold restraint is used to administer a medication.

Findings Include:

Review of the policy titled "Prescribing/Ordering - General Practices," revised 11/01/20, showed " ... PRN: [as needed] . . . Orders will be written to administer oral medication first (if available), if patient refuses oral medication then follow up with IM form (only if written order given by physician or midlevel provider) . . ."

Review of the policy titled "Patient Right and Responsibilities," revised 10/28/20, showed a patient has the right to " ...receive information about any proposed treatment or procedure he/she may need to participate in the development of the plan of care, give informed consent or to refuse the course of treatment ... remain free from restraint and seclusion of any form that are not medically necessary ..."

Review of the policy titled "Restraint or Seclusion Use," revised 10/21/20, showed " ... CMS [Centers for Medicare and Medicaid Services] defines a restraint as: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of patient to move his or her arms, legs, body, head freely. . . Examples of common practices that can also be considered restraints: . . . The application of force to physically hold a patient to administer a medication against the patient's wishes is considered a restraint. . . Before restraints or seclusion are used, methods to de-escalate the patient will be deployed. Staff are directed to use various techniques and interventions to make every attempt to avoid the use of restraints or seclusion ...."

Review of Kansas Statutes Annotated (K.S.A) 59-2976(b) showed, ... "No medication or other treatment may be administered to any voluntary patient without the patient's consent, or the consent of such patient's legal guardian or of such patient's parent if the patient is a minor."

Review of Patient 5's medical record showed a 66-year-old female, voluntarily admitted on 07/31/20 and discharged on 09/06/20 with diagnoses of Major Neurocognitive Disorder with Behavioral Disturbance.

Review of the "Initial Psychiatric Evaluation" dated 08/01/20, showed Patient 5 was originally brought to the emergency department at a different hospital by her husband because " ...he was worried because she was shocked by her defibrillator multiple times. Upon arrival, the AICD (automated implantable cardioverter) defibrillator fired 22 times in 48 hours. While at [hospital name], the patient had been aggressive, combative, and almost left AMA [against medical advice]. She said nothing was wrong and she didn't want to stay in the hospital. Due to this, she was sedated and restrained ..." She was later transferred to this facility.

Review of the Medication Administration Record (MAR) showed Patient 5 received Geodon (an antipsychotic medication that changes effects of chemicals in the brain), IM on 08/19/20 at 9:59 AM, on 08/26/20 at 4:19 PM, on 08/27/20 at 12:19 PM, and on 08/28/20 at 9:03 AM.

Review of a "Nursing Shift Assessment" note, dated 08/16/20 at 9:38 AM, showed " ...refused to take her oral medicine. She was paranoid with staff. She was thinking the nurse was adding poison in their food. She was aggressive with staff. She was verbally aggressive, and she was telling other patient do not take the medicine its poison. This [sic] called Dr [Name] and got order for [unreadable] Geodon 10 mg (milligrams) x 1 only. She had shot."

There is no documentation to show Patient 5 was agreeable to the injection, cooperated with procedure, or what other interventions were attempted to de-escalate situation.

Review of a "Nursing Shift Assessment" note, dated 08/19/20 at 9:24 AM, showed " ...took meds with coffee, some meds at bottom of coffee cup dissolved. Pt (patient) paranoid of staff and telling fellow pts (patients) at bkfst (breakfast) that the food is poisoned, and meds are not the right Doctor that ordered them although did take them [sic]. Once bkfst (breakfast) was refused she began to touch and strike out plus cursing at staff and fellow pts (patients). Cont (continue) to knock on bubble window for staff and paranoid ...Pt (patient) received an order 1 x Geodon 10 mg IM given in left buttock ..."

There is no documentation to show Patient 5 was agreeable to the injection, cooperated with procedure, or what other interventions were attempted to de-escalate situation.

Review of Patient 5's "Physician Order Form" dated 08/28/20 at 10:47 AM, showed there was a medication clarification order which read "D/C (discontinue) scheduled Geodon oral add risperidone (an antipsychotic medication that changes the effects of chemicals in the brain) 1 mg TID (three times a day) PO (by mouth), if refuses oral risperidone then give I/M (Intramuscular injection) Geodon 10 mg IM, TID, scheduled and PRN (as needed)."

Review of a "Nursing Shift Assessment" note dated 09/01/20 at 10:45 AM, of a late entry for 08/28/20 at 9:00 AM, by Staff B, Director of Nursing (DON), showed ". . . she was shouting profanities and swinging at the nurses. . . nurse stepped behind patient and placed arms around her from the back. Her lower arms were still mobile, and patient was yelling. The nurse attempting to give the ordered IM injection was able to give it in her left upper arm and apply a band aid. The patient's legs were briefly held bilaterally to avoid patient movement during injection. Once injection was safely administered, pt (patient) was released in a manner so as not to let her fall. . ."

There is no documentation of what other interventions were tried to de-escalate the situation, if the medication was effective, or the physical condition of Patient 5 after being held in order to give the IM injection. Also, there was no restraint documentation or documentation that nursing staff notified the physician of the use of a restraint.

During an interview on 12/29/20 at 9:45 AM, Staff C, Psychiatrist, stated when she gives an order to give an IM injection of Zyprexa (an antipsychotic medication that changes the effects of chemicals in the brain) or Geodon if the patient refuses it orally. Zyprexa is for agitation, and if the patient refuses oral medication and escalates more, then IM injection is given. When asked how this is not a forced medication, Staff C, Psychiatrist, stated "If they refuse oral and are escalating, that's when IM is given. It's a standard of care by psychiatric hospitals. They [patients] come here to be stabilized." She stated, "it's not a standard medication, it's only given in instances when they come in acutely agitated or actively psychotic." When asked about physical holding being a restraint, she stated "I don't see staff holding patients down." She stated her definition of hold is "holding all four limbs and holding down with complete restriction." She stated she "views it as a standard practice of care by physicians."

During an interview on 12/29/20 at 1:45 PM, Staff B, DON, stated, after reviewing her documentation in Patient 5's nurses' notes of the late entry for 08/28/20, she would consider holding Patient 5 for the IM injection to be a restraint.

Based on policy review, record review, document review, observations, and interviews, the hospital failed to ensure methods were developed and implemented for preventing and controlling the transmission of infections, specifically COVID-19, within the hospital and between the hospital and other institutions and settings. This deficient practice has the potential to spread infection between patients and staff.

Findings Include:

1. Review of a hospital policy titled "Influx of Potentially Infectious Patient - Addendum: COVID-19," revised 11/09/20, showed " . . . Hand hygiene . . . When indicated, even if gloves are used, in the following situations: Use hand-sanitizer when available. When hands are visibly soiled . . . if there are shortages of approved hand sanitizer and alcohol-based sanitizer is not available, hand hygiene using soap and water is used instead Before and after contact with patients After contact with blood, body fluids, or visibly contaminated surfaces or other objects and surfaces if the care environment. After removing personal protective equipment . . . and Before performing a procedure such as an aseptic task. . ."

Observation on the psychiatric unit on 12/29/20 from 6:50 AM to 8:00 AM, showed at 7:08 AM Staff E, Registered Nurse (RN), entered Patient 6's room to take her vital signs (VS). Staff E, RN, took her pen with contaminated gloved hands, after having held Patient 6's arm to take her blood pressure, to document Patient 6's blood pressure and temperature. There was no trash container in the room for Staff E, RN, to discard the thermometer probe (held in her hand until she exited the room to discard it). She then touched her mask with her contaminated gloved hand. Staff E, RN, walked to the nursing station and opened the door to the station with her contaminated gloved hands. When inside the nursing station, Staff E, discarded the thermometer probe in the trash can, removed her gloves, and washed her hands. Observation showed Staff E, RN, did not remove her gloves and perform hand hygiene after patient contact and before moving to another task.

Observation in the nursing station on 12/29/20 at 7:15 AM, showed Staff E, RN, removed her gloves after cleaning patient care equipment and documented on paperwork without performing hand hygiene.

Observation on 12/29/20 at 7:20 AM, in the nursing station showed Staff E, RN, gloved, picked up her pen (had not been disinfected after touching it with contaminated gloves after assessing Patient 6's VS), went to Patient 7's room to assess her VS, and wrote the VS on the paper with contaminated gloved hands after touching Patient 7's arm. She placed the contaminated blood pressure cuff in the basket on top of the other blood pressure cuff in the basket. Staff E, RN, touched the thermometer case with contaminated gloved hands to place the probe into the thermometer case attached to the rolling blood pressure monitor. She then walked to the nursing station and opened the door to the station with contaminated gloved hands. When inside the nursing station, Staff E, RN, removed her gloves and washed her hands. Continuous observation showed Staff H, Licensed Practical Nurse (LPN), touched the contaminated rolling blood pressure monitor with ungloved hands to move it aside before it had been disinfected.

Observation in the nursing station on 12/29/20 at 7:26 AM showed Staff E, RN, removed her gloves after cleaning patient care equipment and did not perform hand hygiene before documenting in the medical record. She then redonned gloves without performing hand hygiene.

During an interview in the common area of the psychiatric unit on 12/29/20 at 7:48 AM, Staff E, RN, stated that the observations made by the surveyor were breaches in infection control. She stated she was supposed to perform hand hygiene between each patient. She stated she's aware she's supposed to perform hand hygiene when moving from one task to another. She stated she "can't say why I didn't do it."

2. Review of a hospital policy titled "Influx of Potentially Infectious Patient - Addendum: COVID-19," revised 11/09/20, showed ". . . Re-usable medical equipment (i.e. pulse oximeter, blood pressure cuffs, thermometers, blood glucose meters and test strip canisters) must be low-level cleaned after each use. . ."

Observation in the nursing station on 12/29/20 at 7:15 AM, showed Staff E, RN, donned gloves and used a "Sani Cloth Germicidal Disposable Wipe" (used to clean and disinfect surfaces and patient care equipment) to wipe the blood pressure cuff and oximeter probe (probe placed on a patient's finger to test the oxygen level of the blood). She then placed the disinfected blood pressure cuff in the basket attached to the rolling blood pressure monitor on top of another blood pressure cuff that had not been disinfected. She then removed her gloves and documented on paperwork without performing hand hygiene.

Observation in the nursing station on 12/29/20 at 7:26 AM, showed Staff E, RN, donned gloves, wiped the blood cuff with a "Sani Cloth Germicidal Disposable Wipe" and placed the blood pressure cuff back in the basket on top of the blood pressure cuff that had not been disinfected. She then removed her gloves and did not perform hand hygiene.

During an interview in the common area of the psychiatric unit on 12/29/20 at 7:48 AM, Staff E, RN, stated the observations made by the surveyor of Staff E, RN, cleaning patient care equipment were breaches in infection control. She stated she was supposed to perform hand hygiene when moving from one task to another. She stated she "can't say why I didn't do it."


3. Review of a hospital policy titled "Influx of Potentially Infectious Patient - Addendum: COVID-19," originated 10/31/18 and revised 11/09/20, showed ". . . Patients seeking admission . . . from a facility with one or more suspected or confirmed cases of COVID-19 must complete two (2) negative COVID-19 tests prior to admission at least 24 hours apart. . ." Review showed the Infection Preventionist responsibilities included implementing "an illness surveillance plan for identifying, tracking, monitoring, and/or reporting fever, respiratory illness, and other signs/symptoms of COVID-19. The surveillance plan describes methods for early detection, management of potentially infectious/symptomatic patients, and implementation of appropriate transmission-based precautions/PPE. . ."

Review of Patient 1's medical record showed he was admitted on 12/22/20 with diagnoses of anxiety, delusional disorder, major depressive disorder, schizoaffective disorder, frontotemporal dementia, and Alzheimer's.

Review of Patient 1's "Nursing Shift Assessment" of 12/26/20 and 12/27/20 showed no documented evidence that he was screened by the nursing staff for signs and symptoms of COVID-19.

Review of Patient 2's medical record showed he was admitted on 12/02/20 with diagnoses of depression, anxiety, hallucinations, harm to others, and dementia and was discharged on 12/11/20. Review of his "Nursing Shift Assessment" for 12/10/20 and 12/11/20 showed no documented evidence that he was screened for signs and symptoms of COVID-19.

Review of the "Nursing Shift Assessment" for 12/11/20 at 8:00 AM showed "He tested for COVID yesterday. The result came back + [positive]." There was no documentation in the record related to signs and symptoms present that warranted COVID-19 testing or the reason why Patient 2 was tested.


Review of Patient 3's medical record showed he was admitted on 12/09/20, with diagnoses of exit seeking, major depressive disorder, and insomnia and discharged on 12/18/20.

Review of Patient 3's "Nursing Shift Assessment" for 12/10/20 through 12/18/20, showed no documented evidence that he was screened for signs and symptoms of COVID-19.

Review of the "Nursing Shift Assessment" for 12/17/20 at 6:00 PM, showed Patient 3's son was notified Patient 3 tested positive for COVID-19, and he was placed on isolation precautions. There was no documentation in Patient 3's medical record of signs and symptoms of COVID-19 or the reason he was tested for COVID-19.

During an interview on 12/28/20 at 4:30 PM, Staff J, RN, stated Staff B, Director of Nursing (DON), screens the patients for COVID. She stated she [Staff B, DON] asks patients if they have signs and symptoms of COVID-19. Staff J, RN, stated she doesn't think they have a certain paper to document on, but if patients have signs and symptoms of COVID-19, they document that in the nurses' notes. She stated she doesn't ask patients questions about signs and symptoms, but she observes for signs and symptoms. She stated a lot of patients can't answer questions due to dementia.

During an interview on 12/29/20 at 7:00 AM, Staff F, RN, when asked if she screened patients for COVID-19, she stated she took patients' temperature and watched for complaints of stomach ache, chills, fatigue, and refusing to eat. She stated she doesn't document doing a screening, but she would document if there was an abnormality.

During an interview on 12/29/20 at 1:45 PM, Staff B, DON, stated that all patients are tested for COVID-19 when being discharged, because the facility they're going to requires a COVID test to be done. She stated that is why a COVID-19 test is done. She stated she would like to see nurses document signs and symptoms of COVID-19 that patients exhibit, so she can track the beginning.

During an interview on 12/29/20 at 4:16 PM, Staff B, DON, stated that they have no system in place for tracking, monitoring, and identifying COVID-19 signs and symptoms of patients admitted to the psychiatric unit.