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Based on policy and procedure review, medical record review, and staff interview hospital staff failed to identify an allegation of abuse as a grievance and follow the investigation process for 1 of 1 patients alleging abuse (Patient #1).

The findings include:

Review of policy titled "Patient and Family Complaint/Grievance Reporting", origination date 10/25/2017, revealed "...DEFINITIONS: (as defined by Centers for Medicare & Medicaid Services - "CMS"): 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....1. When a patient or the patient's representative requests their complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is to be treated as a grievance....Responding to the patient/family: All patient grievances must be responded to in writing as soon as possible. At a minimum, a written response will be provided within 7 days from the first date that the Grievance was received by anyone in the organization which includes the required elements set forth by CMS....Most grievances can be resolved and the resolution communicated in writing within the 7--day timeframe when that is not possible, the patient/patient's legal representative will be notified. 3. The written response must include the substance of the grievance, the steps taken to investigate the grievance, the results of the investigation, the date of completion and the hospital contact person. The response must include the respondent's name and telephone number as well as the name and phone number of the responding authority. ..."

Review of policy titled "Identification and Management of Suspected Abuse Victims", revision date 06/16/2015, revealed PROCEDURE - [Hospital Name] INPATIENT: ....Additionally, the Care Management Staff will focus on cases of suspected patient-to-patient and staff-to-patient abuse with the health care team and with Administration as appropriate. .." Review did not reveal any other information specific to investigation of alleged staff-to-patient abuse/neglect.

Emergency Room (ER) Record review for Patient #1, on 02/27-28/2018, revealed the 31-year-old (yo) arrived to the ER 01/01/2018 at 0414. Review of "ER (Emergency Room) Report" note, at 0549, revealed Patient #1 "...stated she needed to be admitted to (psychiatric unit name) because her medications are 'messed up.' ....Physical Exam ....Psychiatry: Agitated, aggressive, demanding, inappropriate, reports desire for harm of the staff. Passive claims that she wants to harm herself without plan. She does not appear to be responding to any internal stimulus Assessment/Plan ....She has been slamming doors and screaming at people in the emergency department. ..." Review of an ER Report note, service date and time 01/01/2018 at 0832, revealed "...Patient was repeatedly verbally assaultive towards myself and staff without any provocation....I've called security and behavioral health has called law enforcement. Patient is discharged with law enforcement to jail." Review of an ER Report note, on 01/01/2018 at 1105, revealed "Patient....presents to the department today via law enforcement. She was just discharged from the Emergency Department and they found that she had an IVC order and was brought back. Record review revealed Patient #1 was placed in Violent Restraints on 01/01/2018 at 1049. Review of Violent Restraint Flowsheet, dated 01/01/2018 at 1323, revealed the restraints were discontinued at 1310 and the patient was moved to a Psychiatric Evaluation Unit in the same hospital. Review of a Progress Note by a FNP (Family Nurse Practitioner) on 01/01/2018 at 1605 revealed "...Asked by nursing to evaluate this patient for c/o right wrist pain s/p (status post) restraints. Review of a Physician Progress Note, on 01/02/2018 at 0854, revealed "...(Patient #1)....wanted to talk about the abuses she feels she suffered in the ED. She states she was abused by security for 3 hours. ..." Further medical record review revealed scanned in handwritten documents. One document, dated 01/01/2018 revealed "Attn (Attention) Risk Management Office of patient experience Today at approximately 5:00pm, I asked for an ADA (Americans with Disabilities Act) accomidation (sic) for my HOH (hard of hearing). Instead of assisting me, Nurse (name) laughed at me, said my ears were fine, and he didn't feel like playing games. Then he slammed the door of the nursing station on my broken arm.... Please investigate this crime by notifying law enforcement as well as conducting an internal investigation ....Please follow up w/ (with) me in person & via email. Pt's hand is injured transcribed by Nurse ..." Record review revealed another scanned handwritten document, no date. Review revealed "Att (Attention): Patient exp (experience): Grievance...Re: (name) I am being targeted by the female named (name) she harrasses (sic) me (Name) regularly & systematically is passive and negligent....she targets and bullies me... ."

Interview with Manager #1, on 02/17/2018 at 1525, revealed Patient #1 called the facility on 01/03/2018 to complain that she thought she had been abused by security. Interview revealed these were the same concerns that were brought forward while Patient #1 was still a patient in the hospital and they had already been investigated. Because the evaluation was already completed, it was decided that was sufficient as well as in the best interest of the Patient. Interview revealed the concern was considered a complaint, not a grievance because it was investigated and closed prior to the Patient's transfer out of the facility.

Interview with RN #4, on 03/01/2018 at 1100, revealed RN #4 was filling in for another Tech. Patient #1 was very aggressive with Tech #3, so RN #4 switched units with Tech #3. Interview revealed RN #4 worked with Patient #1. RN #4 stated Patient #1 was "pretty manic" and had a lot of requests and she was working with her to calm her. Interview revealed Patient #1 claimed her arm was broken while in the ED, so RN #4 contacted a Nurse Practitioner. Further interview revealed she wrote the letter for Patient #1 stating she was abused because the Patient said her arm was injured again by another nurse. Interview revealed "I wrote word for word what she said as if she wrote it." RN #4 discussed the circumstances around the letter. The RN stated she was in the hallway when Patient #1 came and asked if she saw what another nurse just did. Interview revealed RN #4 did not see what happened, but Patient #1 said "(Name) just slammed my arm in the window." Interview revealed RN #4 looked at the arm and it did not look any different than it had before, there were no marks. RN #4 stated that at the time she did not think of this as an allegation of abuse, that Patient # 1 was "not in reality" at the time.

Interview with Administrative Staff (AS) #2, on 03/02/2018 at 1315 revealed the initial allegation of abuse occurred while Patient #1 was in the hospital and the investigation concluded no abuse took place. When Patient #1 called in after discharge, the department had already reviewed the complaint and therefore took no further action. Interview revealed it was considered a complaint by the Department of Patient Experience because it was investigated at the time and the grievance policy defined care issues which were resolved at the time as complaints. AS #2 stated the way the policy was worded may have created confusion for staff. Further interview revealed Risk Management nor the Department of Patient Experience were aware of the scanned letters in Patient #1's medical record until this week. Interview revealed no investigation had been done on the information in the letters. Interview revealed the Grievance policy related to allegations of abuse/neglect was not followed.

Based on policy review, medical record review and interview, the facility staff failed to document in the patient's medical record the date and time the death was recorded in the internal log, for 2 of 2 sampled patient records (Patients' # 2 and #3) of a death that occurred within 24 hours after the patient was removed from soft wrist restraints.

The findings included:

Review on 03/02/2018 revealed the hospital restraint policies did not include staff documenting in the medical record the time and date a death was recorded in the internal log.

1. Review on 03/02/2018 of Patient #2's medical record, revealed a 66 year old male transferred directly to the ICU (Intensive Care Unit) on 02/26/2018 at 00428, from an outside ED (Emergency Department). The patient's diagnoses included severe sepsis with shock (life-threatening organ dysfunction in response to an infection, with persisting low blood pressure), acute renal failure (an abrupt or rapid decline in kidney filtration function), pericardial effusion (fluid around the heart), cardiomyopathy (diseases of the heart muscle), volume depletion (a reduction of fluid outside the cells), reported hematemesis (vomiting blood), and severe metabolic acidosis (when a problem in your cells throws off the chemical balance in your blood, making it more acidic). The patient was intubated (a tube inserted into the trachea for ventilation) at 1127 for "acute respiratory failure and airway protection." Review revealed a physician's orders on 02/26/2018 at 1108 for non-violent limb restraints due to "compromised safety and well being and interference with medical interventions." Nursing documentation by the patient's RN at 1130 revealed bilateral wrist restraints. "Pt [patient] confused and resisting nursing and respiratory interventions, interfering with care." Re-assessment of the bilateral wrist restraints was documented at 1200 and they were discontinued at 1330. Review revealed a CODE BLUE (a hospital code used to indicate a patient requiring immediate resuscitation), was started at 1328, and the patient was pronounced dead on 02/26/2018 at 1400. Review revealed the date and time the death was recorded in the internal log, was not documented in the patient's medical record.

Interview with Administrative Staff #2, revealed staff document in the medical record the date and time reportable deaths are reported, but the hospital did not have a policy or system in place for staff to document the date and time the death was recorded in the internal death log. Interview revealed, going forward, they will expand their process to have nursing staff document the date and time the death information was placed on the internal log, and Risk Management (RM) "will track the policy to match the expanded process."

2. Review on 03/02/2018 of Patient #3's medical record, revealed a 59 year old male found unresponsive by a family member, arrived to the hospital ED via ambulance on 12/15/2017 at 1012. The patient was found to have a subacute right occipital and right parietal infarct (a stroke - when blood supply to the brain is blocked) and hypertensive crises (severe increase in blood pressure that can lead to a stroke). Review revealed a physician's order written on 12/15/2017 at 1830 for non-violent limb restraints due to "compromised safety and well being and interference with medical interventions." RN documentation on 12/15/2017 at 1830 revealed bilateral wrist restraints started due to "pt being intubated and sedated, unsure of neuro status. Concern for pt safety if he wakes up confused." Documentation revealed the bilateral soft, wrist restraints were discontinued on 12/16/2017 at 0200. Review revealed on the morning of 12/6/2017, the patient had blown, non reactive pupils (a fixed, dialted pupil, often a symptom of intracranial pressure), was sent for an MRI (Magnetic Resonance Imaging) which showed extensive infarction. The patient's family member made the decision to withdraw care, and the patient died shortly thereafter on 12/16/2017 at 1531. Review revealed the date and time the death was recorded in the internal log, was not documented in the patient's medical record.

Interview with Administrative Staff #2 on 03/02/2018, revealed staff document in the medical record the date and time reportable deaths are reported, but the hospital did not have a policy or system in place for staff to document the date and time the death was recorded in the internal death log. Interview revealed, going forward, they will expand their process to have nursing staff document the date and time the death information was placed on the internal log, and RM "will track the policy to match the expanded process."

Based on review of ([Brand name of] Nursing Practice guidelines used by the facility, observation and interview, the nursing staff failed to follow appropriate infection control techniques in 1 of 2 observations of drawing up injections (RN [Registered Nurse] #2).

The findings included:

Review of the "[Brand Name of Nursing practice guidelines] procedures - Intramuscular Injection," revised August 18, 2017, revealed "... DRAWING UP MEDICATION FOR INJECTION... For single-dose or multidose vials: ... Wipe the stopper of the medication vial with an alcohol pad and allow it to dry completely. Draw up the prescribed amount of medication..."

Observation on 03/01/2018 at 0935 of RN #2 performing a medication pass for Patient #4 on the Orthopedic Unit, revealed the medication pass included administering a pneumococcal vaccine (pneumonia vaccine). Observation revealed the RN popped the top off the 0.5 ml, single dose vial of medication, inserted the needle into the rubber stopper, withdrew the medication and administered the vaccination. Observation revealed the RN failed to wipe the rubber stopper with alcohol prior to inserting the needle to withdraw the medication.

Interview on 03/01/2018 at 1000, after the observation, revealed if the vial has a "popped top" it was sterile and the RN did not wipe the rubber septum with alcohol prior to inserting the needle. Interview revealed if the vial was a multi-dose vial without the top, "it needs to be wiped [with alcohol]."

Interview on 03/02/2018 at 1145 with the Director of the Orthopedic Unit, revealed the "rubber stopper" on new vials with tops, was "considered clean, not sterile" and should be wiped with alcohol prior to inserting the needle. Interview revealed the hospital followed the Lippincott Procedures as a guideline for drawing up medication for injection. Interview revealed "We are re-educating our teams."