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Based on document review and interview, it was determined the facility failed to inform patients of their rights in advance of furnishing or discontinuing patient care for four (4) out of thirteen (13) patients sampled (Patients # 4, 8, 11, and 12).

The findings include:

1. On July 26, 2018, surveyors reviewed the electronic medical record for Patient #4 with Staff Member #6. During that review, surveyors could not find the facility's ten (10) page "CONSENT FOR SERVICES AND FINANCIAL RESPONSIBILITY" form that provides notification to patients of their rights.

2. On July 26, 2018, surveyors reviewed the electronic medical record for Patient #8 with Staff Member #6. During that review, surveyors located the facility's ten (10) page ""CONSENT FOR SERVICES AND FINANCIAL RESPONSIBILITY" form that provides notification to patients of their rights. Unfortunately, all blanks indicating receipt, or witnessing receipt of the form were blank.

3. On July 26, 2018, surveyors reviewed the electronic medical record for Patient #11 with Staff Member #7. During that review, surveyors located the facility's ten (10) page "CONSENT FOR SERVICES AND FINANCIAL RESPONSIBILITY" form that provides notification to patients of their rights. Unfortunately, the area indicating receipt of the form noted "Pt unable to sign" with no date or time provided and the area labeled "Reason Individual is Unable to Sign, i.e., Minor or Legally Incompetent" was left blank. Additionally, a signature was provided in the witness block but the time of the signature is blank.

4. On July 26, 2018, surveyors reviewed the electronic medical record for Patient #12 with Staff Member #7. During that review, surveyors located the facility's ten (10) page ""CONSENT FOR SERVICES AND FINANCIAL RESPONSIBILITY" form that provides notification to patients of their rights. The area indicating receipt of the form noted "Pt unable to sign" without a reason why the patient could not sign the form, in the area labeled "Reason Individual is Unable to Sign, i.e., Minor or Legally Incompetent."

A interview was conducted on July 26, 2018 at 9:40 a.m., with Staff Member #8 at Main Entrance Registration. For direct admissions to the facility; Staff Member #8 stated, "We are responsible here for the patient's admission packs. It included their privacy notice and consent. We have to offer them their rights. It is signed electronically." Staff Member #8 reported if a patient was admitted to the facility through the emergency department (ED), "the ED has their own registration team."

An interview was conducted on July 26, 2018 at 9:53 a.m., with Staff Member #9, a member of the ED registration team. Staff Member #9 stated, "We only work in the emergency department. Once the patient has been seen [by ED physician] we register the patient. We explain everything and they sign an electronic pad. We print everything, including their rights and consents." Staff member #9 reported if the patient cannot sign, "we look for a family member, if there is no one then the paperwork goes with the patient to the unit if they are admitted."

An interview was conducted on July 27, 2018 at 8:38 a.m., with Staff Member #6 during the medical record reviews. Staff Member #6 reported the "Consent For Services And Financial Responsibility" should be taken care of/signed during the ED admission or by the nursing staff on the unit. Staff Member #6 reported the "Consent For Services And Financial Responsibility" form was the only written proof the patient had received their privacy notice and patient rights. Staff Member #6 reported he/she did not know the process for patients that were unable to sign and did not have a family member or patient designated representative. Staff Member #6 reported he/she would provide the facility's policy for the surveyors to review.

A review of the facility's policy titled "PATIENT RIGHT AND RESPONSIBILITIES" states in part"

"All patients (or legally authorized representative of incompetent or minor patient) shall be given a notice at the time of admission, if possible, outlining certain general rights and responsibilities. The patient (or his /her representative) shall be provided with an opportunity to review the notice and ask any questions, which shall be answered in layman's terms."

Based on interviews and document reviews it was determined the facility staff failed to follow through on a voiced grievance and failed to list the patient on the facility's complaint/grievance log for one (1) of four (4) patients included in the survey sample related to complaint/grievances or adverse events. (Patient #3)

The findings included:

During the entrance conference on July 26, 2018 starting at 8:56 a.m., with Staff Members #1 - #7, there surveyors requested the facility's compliant/grievance log and adverse event log for the past year. During sample selection, two (2) patients were selected from each log. Patient #3 was selected from the adverse event log.

During the document review on July 27, 2018, with Staff Member #6 an entry read in part regarding Patient #3: "Since discharge, [he/she] has called back and expressed that [he/she] feels the hospital failed to provide a safe environment while [he/she] was here." Staff Member #6 verified the documented statement should have been considered a complaint/grievance.

Staff Member #6 and the surveyor checked the facility's "2018 Grievance Tracker" for Patient #3's name. Staff Member #6 verified Patient #3's name did not appear on the "2018 Grievance Tracker." The surveyor requested the facility's policy related to complaints and grievances.

Review of the facility's policy titled "Patient Grievance Process" listed the definition and process for complaints and grievances. The policy read in part: "B. Receiving a Concern/Grievance 1. d. Calls received from patients, or a patient's representative, wishing to voice a concern will be managed by the Department Manager or Director and/or patient advocate. Call will be classified as either grievances or complaints and handled as such. 2. Grievances will be logged on the Patient Grievance log by The Patient Advocate or the Department Manager in order to document action steps, monitor timeliness, and trend patient grievances information." The policy further provided the process of follow through with sending the patient a letter within seven (7) day regarding the resolution or the continued effort towards resolution.

The surveyor informed the facility staff during the end of the day meeting on July 27, 2018. Staff Member #1 reported the information regarding Patient #3's call to the facility expressing his/her feelings about care in an unsafe environment was missed as a grievance. Staff Member #1 reported since an investigation was in the process related to the adverse event, staff failed to log the concern as a separate event. The surveyor inquired whether Patient #3 received a letter or other follow-up regarding his/her concern/grievance. Staff Member #1 stated, "No. It was not logged. We failed to see it as a grievance." Staff Member #1 acknowledged the concern should have been handled as a grievance, with follow-up to the patient. Staff Member #1 verified the call from Patient #3 was separated from the adverse event investigation.

Based on document review and interview, it was determined the facility failed to provide care in a safe setting for one (1) out of thirteen (13) patients sampled (Patient #1).

The findings include:

On July 26, 2018 at 2:24 p.m., surveyors reviewed the electronic medical record of Patient #1 with Staff Member #7. During that review, surveyors located a nursing note dated March 27, 2018 at 10:30 a.m. entered by Staff Member #38. The note stated, "PT WALKED OUT OF THE ROOM AND LEFT THE FLOOR AND LEFT THE HOSPITAL. THE POLICE NEEDED TO PICK [redacted] UP. [redacted] WAS RETURNED TO THE HOSPITAL. RESTRAINTS WERE ORDERED. PATIENT WAS COOPERATIVE AND IS RESTING QUIETLY."

A further examination of the elopement revealed emergency department (ED) records indicated the patient arrived at the facility's ED on March 24, 2018 at 12:22 p.m. A nursing note entered by Staff Member #39 at 12:29 p.m. indicated Patient #1's aid found him/her "in a closet not responding" and the patient arrived at the ED via ambulance. Staff Member #39 further placed a note in the medical file stating, "AID SAID THAT THERE ARE 21 PILLS MISSING OUT OF [redacted] DIAZEPAM PACK." The ED physician, Staff Member #40, noted at 12:37 p.m., "Altered Mental Status, Possible Overdose" and "The patient presents with confusion, decreased responsiveness." The final ED disposition entered into the medical record at 3:29 p.m., advised Patient #1 would be hospitalized as ordered by Staff Member #41 with a preliminary diagnosis of "Acute and Chronic respiratory failure with hypercapnia."

On March 24, 2018 at 7:58 p.m., Staff Member #42 entered a nursing note indicating movement of the patient from the ED to an inpatient room. The note advised, "ALERT X 2 AND TALKED WITH A SLURRED SPEECH AND WAS IRRITABLE. [redacted] SAID THAT [redacted] WANTED [redacted] SUPPER AND THAT [redacted] KNEW [redacted] RIGHTS AND THE CONSTITUTION. KEPT REMOVING [redacted] OXYGEN AND WHEN ASKED TO PUT IT BACK ON [redacted] SAID [redacted] KNEW [redacted] RIGHTS."

A review of nursing notes from the patient's inpatient stay starting on March 24, 2018 until his/her elopement on March 27, 2018 revealed the following.

March 24, 2018 9:44 p.m. Staff Member #43 noted, "PT HAS PULLED IV OUT. PT VERY UNCOOPERATIVE AT THIS TIME. DOES NOT WANT TO BE TOUCHED BY STAFF. An additional note by Staff Member #43 at 11:15 p.m., "PT CONTINUES TO GET OOB. PT IS COMBATIVE WHEN TOUCHED, PT WALKING OUT INTO HALL... NURSE SITTING IN ROOM WITH PT. NOTIFIED DR [redacted]. ATIVAN ORDERED. WILL ADMINISTER." Another note by Staff Member #43 at 11:55 p.m., "ORDER GIVEN FOR WRIST RESTRAINTS D/T PT HIGH FALL RISK. REFUSING IV FOR REHYDRATION FLUIDS, AND REFUSING O2. WILL PLACE WRIST RESTRAINTS AND CONTINUE TO MONITOR.

The nursing notes continue in this fashion until the patient's elopement on March 27, 2018 thus no additional nursing notes will be referenced.

A review of restraint records and 1-1 Observation Check Sheets revealed the facility placed Patient #1 in restraints on March 25, 2018 at midnight. Patient #1 remained restrained until March 26, 2018 at 8:00 a.m. After removal of restraints, 1-1 observations began until the patient eloped shortly after 9:15 a.m. on March 27, 2018. The facility reapplied restrains upon Patient #1's return to the facility via police after the elopement around 9:30 a.m.

On March 24, 2018 at 1:57 p.m., the admitting physician, Staff Member #41, noted the following during a patient assessment, "Case manager consult for potential placement as per the patient's caseworker [redacted] may be a risk to [redacted, themselves] as [redacted] had been taking [redacted] meds inappropriately Consult requested with Dr. [redacted, Staff Member #26] to determine if the patient has mental capacity to refuse medial care and live on [redacted] own."

On March 25, 2018 at 5:55 p.m. during the consult requested above, Staff Member #26 noted, "The patient is not cooperative at this point (in part due to the sedation) for adequate assessment of [redacted] capacity to meaningfully consent for treatment and for appropriate placement. However, based on the patient's recent behaviors (including refusing treatment, threats towards the nursing staff, leaving against medical advice, endangering [redacted] life while threatening treatment providers), the patient lacks capacity to meaningfully consent for recommended treatment."

On March 26, 2018 at 6:21 p.m. a resident physician, Staff Member #44 noted during an assessment, "They [psychiatry] recommended discharge to psychiatric facility when medically stable."

On March 27, 2018 at 5:26 p.m., after the elopement occurred, Staff Member #44 noted during an assessment, "Patient was seen at bedside this morning after attempting to leave against medical advice. Patient walked out of the building, and was apprehended by the police. [redacted] was brought back to [redacted] room and placed in restraints. The patient appeared to be acutely psychotic, asking about needing surgery and other imaging. Patient was not aware of [redacted] situation. We feel that the patient medically is clear for discharge, but we are awaiting placement in a psychiatric facility."

On July 27, 2018 at 2:18 p.m., surveyors interviewed the patient safety attendant (PSA), Staff Member #30, who performed the 1-1 observation the morning of the elopement. Staff Member #30 advised he/she never received training on 1-1 observations and that he/she is not a nurse and cannot "put hands on" a patient. Staff Member #30 further advised he/she received no training on what to do if a patient tries to leave and has never had a person try to leave before. Staff Member #30 advised the previous PSA who conducted the 1-1 advised her/him of the patient's behavior. Staff Member #30 advised during the 1-1 Patient #1 would get-up on a regular basis and yell out of the room down the hall. Patient #1 advised Staff Member #30 of a desire to see the doctor and if the doctor did not appear then Patient #1 planned to leave the hospital. Patient #1 then began to search for his/her clothes, which Staff Member #30 did not believe the patient could find, but Patient #1 found them and put them on. Patient #1 then exited the room and walked toward the elevator. Staff Member #30 advised he/she followed the patient and notified Staff Member #38 of the patient's attempt to leave. This was the first time Staff Member #30 advised someone in the nursing staff of Patient #1's threats at elopement. Staff Member #30 advised he/she attempted to convince the patient to return to the treatment room but Patient #1 yelled about constitutional rights and entered the elevator. Staff Member #30 advised he/she rode the elevator to the ground floor with Patient #1 who then exited the front door of the hospital and began searching the area outside for cigarette butts. The patient then crossed the street outside the hospital exit doors leaving the hospital grounds, approached a local pharmacy, and then continued out of sight of Staff Member #30. Staff Member #30 advised he/she walked back into the hospital and asked a staff member at the information desk to contact security. Staff Member #30 advised he/she believes at some point security located the patient at Patient #1's nearby assisted living community and police officers returned Patient #1 to the hospital.

On July 26, 2018 at 12:56 p.m. surveyors spoke with Staff Member #26 who performed the psychiatric assessment on Patient #1 prior to his/her elopement. Staff Member #26 discussed a waiting period that existed before Patient #1 could be admitted to the behavioral health unit because the patient required medical stabilization. Staff Member #26 further advised the patient needed psychiatric services and did not possess the capacity to make informed decisions about medical treatment.

On July 27, 2018 at 1:51 p.m. surveyors spoke with the staff member who entered the original nursing note located by surveyors about the elopement. Staff Member #38 advised the patient displayed previous aggressive behavior and attempts at elopement. On one occasion the patient blocked the door preventing Staff Member #38 from exiting and threatened to "beat (him/her) up." On another occasion, the patient attempted to elope and made it to the stairwell where Staff Member #38 convinced him/her to return to the treatment room. Staff Member #38 believed the patient could make medical decisions and estimated the patient's time away from the hospital as about ten (10) minutes. Staff Member #38 did not have additional insight and advised he/she did not recall the patient being placed back in restraints upon return to the hospital by police nor did Staff Member #39 recall the issuance of a temporary detention order (TDO).

On July 26, 2018 at 3:56 p.m., during an interview with Staff Member #3 and Staff Member #21, surveyors learned the elopement did not get reported as an adverse event for later debriefing and root cause analysis. Staff Member #21 further advised elopements should be reported as an adverse event and he/she would pull the policy and procedure. Staff Member #21 did advise the police and procedure is "clear as mud."

On July 30, 2018 at 4:49 p.m. surveyors spoke with Staff Member #1 who is responsible for the facility's quality, assessment and improvement program (QAPI). Staff Member #1 advised the elopement did qualify as an event that should be reported as an adverse event and it is expected that staff members will make those entries into the electronic database. Staff Member #1 further advised he/she believed the nursing staff had so much going on the entry was overlooked.

A review of the facility's police titled, "Incident Reporting/Accident Investigation" states in part:

"An incident is any occurrence which is not consistent to the routine operation of the hospital or the routine care of a particular patient." and "Errors in medication and/or treatment or other incidents involving patient care should be reported in order to minimize untoward effects or errors, gather facts to assess cause and corrective actions, and provide statistical data."

A review of the facility's policy titled, "Sitter Policy" states in part:

"Patients in the acute medical/surgical nursing areas, who are highly confused, have a history of multiple falls, and/or have certain psychiatric conditions may necessitate direct observation to ensure they do not harm themselves... The sitter will provide a safe, caring environment. The assigned nurse remains responsible for the patient's nursing care throughout the shift. The sitter is required to be in the presence of the patient at all times until someone relieves them... A patient who is exhibiting actions that are of safety concerns to themselves or others will be assessed by the nurse as to the need for support based on the sitter algorithm."

Based on interview and document review it was determined nursing staff failed to obtain an order for non-violent medical restraints for one (1) of thirteen (13) restrained patients included in the survey sample. (Patient #8)

The findings included:

An interview was conducted on July 26, 2018 at approximately 9:09 a.m. during the entrance conference with Staff Members #1 - #7. Staff Member #1 reported the physician's orders for non-violent restraints were "written daily, not every twenty-four (24) hours." Staff Member #1 reported that a renewal order to continue non-violent restraints needed to be written some time on the date the restraints continued to be employed.

Review of Patient #8's electronic medical record (EMR) conducted on July 26, 2018 at 2:30 p.m., with Staff Member #6. Patient #8 was admitted to the facility's critical care unit (CCU) on January 19, 2018. Nursing notes document Patient #8 was placed in non-violent bilateral wrist restraints on January 19, 2018. Review of nursing documentation on January 22, 2018 read in part, "Patient is now on Venti Mask 50% 12 Liters [oxygen] ... Attempted to perform oral care/suction, Patient hit this nurse twice. Placed Patient back in bilateral wrist restraints ..." Staff Member #6 verified replacing the bilateral wrist restraints on Patient #8 constituted a new episode and would require a new order. Review of the monitoring sheets "24 Hour Restraint Record" indicated Patient #8's restraints were discontinued during the evening of January 22, 2018. A second "24 Hour Restraint Record" documented the continued utilization of bilateral wrist restraints for January 22, 2018.

Review of the restraint orders for Patient #8 provided evidence of only one order for restraints dated for January 22, 2018. Staff Member #6 agreed if the order was utilized for the continuation of the restraints for January 22, 2018 prior to the discontinuation, then an order would be needed for the second episode of restraints on January 22, 2018. Conversely, if the order dated January 22, 2018 represented the order for the re-application of restraints, the staff failed to obtain a physician's order for January 22,2018 - prior to the removal of Patient #8's restraints. Staff Member #6 reviewed additional areas of Patient #8's EMR for scanned documents, physician's notes and nursing documentation. Staff Member #6 verified Patient #8's EMR contained only one (1) physician's order for non-violent bilateral wrist restraints dated for January 22, 2018.

Staff Member #6 and the surveyor reviewed the facility's policy titled "Restraint & [and] Seclusion Management." The policy read in part, "An Episode - is a continuous use of restraint without interruptions or discontinuance of the order. If the patient has to be placed back in restraints after the order has expired or discontinued, this constitutes a new episode. Each new episode requires a new order and a Restraint Evaluation ..."

Based on document review and interview, it was determined the facility failed to track adverse patient events for one (1) out of (2) adverse events examined.

The findings include:

On July 26, 2018 at 2:24 p.m., surveyors reviewed the electronic medical record of Patient #1 with Staff Member #7. During that review, surveyors discovered a psychiatrist, Staff Member #26, determined Patient #1 lacked the capacity to make informed decisions about his/her medical care. After this determination, and while under a 1 to 1 observation with Staff Member #30, Patient #1 eloped from the hospital ultimately being returned to the facility by police with a temporary detention order (TDO) issued upon return.

On July 26, 2018 at 3:56 p.m., during an interview with Staff Member #3 and Staff Member #21, surveyors learned the elopement did not get reported as an adverse event for later debriefing and root cause analysis. Staff Member #21 further advised elopements should be reported as an adverse event and he/she would pull the policy and procedure. Staff Member #21 did advise the police and procedure is "clear as mud."

On July 30, 2018 at 4:49 p.m., surveyors spoke with Staff Member #1 who is responsible for the facility's quality assurance and performance improvement (QAPI). Staff Member #1 advised the elopement did qualify as an event that should be reported as an adverse event and it is expected that staff members will make those entries into the electronic database. Staff Member #1 further advised he/she believed the nursing staff had so much going on the entry was overlooked.

A review of the facility's police titled, "Incident Reporting/Accident Investigation" states in part:

"An incident is any occurrence which is not consistent to the routine operation of the hospital or the routine care of a particular patient." and "Errors in medication and/or treatment or other incidents involving patient care should be reported in order to minimize untoward effects or errors, gather facts to assess cause and corrective actions, and provide statistical data."

Based on interview and document review, it was determined the facility failed to maintain an emergency preparedness (EP) plan that is reviewed and updated at least annually.

The findings include:

On June 27, 2018 at 10:45 a.m., surveyors reviewed the facility's EP plan with Staff Member #28, Staff Member #32 and Staff Member #3. Surveyors found an approval date of August, 2014 and a due for review date of August, 2017 documented on the plan.

Surveyors discussed with the staff members the requirement to review and update the EP plan annually. Staff Member #28 advised a review and revision of the plan is currently in-process awaiting approval as of July 2018. Staff Member #28 further advised the facility uses a three year policy review and revision cycle as documented on the EP plan.