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Based on record reviews and interviews, the hospital failed to implement its grievance process as evidenced by failure to identify a patient's written complaint as a grievance for 1 (#2) of 2 (#1, #2) psychiatric patients complaints reviewed and 1 (R1) of 1 (R1) random patient complaint reviewed.

Findings:
Review of the Hospital Policy titled Patient Complaint/Grievance Resolution Procedure, revised 5/2012, revealed in part:
Definition: Grievance: A formal or informal written or verbal complaint that is made by a patient/significant other when a patient ' s issue cannot be resolved promptly by staff present.
Investigation of complaints/grievances will occur when the Hospital is in receipt of notification by the patient or representative of dissatisfaction with issues that have been unresolved. The notification may be in writing, by phone call, personal visit, or e-mail.
Grievances must receive a written response within a timely manner, as defined in this policy. The written notice will include steps taken, results of investigation, name of Hospital ' s contact person, and the resolution.
1. A. All grievances concerning situations that endanger the patient such as neglect or abuse will be reviewed and investigated immediately, and handled in accordance with LCMH policy and procedures and other regulatory standards.
B. All grievances are documented in writing using the Complaint/Grievance Resolution form.
3. The patient or complainant should be contacted by the Department/Director as soon as possible (24-72 hours) to discuss the problem. This signifies the beginning of the investigation process.
4. The investigation and written response to the patient must be completed within a period of seven (7) days.

Patient #2
Review of a Complaint Summary document dated 11/25/13 listed Patient #2 as the complainant. On page 2 of the document, a space to write a " check mark " if the complaint was truly a complaint or a grievance revealed "complaint" and "grievance" were both selected by Patient #2. Review of the complaint statement revealed: nurse no listening and yelling at pt. (patient). Pt. is in pain and sick, throwing up, itching and headaches. Pt. can ' t get anyone to believe her that she is sick. Review of the investigation revealed: nurse manager on unit witnessed pt. complaining to nurse about multiple symptoms, nurse offered medications, patient turned to nurse manager and said " no one is helping me " . Pt. was informed there was no itching meds ordered.
Review of Actions taken: will continue to monitor pt. on unit
Resolution: Pt. was offered medication and declined, pt. exhibiting childlike behaviors, speaking like a child.

Review of a Complaint/Grievance Resolution Tool dated 11/25/13 at 9:00 revealed the above mentioned complaint had been written by Patient #2 and received by S4NurseManager.

In an interview on 1/6/14 at 3:38 p.m. with S4NurseManager, she said she remembered Patient #2 and had investigated the complaint filed on 11/25/13. S4NurseManager said Patient #2 was the one that marked the Complaint/Grievance Resolution Tool as a grievance and a complaint. S4NurseManager said although the complaint was written by Patient #2, it was recorded as a complaint and no written response had been given to Patient #2.

In an interview on 1/6/14 at 3:55 p.m. with S6PatientRepresentative, she said she was a patient representative and handled complaints/grievances. S6PatientRepresentative said she remembered Patient #2 and her complaint taken on 11/25/13 was registered as a complaint and not a grievance because it was resolved during the course of the same day. S6PatientRepresentative also said she realized a written complaint which required investigation was always a grievance, and the complaint on 11/25/13 had been written by Patient #2 and required investigation. S6PatientRepresentative stated she did not give a written response to Patient #2 about her grievance.

Patient R1
Review of a letter written to the hospital by Patient R1 revealed the following: I called my nurses phone for pain meds (medications) and never got a response. I had another nurse come in and I asked her about pain meds. She said she would get with my nurse. I waited 6 hours for pain meds. By the time they came I was in tears from the pain. I am a new mother and I don ' t know what to expect and how to handle it. My nurse wouldn ' t come in my room for hours. I did not want to feel like I was bothering her. I was never offered anything for gas pains after I brought it to her attention. Also my female pads were never changed until I got up to walk.

Review of the document titled " Complaint/Grievance Resolution Response Tool " revealed the above mentioned complaint was received on 10/3/13 at 8:30 a.m.

In an interview on 1/8/14 at 9:00 a.m. with S2CNO, she verified the complaints for Patient #2 and Patient R2 were actually grievances instead of complaints. S2CNO said the both patients should have received written resolutions of their grievances per hospital policy.

Based on clinical record review and interview the hospital failed to promote patient rights by failing to notify the patients ' emergency contact of a health status change after he was admitted to Intensive Care Unit (ICU) for a hypotensive shock episode for 1 (#3) of 10 (#1, #2, #3, #4, #5, #6, #7,#8 ,#9, #10) patients reviewed.

Findings:
Review of Patient # 3 ' s medical record revealed an Admission date of 11/22/13 with diagnoses that included the following: Schizophrenia, Mental Retardation, Ileostomy, Asthma, Hypertension, and Hypotension.

Review of Patient #3 ' s medical record revealed a listed emergency contact person (relationship other) with contact telephone information.

Review of Patient #3 ' s nursing notes revealed the following, in part: 11/28/13, 05:53 a.m.: At 4 a.m., MHT (Mental Health Technician) notified writer that patient ' s B/P (blood pressure) was 70/36. Writer took the B/P again and it was 66/30. Patient ' s B/P was taken by four other individuals, 2 RN ' s (registered nurses) and 2 MHT ' s and B/P could not be heard. At 4:45 a.m. Patient #3 was placed in Trendelenburg position and B/P was not heard. 05:00a.m. B/P was 71/45. Rapid Response Team was called. Rapid Response Team respond at 5:10 a.m. Dr. Woodard was notified at 05:30 a.m., order received to transfer Patient #3 to ICU (Intensive Care Unit) due to shock. Patient #3 was transferred at 05:40 a.m..

In an interview on 1/6/14 at 12:40 p.m., with S2CNO, she stated there was no specific policy for notification of family members/patient representatives related to patient status change.

In an interview on 1/7/14 at 9:48 a.m. with S5MD, he explained Patient #3 had developed morning episodes (around 4 a.m.) of hypotension. He said the patient was admitted to ICU for treatment of hypotension. He was asked if family/responsible party was notified of Patient #3 ' s transfer to ICU and he said the staff would have notified the family of the patient ' s transfer/condition change.

In an interview on 1/7/14 at 9:54 a.m. with S16RN she said staff practice would have been to notify family/responsible party of patient condition change/transfers.

In an interview on 1/7/14 at 12:43 p.m. with S3DirPsychServices she confirmed there was no documentation of notification of Patient #3 ' s family/emergency contact of his transfer to ICU. She also said, to her knowledge, there was no facility policy specific to notification of patient family/responsible party of condition change/transfer.

Based on observation, interview and record review, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) failing to ensure rooms were locked on the adolescent psychiatric unit which contained potentially harmful items. This deficient practice had the potential to affect all 6 current residents on the unit.
2) failing to have hospital policies and procedures for escorting seclusion/restraint patients to the restroom on the adolescent psychiatric unit. This deficient practice had the potential to affect all 6 current residents on the unit.
3) failing to have psychiatric safety beds available for 6 of 18 adult psychiatric beds and 12 of 12 geriatric psychiatric beds.

Findings:

1) Failing to ensure rooms were locked on the adolescent psychiatric unit which contained potentially harmful items.
In an observation on 1/8/14 at 10:35 a.m. of the adolescent psychiatric unit, a room containing a washer and dryer was unlocked and accessible by patients. Observation revealed the laundry room contained electrical outlets, laundry chemicals, secured patient belongings from admission, plastic bags, unsecured ceiling tiles, and glass mirrors. Further observation revealed a day room unlocked with cords from the television and a video player. Upon further observation of the unit, a conference room was noted to be unlocked and contained hot coffee in a pot, television cords, a blood pressure machine with power cords, and plastic garbage can liners.

The above mentioned observations were verified on 1/8/14 at 10:50 a.m. by S15PsychServicesCoord. S15PsychServicesCoord verified the doors should have all been locked, but she could not give an explanation as to why the doors were unlocked or how long they had been unlocked.

Review of the current census on the adolescent psychiatric unit, dated 1/8/14, revealed 6 current residents.

2) Failing to have hospital policies and procedures for escorting seclusion/restraint patients to the restroom.
An observation of the adolescent psychiatric unit on 1/8/14 at 10:45 a.m. revealed the seclusion/restraint room had no vestibule containing a restroom. The nearest restroom was across an unrestricted hall inside another room.

In an interview on 1/8/14 at 1:45 p.m. with S3DirPsychServices, she verified she had no policies and procedures for providing safety when patients in the seclusion/restraint room had to be escorted to the restroom.

3) Failing to have psychiatric safety beds available for 6 of 18 adult psychiatric beds and 12 of 12 geriatric psychiatric beds.

A tour of the Adult Psychiatric Unit on 1/8/14 at 11:10 a.m. revealed 6 of the 18 psychiatric patient beds were open-frame hospital beds with working cranks, side rails and moveable parts.

Observation of the Geriatric Psychiatric Unit on 1/8/14 at 1:30 p.m. revealed all of the 12 beds on the unit were electric medical beds with working side rails.

In an interview on 1/8/14 at 1:50 p.m. with S3DirPsychServices, she said she did not have any hospital policies or procedures for the safety of adult psychiatric patients assigned to the 6 open-frame hospital beds with side-rails, working cranks, and moveable parts. S3DirPsychServices also stated she could not provide any waivers from the Department of Health and Hospitals to use the 12 electric medical beds for the patients on the geriatric psychiatric unit. S3DirPsychServices also said the admission criteria for the geriatric psychiatric unit was 55 or older and all of the patients did not require a bed with side rails. S3DirPsychServices also said no other type beds were available to replace the crank style or electric beds.

Based on interview and record review the hospital failed to have adequate supervisory staff on the psychiatric units by failing to provide a qualified Director of Psychiatric Nursing Service as evidenced by having an appointed director who did not fulfill the educational or experience requirements for the position.

Findings:

Review of the personnel folder for S4NurseManager revealed she received her initial licensure on 1/27/10. Further review revealed she had begun working on the psychiatric unit on 8/21/12. She was listed as having become the nurse manager of the psychiatric unit on 9/15/13.

In an interview on 1/8/14 at 3:45 p.m. with S2CNO, she said S4NurseManager was the Director of Psychiatric Nursing Services. She verified S4NurseManager did not have 5 years of nursing experience. She stated she only had 4 years of nursing experience, 1 ? of which were on the psychiatric floor. S2CNO verified S4NurseManager was not qualified to be the Director of Psychiatric Services as required by State Law.

Based on interviews and record reviews, the hospital failed to ensure a registered nurse evaluated the nursing care for each patient as evidenced by failing to ensure 2 doses of anti-seizure medications were administered to a patient while being held in the Emergency Department (ED) on a Physician ' s Emergency Certificate (PEC) and when admitted to the Adult Psychiatric Unit for 1 (#2) of 10 (#1- #10) patients reviewed.
Findings:
Review of the Hospital policy titled Medication Reconciliation, revised September 2013, revealed in part:
All patients admitted to the hospital will have their home medications reconciled. These steps will include:
1. Obtaining and documenting the most complete and accurate list possible of all current medications.
3. After the medications have been updated, an admission med rec report is printed out and placed on the chart for physician review. The nurse will contact the physician to review each med (medication).
4. Once the physician completes the form, scan to Pharmacy. Place the form under " physician orders " in chart.

Review of the medical record for Patient #2 revealed she was a 33 year old female that had been triaged in the Emergency Department (ED) at the hospital on 11/21/13 at 4:53 p.m. with the chief complaints of Depression, Anxiety, Hallucinations, and Bizarre Behavior. Her diagnoses included seizure disorder.

Review of the medical record for Patient #2 revealed she had a PEC (Physician ' s Emergency Certificate) dated 11/21/13 at 12:20 p.m. with " Dangerous to self " , " Gravely Disabled " and " Unable to seek Voluntary Admission " selected. Further review of the Medical Record for Patient #2 revealed she had a CEC (Coroner ' s Emergency Certificate) dated 11/23/13 at 7:55 p.m. marked " dangerous to self " and " unwilling " .

Review of the " Home Medication Reconciliation Order Form " for Patient #2 completed by the ED (Emergency Department) at the hospital and dated 11/21/13 at 9:00 p.m. revealed the following medications were being taken at home by Patient #2: Dilantin (anti-seizure) 200 mg daily, 100 mg every evening, and 200 mg orally at bedtime. Patient #2 also took Phenobarbital (anti-seizure) 60 mg every day.

Review of the ED notes for Patient #2 revealed the only medications Patient #2 received in the ED were 2mg (milligrams) of Ativan (antianxiety) at 6:14 p.m. and 1000 mg of Tylenol at 9:10 p.m.

Review of the " Admission Assessment Report " for Patient #2 from the Adult Psychiatric Unit revealed she had been admitted to the unit on 11/22/13 at 12:15 a.m.

Review of the MAR (Medication Admission Record) for Patient #2 on the Adult Psychiatric Unit revealed Patient #2 had not received any anti-seizure medications while in the hospital until she received Phenobarbital 60 mg on 11/22/13 at 5:27 a.m. and 200 mg capsule of Dilantin on 11/22/13 at 8:08 a.m.

In an interview on 1/7/14 at 1:23 p.m. with S17RNManagerED, she said home medications are typically not given to the patients in the ED unless they are on a hold for a bed. S17RNManagerED said Patient #2 ' s medications would not have been given until she arrived on the psychiatric floor. S8RNManagerED said they only gave Tylenol and Ativan in the ED to Patient #2 on 11/21/2013.

In an interview on 1/7/14 at 2:40 p.m. with S11Pharmacist, he said when medications were reconciled the list would be scanned to pharmacy and placed on the patient ' s MAR. S11Pharmacist said the medication reconciliation form was not sent to the pharmacy for Patient #2 until 11/22/13 at 1:36 a.m. from the psychiatric floor. S11Pharmacist said he would expect the physicians and nurses in the ED to monitor the patient ' s medications until the patient was placed on hold or admitted.

In an interview on 1/7/14 at 1:40 p.m. with S9RN, she said she remembered Patient #2 on her admission from 11/22/13 until 12/2/13. S9RN said Patient #2 arrived on the adult psychiatric unit on 11/22/13 at 12:15 a.m. S9RN said Patient #2 did not receive her seizure medications until 8:00 a.m. on 11/22/13 when she received Phenobarbital.

In an interview on 1/7/14 at 3:17 p.m. with S12RNDirectorED, she said when a patient is not on hold the ED staff does not give their home medications. S12RNDirectorED said Patient #2 ' s medication reconciliation form was completed at 9:00 p.m. on 11/21/13 in the ED because she was going to be admitted to the psychiatric floor. S12RNDirectorED said Patient #2 ' s medication list was not obtained until the medication reconciliation was done at 9:00 p.m. on 11/21/13 in the ED. She said Patient #2 did not receive any of her seizure medications (Dilantin and Phenobarbital) in the ED. S12RNDirectorED also said Patient #2 was not transferred until midnight to the psychiatric unit. S12RNDirectorED also verified Patient #2 could not have taken her own medications herself after arrival to the ED because she was PEC ' d. She said she did not have policies or a system in place for patients to receive their medications in the ED if they were PEC ' d and waiting to be transferred to a patient floor without being on " hold " .

In an interview on 1/7/14 at 4:14 p.m. with S3DirPsychServices, she said there was no process in place to ensure a PEC ' d patient from the ED admitted to the psychiatric unit received their home medications while in the ED. S3DirPsychServices also verified there was no documentation of the physician being notified by the psychiatric admitting nurse on 11/22/13, S14RN, that Patient #2 had not received her anti-seizure medications since arrival at the hospital at 4:53 p.m. on 11/21/13.

In an interview on 1/8/14 at 7:40 with S13MD, he said he was an ED physician. S13MD verified there was not a process in place to ensure PEC ' d patients received their medications if they were in the ED for an extended period of time and not in " hold " status. S13MD said they would not be considered on " hold " unless the psychiatric beds were full. S13MD also verified the nursing staff and the physicians in the ED were responsible for ensuring the patients receive their needed medications.

In an interview on 1/8/14 at 7:50 a.m. with S14RN, he stated he has worked on the adult psychiatric floor at the hospital and had admitted Patient #2 on 11/22/13 at 12:15 a.m. S14RN said medications for Patient #2 had been reconciled by the ED because she arrived on the unit. S14RN also said the medications Patient #2 received in the ED was on the nursing notes and was told to him in report from the ED nurse. S14RN said he should have called the physician and informed him Patient #2 had not received her 2 evening doses of Dilantin. S14RN said it was a mistake and must have been overlooked.

Based on interview and record review the hospital failed to ensure the nursing staff developed a comprehensive nursing care plan for each patient by failing to address all identified medical problems for 4 (#1, #2, #3, #4) of 5 (#1,#2, #3,#4, #5) patients reviewed.
Findings:
Review of the Hospital Policy titled Treatment Planning, Revised and Reviewed: 1/2013, stated in part: Patients will have an individualized treatment plan as determined by assessments of clinical needs and will be given the opportunity to actively participate in the treatment planning process.
Standards of Care (SOC) 1. Licensed nursing staff is responsible for ensuring that appropriate nursing diagnoses and Standards of care are identified and implemented.
4. Standards of care for non-psychosocial problems will be recorded on the Problems List and reviewed on the Daily Nursing Assessment. The SOC will remain opened until the problem is resolved.
Problems- Behavioral and Physical
B. Physical problems are also addressed in this section. Physical problems include anything that may require observation or intervention during treatment; such as diabetes, hypertension, epilepsy, etc. (etcetera) ....Identified problems that are deferred for this treatment program are also documented.

Patient #1
Review of Patient #1 ' s medical record revealed an Admission date of 9/26/13 with diagnoses that included the following, in part: status post Motor Vehicle Collision- Contusion to head/right eye, Major Depression, and Suicidal Ideation

Review of Patient # 1 ' s Emergency Department Medical and Physical Assessment revealed the following , in part: 9/26/23, 00:09: History of present Illness: Chief Complaint- Motor Vehicle Collision. Patient complains of moderate pain. Patient sustained a blow to the head; Physical Exam: Eyes: Right periorbital area: moderate erythema and swelling.

Review of Patient #1 ' s MD orders revealed the following: 9/26/13: Acetaminophen 325 mg
(milligrams); Order dose: 625 mg every four hours- as needed (PRN); Route: oral;
9/27/13: Ibuprofen 600mg; Order dose: 600 mg 3 times a day- as needed, pain

Review of Patient #1 ' s Medication Administration History Report revealed the following entries for pain medication administration:
Acetaminophen 650 mg, oral: 9/26/13, 18:49: PRN reason: pain; 9/27/13, 04:31: PRN reason: pain; 9/27/13, 07:39: PRN reason: pain; 9/28/13, 18:21: PRN reason: pain; 9/28/13, 20:51: PRN reason: pain.
Ibuprofen 600mg, oral: 9/27/13, 11:21: PRN reason: pain- patient complains of pain to right eye: 6/10; 9/27/13, 20:15: PRN reason: pain; 9/28/13, 08:32: PRN reason: pain- rates 8 on numeric scale of 0/10; 9/28/13, 14:08: PRN reason: pain; 9/29/13, 06:22: PRN reason: pain; 9/30/13, 07:08: PRN reason: pain.
Review of Patient #1 ' s Daily Focus Assessment Report revealed the following, in part:
9/26/13, 08:00 Group Note: Patient #1 states hitting her head in MVA ( motor vehicle accident), large area of bruising noted to right eye orbit, ice pack applied;
9/26/13 08:00 Assessment of Pain: Group note: States soreness to right eye area, ice pack applied; 9/26/13 14:00 Group note: coloring, continuing to use ice pack at times;
9/27/13, 08:15 Group note: Patient #1 has severe swelling and bruising to her right eye;
9/28/13, 07:30 Group note: Patient #1 has bruising noted to right eyelid and surrounding area of eye due to airbags from car accident. Eye is slightly swollen. Ice pack given for comfort and swelling.
Review of Patient #1 ' s current care plan revealed no entries identifying Pain and Contusion to head/right eye as identified medical problems.

Patient #2
Review of Patient #2 ' s medical record revealed an admission date of 11/21/13 with diagnoses that included the following: Bipolar Disorder, Depression, and Seizures.

Review of Patient #2 ' s Medication Administration Record on the Adult Psychiatric Unit revealed she was receiving Phenobarbital (anti-seizure medication) and Dilantin (anti-seizure medication).

Review of the Computerized Physician Order Entry (CPOE) form for Patient #2, dated 11/30/13 at 10:35 a.m., revealed an order for an x-ray of the right knee by S5MD. Further review revealed an order dated 11/30/13 at 11:00 a.m. for Cipro (Ciprofloxacin- antibiotic) 500 mg orally every 12 hours for14 doses.

Review of a Progress Note for Patient #2 dated 11/30/13 at 10:38 a.m. by S5MD revealed in part: Subjective/History of Present Illness: Erythema, mild edema of right lateral knee. Appears to be superficial.

In an interview on 1/7/14 at 12:45 p.m. with S8RN said she took care of Patient #2 while she was in the hospital 11/22/13 through 12/2/13. S8RN said the patient was on seizure precautions on 11/22/13 because she had a history of seizures.

Review of Patient #2 's current care plan revealed no entries identifying seizures and right knee swelling/erythema as identified medical problems.

Patient #3
Review of Patient # 3 's medical record revealed an Admission date of 11/22/13 with diagnoses that included the following: Schizophrenia, Mental Retardation, Ileostomy, Asthma, Hypertension, and Hypotension.

Review of Patient #3 's MD orders revealed the following active orders, in part:
Albuterol Sulfate (bronchodilator) 2.5mg/0.5ml inhalation every 6 hours; Ipratropium Bromide
(bronchodilator) 0.5mg/2.5ml inhalation every 6 hours; Lisinopril (anti-hypertensive) 2.5mg oral, daily at bedtime.

Review of Patient #3 's nursing notes revealed the following, in part:
11/28/13, 05:53 a.m.: At 4 a.m., MHT (Mental Health Technician) notified writer that patient ' s B/P (blood pressure) was 70/36. Writer took the B/P again and it was 66/30. Patient ' s B/P was taken by four other individuals, 2 RN ' s (registered nurses) and 2 MHT ' s and B/P could not be heard. At 4:45 a.m. Patient #3 was placed in Trendelenburg position and B/P was not heard. 05:00 B/P was 71/45. Rapid Response Team was called. Rapid Response Team respond at 5:10 a.m. Dr. Woodard was notified at 05:30 a.m., order received to transfer Patient #3 to ICU (Intensive Care Unit) due to shock. Patient #3 was transferred at 0540.


Review of Patient #3 's current care plan revealed no entries identifying Asthma, Hypertension, and Hypotension as identified medical problems.

In an interview on 1/7/14 at 9:48 a.m. with S5MD, he explained Patient #3 had developed morning episodes (around 4 a.m.) of hypotension during his stay on the Adult Psychiatric floor . He said the patient was admitted to Intensive Care Unit (ICU) for treatment of the hypotensive episodes and was readmitted to the Adult Psychiatric floor.

In an interview on 1/8/14 at 11:40 a.m. with S8RN, she confirmed Patient #3 ' s care plan was incomplete. She verified Patient #3 ' s medical diagnoses should have been reflected in his plan of care. She also verified Patient #3 ' s care plan should have been updated to include potential for Hypotension upon his readmission (post ICU stay for Hypotensive episodes) to the Adult Psychiatric floor.

Patient #4
Review of Patient #4 ' s medical record revealed an Admission date of 11/22/13 with diagnoses that included the following: Suicidal Ideation/Depression, Seizures, status post ORIF (Open Reduction Internal Fixation) RLE (right lower extremity).

Review of Patient #4 ' s Emergency Department nursing notes, dated 11/22/13, revealed the following, in part: Disposition/Discharge: Patient reports pain level on departure as 10/10. Report was given to a nurse via a phone call. Report included patient care, treatment, medications and condition (including any recent changes or anticipated changes). Admitted to Psychiatry.

Review of Patient #4 ' s Emergency Department MD notes revealed the following, in part: Physical exam: extremities: lower extremity edema. RLE (right lower extremity), skin mildly erythematous near clean- appearing staples.

Review of Patient #4 ' s Daily Focus Assessment Report revealed the following, in part: 11/23/13 07:30 Category Note: Patient has multiple staples noted to right knee, lower leg, ankle, and foot due to being hit by a truck on 10/30/13.

Review of Patient #4 ' s Master Treatment Plan, dated 11/22/13, revealed the following, in part: Summary of potential barriers to treatment: Patient reports that he is in pain due to staples in his foot.

Review of Patient #4 ' s plan of care revealed no entries identifying pain, impaired skin integrity (related to indwelling staples), or potential for infection (related to indwelling staples) as identified medical problems.

In an interview on 1/8/14 at 11:45 a.m. with S3DirPsychServices, she verified patient care plans should have included their medical diagnoses.