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Based on record review and interviews, the hospital failed to ensure each patient/patient's representative who filed a grievance was provided a written notice of the hospital's decision regarding the resolution of the grievance for 1 (#2) of 4 (#2, #8, R#1, R#2) grievance reviewed.
Findings:

Review of the hospital titled, Complaint and Grievance: Patient/Family revealed in part, In the case of a grievance, most situation will be resolved and the patient notified of the resolution within twenty (20) days. The letter will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the evaluation and investigation into the grievance, and the date of completion (indicated by the date of the letter to the patient).

Review of a patient grievance form filled out by Patient #2 on 02/08/2021 revealed no evidence a letter was sent to the patient filing the grievance with the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the investigation.

An interview was conducted with S2Asst Adm on 05/03/2021 at 11:15 a.m. S2Asst Adm reported on the advise of the hospital's lawyers a letter was not sent to Patient #2 related to the investigation.

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for psychiatric patients admitted for being a danger to self or others. Findings:

An observation was conducted on 05/03/2021 at 10:30 a.m. of a wooden restraint bed in the seclusion room on the third floor of the hospital. On the left side of the wooden restraint bed, the wood was splintered and posed a safety risk for the patients. S1Adm was present and verified the findings.

An observation was conducted on 05/03/2021 at 10:45 a.m. of the 4th floor hall shower room. The toilet in the shower room had approximately 2 inch screws sticking out of the bottom of the toilet where the toilet was secured to the floor. S1Adm was present and verified the findings.

44495

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with accepted standards of practice and hospital policy. This deficient practice was evidenced by failure of nursing staff to document injection site and reassessment of the patient for therapeutic effect or adverse reaction in 2 (#1, #10) of 3 (#1, #3, #10) patients reviewed with PRN medication administration in a sample of ten patients.
Findings:

Review of Community Care Hospital Nursing Policy and Procedure Manual policy titled, "Medication Administration," revealed in part: Nurses would "Chart medication on Medication Administration Record. Effects of PRN medication and the site of injection must be noted in the Progress Notes as well."

Patient #1
Review of the EMR for Patient #1 navigated by S3LPN and S9DON on 05/04/2021 at 4:40 p.m.
revealed a PRN order, dated 02/03/2021 at 12:39 p.m., for Ativan 2 mg PO/ IM every 6 hours PRN agitation, Benadryl 50 mg PO/IM every 6 hours PRN agitation, and Haldol 5 mg PO/IM every 6 hours PRN agitation.

Review of the MAR for Patient #1, dated 02/04/2021 at 11:30 p.m., revealed the patient was given Ativan 2 mg IM, Benadryl 50 mg IM, and Haldol 5 mg IM. Review of progress notes for Patient #1 dated 02/04/2021 revealed no documentation of site of injection and no documentation of reassessment after administration.

Review of the MAR for Patient #1, dated 02/05/2021 at 8:00 a.m., revealed the patient was given Ativan 2 mg IM, Benadryl 50 mg IM and Haldol 5 mg IM. Review of the MAR and progress notes for 02/05/2021 revealed no documentation of site of injection.

Review of the MAR for Patient #1, dated 02/07/2021 at 12:55 p.m., revealed the patient was given Ativan 2 mg PO, Benadryl 50 mg PO, and Haldol 5 mg PO. Review of progress notes for Patient #1 dated 02/07/2021 revealed no documentation of reassessment after administration.

Review of the MAR for Patient #1, dated 02/07/2021 at 8:42 p.m., revealed the patient was given Ativan 2 mg PO, Benadryl 50 mg PO and Haldol 5 mg PO. Review of progress notes for Patient #1 dated 02/07/2021 revealed no documentation of reassessment after the administration.

Patient #10
Review of Patient #10's EMR navigated by S3LPN and S9DON on 05/04/2021 at 4:45 p.m. revealed a PRN order, dated 04/27/2021 at 3:33 a.m., for Ativan 2 mg PO/ IM every 6 hours PRN agitation, Benadryl 50 mg PO/IM every 6 hours PRN agitation, and Haldol 5 mg PO/IM every 6 hours PRN agitation.

Review of the MAR for Patient #10, dated 05/04/2021 at 12:43 p.m., revealed the patient was given Ativan 2mg PO, Benadryl 50 mg PO, and Haldol 5mg PO as a first dose for all medications. Review of the progress notes for Patient #10 dated 05/04/2021 revealed no documentation reassessment after administration.

The above findings were verified during record review with S3LPN and S9DON on 05/04/2021 at 4:40 p.m.

An interview was conducted on 05/04/2021 at 4:40 p.m. with S9DON and S3LPN. S9DON verified the nurse should document the site of administration of the injection and effect of the prn medication in the nurse notes after the medication had been administered.

Based on observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice. This deficient practice was evidenced by the hospital having two wooden restraint beds, chairs, and a mattress for patient use that was not capable of being disinfected properly.
Findings:

Observations were conducted on 05/03/2021 at 10:30 a.m. to 11:00 a.m. of the following patient used items that could not be disinfected properly:

Two large wooden restraint beds- one in the third floor seclusion room and the other one in the 4th floor seclusion room. The beds were wooden and could not be disinfected properly.

Two holes in the mattress on the 4th floor restraint bed that prevented the mattress from being disinfected properly.

Two green vinyl chairs with torn vinyl seats with the foam underneath visible (1 chair was in the hallway on third floor and one chair was in the hall bathroom/shower room on the fourth floor)

The S1Adm was present during the observations and verified the findings.