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Based on interviews and document review, it was determined the facility staff failed to ensure a grievance by Patient #14's parent was addressed according to the facility's policies and procedures.

The findings include:

The facility staff failed to follow the facility's policies and procedures to address a grievance lodged by Patient #14's parent.

The complainant provided the survey team with copies of email communication between Patient #14's parent and the facility's Chief Medical Officer (CMO). This email communication discussed specific concerns with clinical documentation related to Patient #14. The email communication provided by the complainant indicated the CMO had requested clarifying information related to which clinical documentation was of concern to Patient #14's parent. This email communication also indicated Patient #14's parent wanted his/her concerns to be considered a "formal complaint."

The facility's CMO was interviewed on 3/21/17 at 1:40PM. The CMO reported meeting with Patient #14's parents to discuss concerns. The CMO acknowledged concerns with the aforementioned clinical documentation was discussed. The CMO stated after the meeting he/she did receive email communication from Patient #14's parent with the documentation in question attached. The CMO was unable to provide the survey team with copies of this email communication. The CMO stated the meeting with Patient #14's parents was not documented.

The above referenced email was discussed with the facility's Chief Executive Officer (CEO) and the facility's Director of Risk Management (Staff Member (SM) #4) during a survey team meeting on 3/22/17 at 4:00PM. On 3/23/17 at 9:00AM, SM #4 reported that the facility's CMO was unable to find the email communication with Patient #14's parent.

The following information was found in the facility's policy and procedure entitled, 'Patient Complaint and Grievance' (approved 9/15 and last revised 11/10): "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, issues related to compliance with the CMS Conditions of Participation (COP), or a Medicare beneficiary billing complaint related to rights and limitation provided by 42 CFR 489. A written complaint is always considered a grievance ... A written complaint also includes those complaints received via electronic mail or facsimile. ... Whenever the patient or the patient's representative requests that their complaint be handled as a formal complaint or patient request a response from the hospital, then the complaint is a grievance and all the requirements apply."

The following information related to written notice of the grievance resolution to the complainant was found in the aforementioned facility policy and procedure:
- "Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days."
- "In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion."

The facility's grievance log was reviewed by the survey team on 3/21/17; neither Patient #14 nor the patient's parent was included on the grievance log. SM #4 was interviewed, on 3/21/17 at 1:08PM, related to a potential grievance/complaint related to Patient #14; SM #4 stated no complaint or grievance was found on the facility's log. On 3/21/17 at 2:20PM, SM #4 stated if he/she had been aware that this complaint was made after the patient was discharged then it would have been treated as a grievance.

This is a complaint deficiency.

Based on facility documents and clinical record reviews, the facility failed to obtain a current written restraint order for one (1) out of four (4) patients sampled for restraint review (Patient #3).

The findings include:

On 03/21/17 at 3:35 PM the surveyor reviewed Patient #3 clinical record. The surveyor was navigated through the clinical records by Staff Member (SM) #30. On 03/19/17 at 10:08 PM the physician (SM #31) wrote an order for non-violent bilateral upper soft wrist restraints. According to the clinical record the restraints were initiated at 3:05 AM, almost five (5) hours later. No documentation was noted in the clinical record as to why the restraints were not applied at the time the physician wrote the order.

On the morning of 03/21/17 an interview was conducted with SM #30. He/she stated that the nurse taking care of the patient was trying to prevent the patient from having restraints applied. SM #30 acknowledged the nurse should have gotten another order, prior to applying the restraints at a later time.

On 03/21/17 at 11:34 AM a Policy and Procedure Entitled, "Seclusion, Restraints and Restraint Alternatives" (last revised 12/2016) was reviewed and read in part as follows: "An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release. 1. An order for restraint or seclusion may not be written as a standing order, protocol or as a PRN or "as needed" order. 2. If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order is required."

Based on observations, interviews and document review it was determined that hospital staff failed to follow infection control guidelines including the use of appropriate personal protective equipment (PPE), performing appropriate hand hygiene and educating patients and/or family members related to infection control precautions. These practices affected 4 of 24 patients in the survey sample, Patients #17, #18, #24 and #13.

The findings include:

1. Patient #17 was placed on Enhanced Contact Precautions for Clostridium Difficile (a gram-positive bacillus normally found in the digestive tract and a common cause of antibiotic-associated diarrhea). Hospital policy "Guideline for Patients with Clostridium Difficile" directs that all patients "who are diagnosed with or thought to have C. difficile are placed in Enhanced Contact Precautions". Enhanced contact precautions require hand hygiene with soap and water, gown and gloves. A sign was on the room door designating the need for Enhanced Contact Precautions, but an isolation cart containing PPE supplies was not located nearby.

On 3/22/17 at 9:30 am Staff Member #14 (a registered nurse) was observed entering the room of Patient # 17 without donning PPE or performing hand hygiene. Staff Member #14 left the room without hand hygiene and went down the hall to obtain an isolation cart. Staff Member #14 re-entered the room donned a gown and gloves, gave medications to the patient and removed gloves. No hand hygiene was performed upon entering the room or with glove changes. After removing gown and gloves Staff Member #14 completed soap and water hand hygiene before leaving the room. A family member present in the room stated that hospital staff had not been wearing gowns before this. Patient #17 had been on Enhanced Contact Precautions since 3/19/17. Staff Member #18 the Infection Preventionist was present during the observations.

2. Patient #18 was on contact precautions requiring the use of gloves and gowns. On 3/22/17 at 1:20 pm, the surveyor observed Staff Member #13 (a physical therapist) to be standing at the bedside in front of the patient who was seated in a chair. Staff Member #13 was wearing gloves but no gown (a gown was hanging from the door of the room). A gait belt (used when ambulating a patient) was across Staff Member #13's right shoulder. Staff Member #13 removed his/her gloves, performed hand hygiene and left the room. There was a sign on the door designating contact precautions to be used for this patient. The surveyor asked Staff Member #13 what that would mean to him/her regarding the use of PPE. Staff Member #13 stated "I should have put my gown on when I returned to the room" Staff Member #13 was asked about the gait belt over his/her shoulder, he/she stated that it (the gait belt) was usually cleaned after leaving the patient's room. It was noted by the surveyor that by having the unclean gait belt across his/her shoulder Staff Member #13 was contaminating his/her scrubs. Staff Member #18 was present during the observation.

3. Patient # 24 was on standard precautions. On 3/22/17 at 1:40 pm an individual identified as a nursing student was observed leaving the room without performing hand hygiene. The nursing student retrieved supplies and returned to the patient's room entering without performing hand hygiene. Staff Member #17 (the nursing instructor) was asked what training the students received related to infection control at the hospital. Staff Member #17 stated the students received the same infection control training that hospital employee's get. Staff Member #17 stated he/she would expect the students to perform hand hygiene when entering and/or leaving a patients room. Staff Member #18 was present during the observation.


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4. Patient #13's clinical documentation failed to include: (a) the placement of the isolation precaution signs and equipment and (b) patient and/or representative education related to the isolation precaution.

The following information was found in the facility policy and procedure entitled, "Guideline for Isolation Precautions in Hospitals" (approved and last revised on 1/2017) under the heading "Contact Precautions": "F. Communication 1. A Contact Precautions sign will be placed on the door to the patient's room and on the front of his/her chart. 2. The patient's isolation status must be updated in the electronic medical record. 3. The patient's isolation status must be communicated to all stall interacting with the patient."

The following information was found in the facility policy and procedure entitled, "Guideline for Patients with Clostridium Difficile" (approved and last revised on 1/2017):
- "(Clostridium Difficile) is the most common cause of antibiotic-associated diarrhea (AAD)."
- "All patients who are diagnosed with or thought to have C. difficile are placed in Enhanced Contact Precautions."
- "A. Patients identified with diarrheal stools will be evaluated for placement in Enhanced Contacted Precautions. 1. The nursing staff will place an Enhanced Contact Precautions sign on the patient's room door, retrieve PPE, and place an order for an isolation box or cart in Meditech. ... 4. The patient will be education about Enhanced Contact Precautions, and a handout will be provided."

Patient #13 was admitted on 8/6/16. An "ADMINISTRATIVE DATA" form for this admission indicated the patient was on contact isolation precautions.

Patient #13 was admitted on 8/25/16. An "ADMINISTRATIVE DATA" form for this admission indicated the patient was on contact isolation precautions for "CDIFF".

Patient #13's clinical records for the 8/6/16 and 8/25/16 admissions did not include documentation to indicate who placed the isolation precautions sign and equipment and /or when the sign and equipment was placed.

During an interview on 3/23/17 at 1:00PM, an assistant direction (Staff Member (SM) #1) acknowledged no documentation was found to indicate when the isolation precautions sign and equipment was placed. SM #1 also acknowledged no documentation was found to indicate the patient and/or family was educated about the isolation precautions. (The Vice-President of Quality (SM #24) was present during this interview.)

This is a complaint deficiency.