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Based on interview and document review, the hospital failed to respond in writing to patient grievances for 2 of 2 patients (P2, P17) reviewed who had filed grievances with the hospital. This has the potential for affecting all patients who may file grievances.

Findings include:

In review of the hospital grievances, the grievances and the disposition were documented on a form labeled Grievance Form DHS-6031.

P2 had submitted three grievances dated 7/8/15, however, there was no indication of the actual time the grievance occurred. Information documented on the 7/8/15 grievances identified, "I was on the floor and couldn't breathe and one of the staff said 'well when they wheel you into the ambulance there will be plenty of oxygen tanks for you,' he laughed when he said it."

The grievance form's Step 1 identified: "I [registered nurse RN-D] met with [P2] today to discuss the incident. She [P2] reports that she is no longer upset and it was documented, the grievance had been resolved." There was no indication the hospital had completed a thorough investigation with the identified named staff person nor was there a written response provided for P2 about the grievance.

A second grievance was filed by P2 7/8/15 however, there was no indication of the actual time the grievance occurred. The documentation identified, "I was in a hold and they bent my arm. It hurt so I said 'you are hurting me my Mom will be angry with you,' and the staff said, 'if that is true call your stupid little Mommy and tell her to come pick you up then'." This grievance indicated RN-D was the person who had spoken inappropriately to P2.

The grievance form's Step 1 documentation included: "I [RN-D] met with [P2] today to discuss the incident. She reports that she is no longer upset and it was documented the grievance has been resolved." RN-D was the person identified in the grievance as having said the remark about P2's mom and was also the staff person who met with P2 to discuss the grievance and documented the grievance was resolved. There was no documented evidence the hospital completed further investigation with the identified person nor was P2 provided with a written response regarding the grievance.

A third grievance was also filed by P2 7/8/15, again there was no indication of the time when the actual grievance occurred. The grievance identified, "I was on the floor and I said my body remembers this exact time from 8:00 to 9:30 because my brother raped me so my mental health issues come up more and it is harder to control myself and so one of the staff said 'don't blame this on your stupid mental health problems because you are probably taking on all of this shit'."

The grievance form's Step 1 documentation indicated a meeting had occurred with RN-A and P2. The documentation indicated P2 did not consider the grievance resolved in the Step 1 process, so it was forwarded to Step 2. The incident was discussed with the medical doctor (MD)-B and P2. Documentation indicated that following that meeting, P2 felt the matter had been resolved. The record did indicate evidence of any further investigation related to the staff person mentioned in the incident nor was P2 provided a written response to their grievance.

P17 filed a grievance regarding an incident which occurred on 1/1/15 with no indication of the time the actual grievance occurred. The grievance documentation included, "[human service technician (HST)-A], was shoving me on the ground. I [P17] made the comment several times that I could not breathe. Also I made the comment that people have died like this. HST-A said 'good well let's give a try then he pushed on my chest even harder than he did before'."

Documentation of Step 1 regarding the 1/1/15 grievance identified a meeting had occurred with RN-A and P17. The documentation indicated P17 did not consider the grievance resolved in the Step 1 process, so it was forwarded to Step 2. In Step 2 there was a meeting with registered nurse supervisor (RNS)-A and P17. During that meeting P17 requested that HST-A never be assigned to care for her. RNS-A provided specific reasons for current staffing assignments, and provided methods to help reduce P17's anxiety to maintain personal control. Documentation indicated that following their discussion, P17 felt the grievance had been resolved. However, the record did not include documentation of any further investigation related to HST-A's alleged involvement in the incident, nor was the patient provided with a written response.

P17 filed a grievance regarding an incident which occurred on 1/20/15 however, there was no specific time documented as to when the incident occurred. The grievance identified, "The staff were conducting a report meeting and one staff said maybe if she [not identified] didn't sleep all day she wouldn't be so fat."

Documentation of Step 1 related to the 1/20/15 grievance, identified a meeting with RN-D and P17 had occurred. The documentation indicated P17 did not consider the grievance resolved in the Step 1 process, so it was forwarded to Step 2. In Step 2, there was a meeting with the RNS-A and P17. It had been identified that P17 became anxious when hearing staff speak negatively about other patients. RNS-A talked with P17 about methods that P17 could use to help reduce stress, and RNS-A had told P17 she would remind staff not to say anything that could not be said directly to patients. Following their discussion, the documentation indicated P17 felt the grievance was resolved. The grievance documentation did not include whether there had been any further investigation of P17's concern nor was their documentation that P17 had been provided with a written facility response.

During interview on 8/12/15, at 1:18 p.m. the administer stated all grievances had been thoroughly investigated and were not substantiated based on staff interviews and viewing of the video surveillance cameras. The administrator agreed the documentation lacked evidence of the thorough investigation which she identified had been completed but was just not documented. She also confirmed there had been no written response of the findings provided to the patients.

The hospital's policy, Grievance and Complaint Process, and Safety Concerns, last updated 6/23/2014, included :

Step 1: The child/adolescent or concerned person (e.g. relative, legal representative or case manager) discusses the compliant or grievance with any staff member. The complainant or staff member must fill out a Grievance Form (DHS-6301).
(1) The staff member who received the compliant will speak with the child/adolescent and others as necessary and answer the compliant if he/she feels able to resolve the issue at that level; he/she has 24 hours to respond to the complainant in writing using the attached Grievance Form (DHS-6031).
(2) If the staff member is unable to successfully resolve or answer the complaint or grievance within 24 hours, the staff member must inform the complainant to whom the complaint is being forwarded to (usually the next line supervisor or designee) and that he/she can expect to hear from that person within 72 hours.

Step 2: The supervisor who receives the complaint or grievance at Step 2 has 72 hours to respond to the grievance in writing. If the supervisor is unable to successfully resolve the complaint or grievance, he/she passes the complaint/grievance on (Step 3) to the Local Grievance Committee which also has 72 hours to respond.

Step 3: When the local Grievance Committee receives the complaint or grievance at Step 3, it also has 72 hours to investigate as necessary and respond in writing.

Based on interview and document review, the hospital failed to have a quality assurance and performance improvement (QAPI) program for radiological services, laboratory services, occupational therapy services, physical plant and discharge planning. This had the potential to affect all patients who received care at the hospital.

Findings include:

On 8/11/2015, at 10:30 a.m. the administrator stated the facility had changed to a new data collection provider, and consequently QAPI data was not available yet for September 2014 to April of 2015. A review of the CABHS [Child and Adolescent Behavior Health Service] Workbook, lacked quality indicators for contracted services of lab, radiology, occupational therapy, and physical environment.

The hospital's building had a lease arrangement (contracted service) with Kandiyohi county. The county provided contract services to maintain the physical structure of the building. The administrator/administrative nursing supervisor was interviewed at approximately 2:10 p.m. on 8/13/15, and stated the county maintained the physical structure of the building such as wall repair and painting services. She stated there was no QAPI program related to the physical environment of the hospital, which was maintained by the county, under a contract agreement.

Review of the QAPI program indicated that radiology was a contracted service with Rice Memorial Hospital, there was no QAPI program.

The laboratory services, a contracted service with Rice Memorial Hospital, did not have a QAPI program.

The occupational therapy services, a contracted service with Rice Memorial Hospital, also did not have a QAPI program.

A review of the State of Minnesota Professional and Technical Services Master Contract, dated 7/23/2013, indicated the hospital had a contract with Rice Memorial Hospital for laboratory, radiological and occupational therapy services.



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Review of the QAPI program, did not indicate that the discharge planning department had any identifiable or measurable goals which were tracked as part of a quality improvement program.

On 8/12/2015, at 4:15 p.m. the administrator stated there was not any written quality improvement plan for the condition of discharge planning.

Based on interview and document review, the hospital failed to ensure a suspected adverse drug reaction was immediately reported to the pharmacist for 1 of 3 patients (P14) who had a suspected adverse drug reaction.

Findings include:

P14's face sheet identified they were admitted to the hospital on 5/26/2015, with diagnoses which included post traumatic brain injury and a psychotic disorder. The 5/29/2015, progress notes identified P14 was seen by an advanced practice registered nurse (APRN) on 5/29/2015, at 6:15 p.m. following a patient event which required police intervention and seclusion by the staff. The APRN-A wrote an order to transfer the patient to a hospital emergency room for further assessment related to the patient's overall status, abnormal blood work and an abnormal electrocardiogram (EKG) which had been completed the morning of 5/29/2015. The purpose of the emergency room visit was to rule out neuroleptic malignant syndrome, a possible ADR related to psychotropic medication.

The Adverse Drug Reaction Report and Evaluation form was initiated by a registered nurse on 5/29/2015 (no time listed). The ADR form indicated suspected drugs the patient was on included Haldol, Risperdal and Zyprexa (antipsychotic medications) which had the potential to cause neuroleptic malignant syndrome, an ADR. This medication for P14 was placed on a hold, pending the results of the hospitalization.

Medical doctor (MD)-A completed the ADR Report and Evaluation form on 6/1/2015, three days after the ADR was suspected. The physician indicated Haldol and Risperdal should be discontinued.

There was no indication on the ADR form that the pharmacist had been notified of the suspected ADR for P14. A review of P14's progress notes did not indicate the pharmacist had been notified of the suspected ADR nor if the pharmacist had addressed the potential of an ADR.

Pharmacist-A was interviewed on 8/12/2015, at 1:15 p.m. She stated the pharmacist was notified of a potential ADR when the ADR Report was left in the pharmacist's mailbox. She stated the pharmacist used the Naranjo algorithm to determine the likelihood of whether an ADR was actually due to the drug rather than the result of other factors. She stated the pharmacist was responsible to evaluate the ADR and to discuss the ADR reports at the next Pharmacy and Therapeutics Committee meeting, which meets quarterly. The pharmacist agreed it may be better to scan and e-mail the ADR report to the licensed independent practitioner and pharmacist to ensure they received the report immediately.

Pharmacist B, assigned to the hospital, was interviewed by telephone on 8/13/2015, at 10:05 a.m. He stated he was not aware of the potential ADR related to P14's antipsychotic medication. He stated he did not have a set schedule when he was at the hospital but was available by telephone and e-mail. He stated he was usually at the hospital every one to two weeks.

A review of the hospital policy Adverse Drug Reactions, effective April 14, 2014, indicated the charge nurse would immediately notify the licensed independent practitioner and other pertinent staff, which included the pharmacist. The administrator was interviewed on 8/13/2015, at 9:15 a.m. and identified the licensed independent practitioner and the pharmacist were to be notified immediately if an ADR was suspected.

A review of the Pharmacy and Therapeutics Committee meeting minutes, dated 6/25/2015, indicated P14's potential adverse drug reaction was not discussed at the committee meeting.

Based upon observation, interview and document review, the hospital was found to be out of compliance with Life Safety Code Requirements. These findings had the potential to affect all patients in the acute care hospital.

Findings include:

Please refer to Life Safety Code inspections tags K15, K54, K144.

Based on interview and document review, the hospital failed to conduct an evaluation process of all hospital discharges on an ongoing basis for 7 of 7 patients (P3, P4, P21, P22, P23, P24, P25) who were discharged from 3/22/2012 to 5/9/2014.

Findings include:

P3's Discharge Summary dated 3/30/2012, identified the patient's initial admission was 2/14/12-3/22/12, with diagnoses of attention deficit hyperactive disorder, post traumatic stress disorder and oppositional disorder. P3's Psychiatric Assessment of 3/26/2012, listed the second admission, 3/25/12-4/23/12 with the same diagnoses. According to this assessment P3 required a second admission due "aggressive to mother and threatened his sibs [siblings]."

P4's Face Sheet of 9/5/13, identified the initial admission 9/5/13 -11/13/13. P3's diagnoses were: post traumatic disorder, mood disorder, major depression, and anxiety. P3's second admission was from 1/21/2014- 2/8/2014 with the same diagnoses. The third readmission was 2/8/2014 -2/9/2014. This discharge was due to an elopement. The fourth readmission identified in a face sheet of 2/9/14, was from 2/9/2014-3/21/2014, with the same diagnoses in addition to attachment disorder. The fifth readmission per admission face sheet dated 4/15/14 was from 4/15/2014-5/12/2014. Reason for this readmission was due to poor adapting skills in shelter and attempted suicide.

P21's Discharge Summary, dated 5/12/2014 identified the initial admission was from 4/22/2014 to 5/9/2014, with the diagnoses of Autism Spectrum Disorder (ASD); complex pediatric trauma; and anxiety. P21's Psychiatric Assessment of 5/13/2014 identified second admission was 5/13/2014 to 11/11/2014. Per this assessment, P21 first discharge was not successful as the patient "violently aggress towards mother."

P22 's Discharge Summary dated 6/27/12, identified initial admission was 4/25- 6/27/2012. P22's diagnoses included pervasive development disorder, fetal alcohol syndrome, mental retardation and reactive attachment disorder. According to P22's Psychiatric Assessment dated 6/29/2012, P22 was readmitted 6/29/2012-7/12/2012 with the same diagnoses.

P23's Discharge Summary dated 1/7/2013, identified the initial admission was on 9/18/12- 9/21/13. The admitting diagnoses were psychosis, obsessive compulsive disorder and marijuana abuse. P23's discharge on 9/21/13, was due to two elopement attempts, which necessitated a more secure placement for this patient. This Discharge Summary further identified that P23 was readmitted 10/31/2012 and remained until 1/8/2013. His diagnosis remained the same as on initial admission.

P24's Discharge Summary, dated 10/25/13, identified P24 was initially admitted on 9/23/13- 10/23/13, with diagnoses of generalized anxiety disorder and polysubstance abuse. According to the Psychiatric Assessment of 10/25/13, P24 was readmitted on 10/25/2013, and remained until 3/7/2014. His diagnoses remained the same with the addition of suicidal ideations.

P25's Admission Face Sheet listed initial admission on 8/13/2012-8/16/12 with a diagnosis of obsessive compulsive disorder (OCD). Patient was discharged on 8/16/2012 to an acute medical hospitalization and was then readmitted on 10/18/2012 -10/24/12 with the additional diagnosis of eating disorder. P25's third admission per Discharge Summary dated 4/18/13, was from 11/1/2012- 4/17/2013.


There was no evidence the readmissions for the period of 2012 to 2014 had been re-evaluated for effectiveness of their discharge planning process, and readmissions.
During an interview with the administrator on 8/12/15, at 4:15 p.m. she stated there had been a time when they looked at readmissions rates, however, that was dropped from their tracking tool as there had not been any readmissions to date for 2015.

During interview on 8/13/15, at 11:14 a.m. RN-A said she was unable to provide a reason as to why there haven't been any readmissions so far in 2015.

Although the hospital had readmissions from 2012 to 2014, they had not had any readmissions in 2015. The hospital had not completed an overall plan to ensure they were consistent with their discharge planning process for patient readmissions.