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48050

Based on record review and interview, the hospital failed to ensure grievances were resolved in a timely fashion and following established timelines. The deficient practice is evidenced by failure of the hospital representative to send a letter explaining that it would take longer than 7 days to resolve a grievance for 1 (#4) of 9 (#2, #4-#11) reviewed grievances.
Findings:

Review of Policy 0111, "Process for Acknowledging and Resolving Patient Complaints and Grievances," revised 12/2020, revealed in part, "If a grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the Department of Patient Experience will inform the patient or the patient representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response with 15 days."

Review of the report of the incident submitted to the licensing authority revealed on 05/14/2024 Patient #4 reported that security had physically abused her after an attempted elopement causing pain in her arm. Further review of the report revealed that the grievance was not substantiated and was closed on 05/21/2024.

In interview on 05/10/2024 at 2:53 p.m., S9RM verified that a letter had not been sent because the parties involved were trying to decide which investigator would be listed as the contact in the letter. S9RM verified it had been 20 days since the grievance was closed.

In interview on 06/11/2024 at 12:28 p.m., S3DS and S4MRA verified there was no documented contact or letter sent to the patient when it was determined that the grievance could not be thoroughly investigated within 7 days as per the policy.

48050

Based on record review and interview, the hospital failed to ensure all grievances were investigated and resolved according to hospital policy. The deficient practice is evidenced by: 1) failure to include the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process in the written notice sent to 6 (#5, #7, #8, #9, #10, #11) of 6 (#5, #7, #8, #9, #10, #11) reviewed letters sent after closure of a grievance; and 2) failure to document that a letter was sent after closure of a grievance to 1 (#2) of 3 (#2, #5, #6) reviewed grievances involving sexually inappropriate behavior by a member of hospital staff.
Findings:

Review of Policy 0111, "Process for Acknowledging and Resolving Patient Complaints and Grievances," revised 12/2020, revealed in part, "Grievance: is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with CMS Hospital Conditions of Participation, or Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. . . . In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains: the name of the hospital contact person; the steps taken on behalf of the patient to investigate the grievance; the results of the grievance process; and the date of completion."

1) Failure to include the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process in the written notice.

Review of the grievance letters for Patients #5, #7, #8, #9, #10, and #11 revealed the same grievance letters sent to all patients which did not include steps taken on behalf of the patients or the results of the investigation.

In an interview on 06/11/2024 at 12:30 p.m. S15ELPE verified that the hospital does not include the steps on behalf of the patient in the grievance investigation or the results of the investigation in the letter that is sent to the patient. Furthermore, S15ELPE verified that all patients receive the same generic letter after the investigation is complete.

2) Failure to document that a letter was sent after closure of a grievance involving sexually inappropriate behavior.

Review of the report sent to the state licensing agency revealed Patient #2 reported on 04/30/2024 that she felt she was inappropriately touched by S10CT during a study for evaluation of segmental pressures of the lower extremities. The report documented that an investigation was completed and the accusation was not substantiated. Further review of the provided documentation failed to reveal a letter was sent to Patient #2 explaining how the grievance was investigated and the results of the investigation.

In interview on 06/11/2024 at 2:03 p.m., S3DS verified a letter was not sent to Patient #2 after the grievance was closed.

Based on record review and interview, the facility failed to provide care in a safe setting. The deficient practice is evidenced by failure to provide documentation of education for contracted security staff on hire and after an elopement. Findings:

Review of the elopement of Patient #1 on 05/12/2024 revealed a contracted security person, S12AS, was assigned to monitor the traffic in and out of the door where Patient #1 exited, but failed to alert hospital police when a patient in paper scrubs exited the building through the door he/she was monitoring.

On 06/10/2024 the surveyor requested verification that the contracted security personnel were re-educated. The documentation provided on 06/11/2024 had no date on it and only 7 from a total of 36 employees had reviewed the educational information. Further review revealed S12AS had not been re-educated after the incident.

On 06/11/2024 at 9:40 a.m., the surveyor requested to review the personnel file for S12AS

In interview on 06/11/2024 at 10:59 a.m., S4MRA verified they did not have complete records for the contracted security and were waiting for them to be sent from the agency.

In interview on 06/11/2024 at 1:27 p.m., S6DHR stated that the contracted agency was responsible for the credentialing and education of its employees and, per the contract, the documentation was to be made available to the hospital as needed.

In interview on 06/11/2024 at 2:30 p.m., S4MRA verified Agency A had only documented the education of 7 from a total of 36 employees and S12AS had not received the education.

At the time of exit at 3:20 p.m., the personnel file with education and orientation for S12AS still had not been provided. S4MRA and S6DQIC verified the facility had not provided any proof S12AS was ever educated on his/her duties at the hospital.

48050

Based on record review and interview, the hospital failed to protect patients from possible abuse and/or neglect. The deficient practice is evidenced by the failure of individual departments to submit information about disciplinary actions to the human resources department for documentation in the official personnel file for 2 (S10CT and S11EDC) of 2 reviewed personnel with disciplinary actions.
Findings:

S10CT
Review of the reported incident from 1/27/2021 revealed Patient #6 complained that she had been inappropriately touched by S10CT while he performed a transthoracic echocardiogram. The hospital investigation determined the accusation could not be substantiated. Further review of the document revealed the report was prepared by S9RM and S13NMIC, the manager over S10CT, was listed as a participant in the investigation.

Review of the reported incident from 03/22/2022 revealed Patient #5 complained that she had been inappropriately touched by S10CT while he performed and echocardiogram. The hospital investigation revealed the accusation could not be substantiated. The document was prepared by S9RM and documented "NA" after Question #12 which asked, "Did the aggressor have a history of this behavior? If yes, what interventions related to the behavior were in place at the time of the incident?" Further review of the report revealed S10CT was immediately pulled from his duties to speak with S13NMIC. Education and training was provided to S10CT and S10CT was required to have a chaperone when performing echocardiograms or document verbal consent from the patient that a chaperone was not necessary.

Review of the reported incident from 04/30/2024 revealed Patient #2 reported she was inappropriately touched by S10CT during a study for evaluation of segmental pressures of the lower extremities. The hospital investigation revealed the accusation could not be substantiated. The document was prepared by S9RM and there was no answer after Question #12 which asked, "Did the aggressor have a history of this behavior? If yes, what interventions related to the behavior were in place at the time of the incident?" Further review of the report revealed S10CT was immediately pulled from his duties to speak with S13MNIC and S6DHR. S10CT was suspended from his duties pending the completion of the investigation. Under the Comments Section of the form the facility documented, "The complaint will be documented in the employee's file to monitor for trends. [S10CT] will receive counseling on maintaining body awareness and ensuring our patients receive safe and comfortable care."

On 06/11/2024 at 9:40 a.m., the surveyor requested copies of the investigation into Patient #2's grievance and was later provide with documentation of the disciplinary actions for S10CT from 03/22/2022 and 04/10/2024. In the verbal counseling from 05/10/2024 it stated that S10CT had no prior incidents documented.

In interview on 06/11/2024 at 11:30 a.m., S13MNIC was questioned why the documentation of the disciplinary action from 05/10/2024 documented that there had been no prior similar incidents with S10CT. S13MNIC verified that she had not written the letter, only signed it. S13MNIC verified S6DHR wrote the letter.

In interview on 06/12/2024 between 1:14 p.m. and 1:30 p.m., S6DHR verified the complaints and disciplinary actions for S10CT were not documented in the file maintained by the Human Resources Department. The documents were maintained in the file held by the department where each worked by the director of the department. S6DHR was questioned about the documented disciplinary action from 05/01/2024 and why it stated there were no other similar incidents. She stated that she called and asked S13MNIC if there had been any prior incidents involving S10CT before writing the letter, and S13MNIC verified that there were no other incidents.

S11EDC
Review of the report sent to the licensing agency revealed Patient #1 was admitted on 05/10/2024 under a Physician's Emergency Certificate (PEC) and was placed on one to one observation with a sitter. On 05/12/2024 around 11:02 a.m., Patient #1 eloped from the ED and exited the hospital through a door with assigned security personnel. An alert for the elopement (Dr. Fight) was announced when the assigned sitter realized Patient #1 was missing. The report documented that S11EDC had turned away from her one to one assignment to scan documents, and was negligent in her duties as a one to one sitter.

Review of the personnel file for S11EDC on 06/11/2024 failed to reveal the employee had any disciplinary actions.

In interview on 06/11/2024 between 11:14 p.m. and 1:30 p.m., S6DHR verified there was no disciplinary action in the personnel file. S6DHR suggested that S5EDD be contacted for the documentation.

In interview on 06/11/2024 at 1:53 p.m., S5EDD presented the documentation of the disciplinary action signed by S5EDD and S11EDC on 05/10/2024. S5EDD verified he should have sent the documentation to Human Resources but failed to send it.

48050

Based on record review and interview, the facility failed to ensure the accuracy of data collected as part of the quality improvement process. The deficient practice is evidenced by failure to identify significant errors or omissions in the documentation for 4 (#1, #2, #4, #5) of 5 (#1, #2, #4, #5, #6) reviewed records with investigations involving allegations of possible abuse or neglect.
Findings:

Patient #1
Review of the medical record for Patient #1 revealed admission on 05/10/2024 for altered mental status and electrolyte imbalances. Patient #1 eloped from the ED on 05/12/2024 when the sitter assigned to the one to one observation turned her back on the patient's room to scan documents.

Review of the report sent to the licensing authority revealed the specific location of the event was documented as ED Room 2567.

During the tour of the ED on 06/11/2024 between 2:30 p.m. and 2:50 p.m., the surveyors asked to see ED Room 2567 to understand its proximity to the nursing station and the scanner. S5EDD was guiding the tour and expressed doubt that the room number in the report was right, because the scanner was on the end of nursing station other side of the room in all the pods. S5EDD verified that all the pods were parallel and identically arranged.
S4MRA called to have the medical record reviewed and it was verified that Patient #1 was in ED Room 2553, which was in a different pod and situated near the end of the nursing station where the scanner was also located.

Patient #2
Review of the clinic record for Patient #2 revealed she was an outpatient in the clinic who presented to Non-Invasive Cardiology for bilateral segmental pressures of the lower extremities on 04/30/2024.

Review of the report provided to the licensing authority revealed Patient #2 reported she was inappropriately touched by S10CT while he performed the study. The investigation documented that the accusation could not be substantiated. The report was prepared by S9RM who had prepared two previous reports involving accusations of sexually inappropriate touching by S10CT. S9RM failed to provide an answer after Question #12 which asked, "Did the aggressor have a history of this behavior? If yes, what interventions related to the behavior were in place at the time of the incident?"

In interview on 06/11/2024 at 12:09 p.m., S14FN verified that she had spoken to Patient #2 after the event. She said Patient #2 was not comfortable with the way S10CT tucked the towel in her underwear and that S10CT had raised the level of the bed to a point where Patient #2's hands grazed his genitals.

In interview on 06/11/2024 between 1:14 p.m. and 1:30 p.m., S6DHR verified she met with S10CT immediately after the event as part of the investigation. S6DHR read the report provided to the licensing agency and verified the report did no document that S10CT had tucked a towel in the underwear of Patient #2 as part of the procedure or that he raised the level of the table to comfortable work height which might have been at the level of his genitals.

Patient #4
Review of the medical record for Patient #4 revealed she presented to the Emergency Department on 05/13/2024 with a diagnosis of suicidal ideation.

Review of the report provided to the licensing authority revealed on 05/13/2024 Patient #3 tried to elope but the officer "places a hand on her back and her right arm to usher her back into her room." During the next shift Patient #2 reported to the nurse that she had pain in the right forearm "from when the officer grabbed her earlier." Further review of the document revealed the date of the incident listed at the top of pages 2, 3, 4, and 5 is reported as 04/26/2024.

In interview on 06/10/2024 at 2:53 p.m., S9RM verified she had prepared the document and that the incident had occurred on 05/13/2024 and the investigation was closed on 05/21/2024.

Patient #5
Review of the medical record for Patient #5 revealed admission on 03/22/2022 for surgical repair of a right femoral neck fracture.

Review of the report provided to the licensing authority revealed on 03/22/2022, Patient #5 had an echocardiogram performed by S10CT and reported that S10CT had touched her inappropriately. The investigation documented that the accusation could not be substantiated. The report was prepared by S9RM who had prepared one previous report involving accusations of sexually inappropriate touching by S10CT 2 months prior. S9RM answered NA to Question #12 which asked, "Did the aggressor have a history of this behavior? If yes, what interventions related to the behavior were in place at the time of the incident?"

In interview on 06/11/2024 at 2:46 p.m., S4MRA verified S9RM had prepared the reports for the incidents on 01/27/2022, 03/22/2022, and 04/30/2024 involving accusations of inappropriate touching by S10CT and should have documented the previous accusation in the report for the incidents on 03/22/2022 and 04/30/2024.

48050

Based on record review and interview, the facility failed to take preventative action after an elopement from the emergency department (ED). The deficient practice is evidenced by failure to document re-education of all emergency department staff and security personnel after negligence in performance of duty was determined in the investigation of the event.
Findings:

Review of the report sent to the licensing agency revealed Patient #1 was admitted on 05/10/2024 under a Physician's Emergency Certificate (PEC) and was placed on one to one observation with a sitter. On 05/12/2024 around 11:02 a.m., Patient #1 eloped from the ED and exited the hospital through a door with assigned security personnel. An alert for the elopement (Dr. Fight) was announced when the assigned sitter realized Patient #1 was missing. The report documented that S11EDC had turned away from her one to one assignment to scan documents.

In interview on 06/10/2024 at 2:28 p.m., S4MRA verified there was a security person assigned to door where Patient #1 exited. S4MRA verified the security person should have called for help if he/she saw someone leaving the hospital in purple scrubs.

In interview on 06/10/2024 at 2:32 p.m., S3DS verified they did not know the name of the security person who was assigned to the door where Patient #1 exited. S3DS also verified the contracted agency was supposed to re-educate the security personnel and the contact person was not available to provide the information. S3DS verified she did not know any details about the education and did not know if the hospital had provided the educational material.

In interview on 06/10/2024 between 2: 54 p.m. and 2:58 p.m., S5EDD verified there was no documentation for the education provided to the ED staff after the event.

In interview on 06/10/2024 at 3:13 p.m., S4MRA verified the security person assigned to the exit where Patient #1 eloped was S12AS.

On 06/11/2024, the documentation of the re-education of the security personnel was provided. The educational material had no date for the education and read as follows:

This encompasses multiple policies here at the hospital. Below is what [Agency A] staff need to be trained in concerning the use of purple scrubs within the hospital.

Patients wearing purple scrubs indicates that the patient is a psych hold patient. If an [Agency A] officer assigned to the hospital observes a patient wearing purple scrubs who is not being escorted by medical/ hospital staff, they should inquire and contact DPS Dispatch immediately via their post issued radio or their cell phone. DPS Dispatch will then advise or start the process of identifying the status of the patient and attempt to stop their departure from hospital property.

Further review of the documentation of the education provided to the security personnel from Agency A revealed that only 7 from a total of 26 employees had reviewed the information, and S12AS had not been re-educated.

During an interview on 06/11/2024 at 1:53 a.m., S5EDD provided documentation of the warning given to S11EDC. S5EDD again verified he had no documentation to prove the rest of the ED staff had been educated after the elopement.

In interview on 06/11/2024 at 2:30 p.m., S4MRA verified Agency A had only documented the education of 7 from a total of 26 employees and S12AS had not received the education.

48050

Based on record review and interview, the hospital failed to ensure the Registered Nurse (RN) performed assessments according to hospital policy. The deficient practice is evidenced by failure of the registered nurse to perform the admission assessment within 8 hours of admission for 1 (#1) of 4 (#1, #3, #5, #6) reviewed records of patients admitted to the facility.
Findings:

Review of the policy "Screening, Assessment, and Reassessment," reviewed 12/2021, revealed in part, " Policy:- Assessments- For additional unit specific documentation requirements, refer to unit specific protocols in Appendix B.- Each patient will have an initial nursing assessment completed upon admission." Review of Appendix B revealed the time frame for the initial nursing assessments for admitted patients ranged from within the first hour for intensive care units to within 8 hours for regular units.

Review of the medical record for Patient #1 navigated by S7RN revealed admission on 05/10/2024 at 11:09 p.m. Further review of the medical record revealed the admission nursing assessment was initiated on 05/12/2024 at 10:23 a.m.

In interview on 06/10/2024 at 1:59 p.m., S7RN verified the admission assessment was not performed within the timeframe specified by the hospital policy.