HospitalInspections.org

Based on observation, document review, and staff interview, it was determined the hospital failed to:


a. inform patients of their right to submit a complaint or grievance verbally. See Tag A-0121;


b. follow its policy to provide written notice to patients regarding a response to a grievance. See Tag A-0122;


c. notify patients before admission or at the time of admission that there was no physician on-site at the hospital twenty-four hours a day, seven days a week. See Tag A-0131;


d. comply with the patient's rights to information and assistance with advance directives, to include psychiatric advance directives. See Tag A-0132;


e. provide the necessary facilities to safely seclude and protect patients on the geriatric psychiatric unit and failed to follow its policies related to contraband that put patients at risk for harm. See Tag A-0144; and


f. the hospital failed to ensure allegations of verbal abuse, harassment and neglect were investigated and acted upon. See Tag A-0145.

Based on document review and staff interview, it was determined the hospital failed to inform patients of their right to submit a complaint or grievance verbally. This deficient practice had the potential to affect all patients admitted to the hospital.


Findings:


Patient information provided during the course of the survey showed that patients were informed that a complaint or grievance could only be submitted in writing. It was further determined the hospital only recorded and acknowledged those grievances submitted in writing. The hospital had no documentation of complaints or grievances submitted verbally, by e-mail, or by any other means other than those submitted with the official hospital grievance form.


A hospital policy, dated June 2016 and titled, "Complaint/Grievance Resolution," documented, "... A patient may file a grievance by obtaining a grievance form, filling it out, and turning it in to the [word missing] or to any staff member, who gives it to the patient advocate or places it in the locked grievance box... Any patient who needs assistance completing the grievance form is provided assistance by the patient advocate or any other staff member..."


A patient consent and information packet that was given to all patients upon admission documented, "... How To File A Grievance: Grievance forms are located in every nurses station. Write your complaint on the form and include your desired resolution of the problem. Sign the form and return it to the locked box labeled 'Grievances/Complaints.' You may request assistance from a Cedar Ridge employee or other person in getting the form as well as writing and filing a grievance..."


A patient information packet undated and titled, "Generations Program Important Information," documented,"... How To File A Grievance: Grievance forms are available upon request. Write your complaint on the form and include your desired resolution of the problem. Sign the form and return it to the Grievance Coordinator by placing ir in the lock box on the unit. You may request assistance from a Cedar Ridge employee or other person in getting the form, writing and filing a grievance..."


A patient information packet undated and titled, "Adult (1) Stabilization Program Important Information," documented, "... How To File A Grievance: Grievance forms are located in every nurses' station. Write your complaint on the form and include your desired resolution of the problem. Sign the form and return it to the locked box labeled 'Complaints/Grievances.' You may request assistance from a Cedar Ridge employee or other person in getting the form, as well as writing and filing a grievance. Within a short time after your grievance is filed, an attempt will be made, with your participation, to resolve the problem..."


When administrative staff were asked how patients could submit a complaint or grievance, they stated that complaints could be received verbally or in writing and grievances were submitted in writing. Frontline staff also answered in this manner.


A staff training program, titled, "2016 Annual Education Competency Post-Test" documented, "What should a staff person do when a patient wants to file a grievance? ... if the person still wants to document their complaint, the staff person should provide the patient with a blank grievance form and privacy so they can complete it. Ask the staff person to fold the form and place it in the grievance box that is located on every unit..."

Based on document review and interview, it was determined the hospital failed to follow its policy to provide written notice to patients regarding a response to a grievance. This deficient practice had the potential to affect all patients admitted to the hospital.


Findings:


During the course of the survey, the hospital administrative staff were unclear as to the time frames established by the hospital for the written response to patient grievances. A number of policies and patient information documents were reviewed that gave contradictory information to guide staff and patients on this process.


A hospital policy, dated June 2016 and titled, "Complaint/Grievance Resolution," documented, "... When prompt resolution of the grievance is possible, the hospital will provide the patient with written notice of the IPR decision within 3 days of receipt... If the grievance is not resolved, or if the investigation is not or will not be completed within 7 days, the hospital should inform the patient or the patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days in accordance with the hospital's grievance policy..."


The grievance policy did not specify the hospital would provide a written notice when it was still working to investigate and resolve a grievance.


Information given to patients as a part of the admission paperwork did not specify a time frame when patients could expect a written response to their grievances.


Patient grievances were reviewed for 2015 and 2016. The hospital had no documentation it had responded to grievances in writing when the investigation was still on-going and again with its conclusions when the investigation was completed.

Based on document review and staff interview, it was determined the hospital failed to notify patients before admission or at the time of admission that there was no physician on-site at the hospital twenty-four hours a day, seven days a week. This deficient practice had the potential to affect all patients admitted to the hospital.


Findings:


During the course of the survey, the staff were asked if the hospital was staffed with a physician in-house twenty-four hours a day, seven days a week. They stated it was not.


The hospital administrative staff were asked if the hospital had a system to notify patients a physician was not on-site 24/7. They stated they did not.


A review of the information posted in the public areas and in the patient care areas and a review of information provided to patients on admission had no documentation this information was communicated to patients and families.

Based on document review and staff interview, it was determined the hospital failed to comply with the patient's rights to information and assistance with advance directives, to include psychiatric advance directives. This deficient practice had the potential to affect all patients admitted to the hospital.


Findings:


During the course of the survey, the hospital staff were asked to provide the policies and procedures, forms, documents and patient information related to advance directives. The hospital provided two patient admission packets that had no information about advanced directives.


An undated document within one admission packet, titled, "Statement of Patient Rights," had no acknowledgment of the patient's right to advance directives.


An undated document within the admission packet given to the patients to be admitted to the geriatric psychiatric unit, titled, "Cedar Ridge Patient Rights," had no mention of any form of advance directive.


An undated admission information packet given to the patients to be admitted to the adult stabilization unit had no information regarding any form of advance directive.


A hospital policy, dated February 2014 and titled, "Advance Directives," documented, "... As a part of the admission process, all patients will be provided information regarding advance directives by admission staff... At the time of admission, admission staff will ask the patient whether Advance Directices for end-of-life care or psychiatric care have been executed and document the response on the attached 'Advance Directives Acknowledgement Form..."


The medical records reviewed did not include this acknowledgment form.


Hospital administrative staff provided policies and procedures to guide staff on medical advance directives. The staff stated stated they did not have any policies and procedures specific to psychiatric advance directives.

Based on observation, document review, and staff interview, it was determined the hospital failed to provide the necessary facilities to safely seclude and protect patients on the geriatric psychiatric unit and failed to follow its policies related to contraband that put patients at risk for harm. These deficient practices had the potential to affect all patients admitted to the hospital.


Findings:


1. During a tour of the hospital's geriatric psychiatric unit on 08/01/2016, observations were made of the patients and of all the patient care facilities within the unit. It was observed that non-geriatric patients were also admitted to the unit and were present at the time of the tour. The acting director of nurses (DON) was asked if the unit was limited to geriatric patient admissions only. She stated adults patients of all ages could be admitted to the geriatric unit when the other adult unit was full or when a patient needed some level of medical care.


The DON was asked if the unit had a seclusion or security room. She showed the surveyor a room with a large wood dining table and two wood chairs. The furniture was movable. The room had no door, but did have a glass window that looked into the nurses' station. The view from the window was partially blocked on the nurses' station side by shelves, books and equipment. The DON was asked if this was in fact the seclusion room. She stated, "It can be used for that." She verified the room may be used for patients who were physically out of control. It was pointed out that the room had no door and furniture that was unsafe for a seclusion room. She stated, "That's true, but this is how we seclude a patient."


The identified security/seclusion room was not designed to contain and safely manage a physically acting out patient unless staff physically blocked the door and prevented the patient's exit. In addition, the furniture in the room could be overturned or picked up and thrown.


The hospital provided incident reports for 2015 and 2016. The reports documented incidents when patients on the geriatric unit had become physically out of control or assaultive to others including patients, staff and physicians. The reports documented the staff intervened by physically restraining the patients in a "hold" until they calmed down or were adequately sedated with medication.


A patient grievance submitted in 2016 documented a geriatric patient complained that he/she did not feel safe on the unit when the younger patients were out of control.


2. A hospital policy, dated as revised in July 2016 and titled, "Contraband," documented, "... Definition of Contraband: Items that patients are not allowed to have in their possession or in their room... Clothing that is not necessary such as scarves, bandanas, ties, belts... Glass containers or items... any liquids containing alcohol..."


Hospital documentation showed that on 07/09/2016, a patient requested and was allowed to wear a bandana that the patient then used within an hour to attempt suicide by strangulation or hanging.


On 07/17/2016, hospital documents showed that glass cologne bottles were found in a patient's possession when they should have been identified as contraband on admission and on the shifts after admission.


The hospital administrative staff stated the contraband policy had been revised and the staff had been re-trained since those incidents.

Based on documentation review and staff interview, it was determined the hospital failed to ensure allegations of verbal abuse, harassment, and neglect were investigated and acted upon for eleven (#2, 6, 11, 12, 13, 14, 15, 16, 17, 18, and #19) of nineteen patient records reviewed. This deficient practice had the potential to affect all patients admitted to the hospital.


Findings:


1. The hospital provided written patient grievances that documented allegations of verbal abuse, harassment and neglect by staff P that included the following:


~ A 06/30/2016 grievance submitted by patient #2 alleged staff P was "... inappropriate... rude... unnecessarily mean..." The grievance also alleged staff P stated to the patient, "I'm on a break - do you have a problem?..." The patient also alleged staff P "... yelled at me to get my attention and said, 'Do you see how busy I am? Can you give me privacy!'..."


~ A 07/04/2016 another grievance submitted by patient #19 alleged staff P "... refused to let me use a toothbrush... wouldn't take her earbuds out to pay attention..."


An incident report dated 07/09/2016 documented patient #6 attempted suicide with a bandana tied around her neck and also tied to the bed. A hospital disciplinary action report for staff P regarding the suicide attempt made by patient #6 documented, "[Patient] was a new admission with suicidal ideations with a plan to overdose. [Patient] was found in her room... with a bandana tied around her neck and tied to the bed railing. [Staff P] told the risk manager she did not notify the psychiatrist [about the event] because she did not want to wake him. The campus supervisor was not immediately notified [about the event]. Failure to notify the doctor of the patient's condition at the time the patient was found is considered negligence and a safety violation..."


The report also documented the comments staff P wrote in response to the above: "... Why should I be blame (sic) for the above incident when I was not even in charge of the pt. at the time of this incident? I am upset for the fact that I put effort to document the incident that happens (sic) prior shift. I was not in charge of the unit. [Staff name deleted] calls where (sic) made late after this nurse found out the off going did none thing (sic)..."


A narrative note in patient #6's chart documented, "07/12/2016 [7:00 a.m.]... Pt. complains of staff teasing her through the night... redirected her to the nurse staff..." The note was signed by a mental health technician. The medical record had no documentation the technician reported the information to the RN in charge of the unit or the campus supervisor.


The next narrative note documented, "... [3:00 pm] Pt. in room upon my arrival. Pt. tearful when I went for the [7:00 pm] round. Pt. stated she was fine and going to [discharge] tomorrow. Pt. stormed into the day room stating staff was calling her names. Pt. came out to the day room and sat then became upset. Pt. called the police and was stating she felt unsafe on the unit. Pt. continued to make accusations of the staff talking about her. Staff processed with her about issues on the unit. Pt. continued to be agitated and spoke to police. Pt. transferred to Adult I... [10:00 pm] Staff will monitor [every] 15 minutes for safety... [mental health technician name deleted].


A separate page with a late entry narrative note written by staff P was found in patient #6's record that documented, "07/12/2016 [7:30 pm] 'You people are constantly talking about me and I can hear you from my room. I am calling 911 to report this and turn the nurse in to the nursing board.' This behavior of pt. was a shock to nurse for the fact that pt. and nurse had a very good talk about how she love (sic) her life and her daughter who is [senior] in college. 'I am ready to go home and resume my normal routine [and] job and other activities.' Closely monitored [every] 15 minutes per protocol. [9:10 pm] 2 police showed up to the facility [after] pt. placed a 911 call! 'There is a black nurse who (sic) voice I am hearing saying I am a bitch and I need to die.' When the two police officers came, pt. could not even describe that staff who said mean words to her. During her visit [with] the police she requested to be transfer (sic) to [hospital name deleted].... [After] her visit [with] the police, pt. refused to return to Gero [unit]. Note: Pt. will make up stories and accuse you of things that did not happen. Receive (sic) order from [Dr. name deleted] to transfer to Adult 1 [unit]."


The hospital had no documentation the staff who were told about the patient's complaints also reported the patient's allegations of mistreatment to hospital leadership.


~ A 07/12/2016 grievance submitted by patient #6 alleged staff P was described as one of "3 [staff] bullys" who made "verbal threats" toward her. The allegations included a statement made by staff P, "We should have let you die..." This statement was alleged to have been made in reference to the patient's recent suicide attempt. The grievance also documented staff P was one of four staff who placed the patient in a "hold" that included one staff placing his/her knee in the patient's back.


There was no documentation the hospital investigated and acted upon these allegations the patient wrote on a hospital grievance form.


~ A 07/24/2016 another grievance submitted by patient #18 alleged staff P "... gave me the wrong medications [because] she gets overstressed..."


~ A 07/25/2016 another grievance submitted by patient #17 alleged staff P was "... rude... inconsiderate... neglectful..."


There was no documentation the hospital investigated and acted upon these allegations.


2. A hospital disciplinary action report, dated 11/11/2015, documented staff M (a current employee with documentation of previous disciplinary action by the Oklahoma Board of Nursing) was witnessed telling patient #11, "This is not a bed and breakfast." The report documented the patient became distraught and shortly after this comment attempted suicide.


A 03/08/2016 another grievance submitted by patient #16, documented Staff M "... ignored me and treated me like a dog..." There was no documentation of investigation into this allegation.


A 03/21/2016 another grievance submitted by patient #15, documented staff M responded to a patient's request for medication by saying, "I'll get the meds when I'm good and ready..." There was no documentation of investigation into this allegation.


A 07/25/2016 another grievance submitted by patient #17 documented staff M and others were "rude... inconsiderate... neglectful..." There was no documentation of investigation into this allegation.


3. A hospital disciplinary action report, dated 04/03/2016, documented staff R was recorded "screaming at a patient" who refused to end a call made using the unit telephone. The personnel file for staff R documented she was terminated in July 2016 for allowing another patient to have a contraband item that was later used in a suicide attempt.


4. An undated grievance submitted by patient #12 documented staff E was "rude, disrespectful and neglectful." The hospital had no documentation of an investigation into these allegations.


5. An undated grievance submitted by patient #13 documented staff I (a current employee with documentation of disciplinary action by the Oklahoma Board of Nursing) was "rude to patients." There was documentation a mental health technician witnessed the staff-patient interaction and agreed with the patient's statement. There was no documentation the staff who witnessed the event reported it to hospital leadership. There was no documentation of an investigation into the allegations.


6. A 2016 grievance for patient #14 documented staff J told the patient's family member he was "still working with the crazies." The personnel file for staff J (a current employee) had documentation of license verification that showed a disciplinary action had been taken by the Oklahoma Board of Nursing in March 2015. However, the personnel file did not contain the details of the disciplinary action. On 08/02/2016, the hospital was asked to provide this report. The report from the Board of Nursing documented staff J was witnessed verbally abusing a nursing home resident. Staff J was subsequently terminated from employment at the nursing home.


7. A hospital policy, titled "Investigating Allegations of Misconduct Affecting Client Welfare," documented, "... Any staff member to whom a client has reported staff wrongdoing involving mistreatment, sexual abuse, neglect, of clients will immediately report this information to the Patient Advocate and/or Compliance Officer... The Compliance Officer or designee in conjunction with the Clinical Managers and Director of Nursing will initiate preliminary investigation... The staff member(s) under investigation will not work during the investigation, possibly 'on administrative leave,' or if appropriate, work within an approved safety plan pending the outcome of the investigation..."


The hospital had no documentation of any staff reports when patients made allegations of mistreatment by other staff members. The hospital had no documentation it investigated all patient allegations. There was no documentation of actions taken to protect patients during the investigations.


8. A staff training document, titled "2016 Annual Education Competency Post-Test" documented, "... Abuse/Neglect Reporting Obligations... Staff member's responsibilities: Report this information to the immediate supervisor... Report this information to the unit nurse so that the unit nurse can contact the physician... Report this information to the... therapist... Report suspected abuse to the DHS abuse hotline... Document the information regarding the report... in the patient medical record... inform the Cedar RIdge Compliance Officer and the Cedar Ridge Clinical Manager..."


On 07/12/2016, the Oklahoma State Department of Health was notified that Cedar Ridge staff P made a report to the DHS Adult Protective Services that patient #3 made allegations of rape toward other patients and staff members. The medical record for patient #3 had no documentation staff P had reported to the DHS hotline the patient's allegations of rape. The hospital provided no documentation it was aware of the allegations and the staff leadership stated there was documentation of an investigation.


9. On 08/01/2016, hospital leadership stated that persons assigned to respond to complaints and grievances had failed to identify trends and to investigate or ensure investigation into all allegations made by patients. They stated they were unaware of all the patients' allegations made against staff P and others among the nursing staff. On 08/02/2016, the hospital CEO stated staff P had been terminated from employment on the previous afternoon.

Based on record review and staff interview, it was determined the hospital failed to:


a. require nursing services to report on relevant quality indicators for the provision of care;


b. ensure RN staff assessed and evaluated the care provided to patients. See Tag A-0395; and


c. the hospital failed to ensure medications were administered safely. See Tag A-0405.


Findings:


On 08/01/2016, the hospital leadership was asked to provide documentation of nursing services reports to the quality assessment and performance improvement (QAPI) program for 2015 and 2016. The QAPI data provided for nursing services included rates for nursing staff turnover and employee injuries.


Hospital leadership stated that "obtaining patient vital signs as ordered by the physician, RN nursing assessments" and patient monitoring after the first dose of a new medication" were the focus of the nursing services QAPI program for 2016. The hospital had no documentation to show that reports regarding these quality indicators was provided to the QAPI committee.


Later on 08/02/2016, the hospital leadership provided data summary reports for:


~ "Following the first dose of medication, documentation of the effectiveness of the medication is required within one hour." The document was not dated with the year. However, the report documented 50% compliance in April, 100% compliance in May and 28% compliance in June.


The patient medical records reviewed had no documentation of an RN assessment of the patient's response to new medications, to include the presence or absence of side effects. In addition, the nursing staff did not document the effectiveness of "as needed" medications.


~ "Vital signs will be completed according to physicians order." The document was not dated with the year. However, the report documented 72% compliance in April, 100% compliance in May and 97% compliance in June; and


~ "If the nursing assessment prompts the need for a dietary consult, the dietary consult was completed according to policy." The document was not dated with the year. However, the report documented 100% compliance in April, May and June.


None of these reports were found in the 2015 or 2016 QAPI meeting minutes.


The patient records reviewed did not indicate the RN staff were documenting care to show improvements in those quality indicators.


A review of patient records showed the RN nursing staff completed a pre-printed patient assessment form that included check marks in boxes. The staff stated this was completed once every 24 hours by an RN. None of the records reviewed had documentation of narrative details of the RN assessment. Many records had no documentation of narrative information written by an RN in the progress notes, even when there was a change in the patient's condition. The records indicated changes in condition were usually documented by mental health technicians.

Based on document review and staff interview, it was determined the hospital failed to ensure the RN nursing staff assessed and evaluated the care for each patient.


Findings:


1. On 07/09/2016 at 9:30 p.m., patient #6 was admitted with physician's orders for suicide precautions. Staff R, the RN who completed the admission assessment, documented the patient was actively suicidal. Within two hours of admission, the patient requested and was given her bandana that was then used to attempt suicide at 11:30 pm. Two RN staff, including staff R, the admitting RN, and staff P, were present at the change of shift when the event occurred. There was no documentation of the attempt until staff P added an entry into the medical record sometime later. Staff P made no other entries in the medical record for the remainder of the overnight shift. In addition, the patient's physician was not notified of the suicide attempt until the next day, 12 hours later. Staff P, the RN who wrote the late note about the suicide attempt, stated in a disciplinary record that she did not want to wake the physician that night to tell him about the patient's suicide attempt.


On the morning shift on 07/10/2016, the RN documented the patient made a verbal contract with staff to not harm herself. The next RN documentation was at 12:40 pm when the patient was seen by the physician and placed on 1:1 staff monitoring. There were no other narratives details of an RN assessment on any shift for the first 24 hours of admission. RN staff C documented at 5:00 p.m. the patient was identifying things in her room she could use to commit suicide. At 7:00 p.m., staff C documented the physician was notified and new orders were received. No orders were documented in the medical record for this time period.


2. Admission orders dated 07/09/2016 for patient #6 documented the physician ordered the following lab tests: urinalysis, complete blood count, comprehensive metabolic profile, thyroid profile and urine drug screen. Staff R documented she transcribed the verbal orders at 10:00 pm. Staff P, who was the on-coming shift RN, did not verify the orders had been processed. On 07/10/2016 at 1:35 p.m., the physician documented the patient had "recent heavy use of alcohol and Xanax. The physician's orders were signed as reviewed by multiple RNs after the patient's admission. As of 08/02/2016, the patient's record had no documentation the lab tests were ever obtained or completed. The hospital administrative staff were asked to located the test results and none were found. They stated they could not verify the lab tests were ever obtained.


3. The medical record for patient #16 documented on 03/09/2016 the patient complained of pain, anxiety and sleeplessness. Staff P documented the patient was treated with medications for these complaints. The record did not include a pain assessment and did not document the RN's evaluation of the effectiveness of these medications.


4. The medical record for patient #2 admitted on 06/25/2016 documented the physician ordered lab tests to include a thyroid profile and a Depakote level. The physician's orders were checked that night by staff P for verification that all orders had been correctly processed. The medical record had no documentation the lab tests were obtained.


5. Patient #9 was discharged from the hospital on 07/06/2016. There was no documentation an RN assessed and documented the patient's condition on the day of discharge.


6. Patient #17 was admitted on 07/16/2016 by staff P who documented on a nutritional assessment the patient was 5'7" tall and weighed 121 pounds and had a poor appetite. The RN did not request a dietitian consultation. On 07/20/2016, the patient's weight was documented as 115 pounds. The patient was subsequently ordered an appetite stimulant, a nutritional supplement and medication for nausea. Other than the admission assessment, the medical record had no RN assessment and evaluation of the patient's nutritional status.

Based on document review and staff interview, it was determined the hospital failed to ensure medications were administered safely by the nursing staff.


Findings:


On 08/02/2016, the hospital leadership was asked to provide documentation of medication errors from August 2015 to the August 2016. During that period, the hospital documented 201 occasions when medication errors were identified by staff. Some of the events represented multiple medication errors for one or more patient, over multiple shifts and days and with one or more medications.


The types of medication errors included:


~ failure to transcribe correct medication names, dosages or timing of administration in the medical records

~ transcription of a medication orders in the wrong patients' records

~ failure of the nursing staff to check and verify medication orders and transcriptions in the medical record for accuracy

~ failure to transmit medication orders to the pharmacy

~ failure of the physician to verify and authenticate verbal or telephone orders transcribed into the patients' medical records

~ failure to administer medications that were ordered

~ failure to document when medications were administered

~ administering the wrong medication to patients

~ administering medications without a physician's order

~ administration of excessive dosages of medications

~ administering high risks medications without verification they were correctly ordered


A review of clinical records for patients in the survey sample had documentation the nursing staff transcribed routine and "as needed" medications on a single medication administration record, rather than separating "as needed" medications on another page. This practice was found in all 15 records reviewed. By looking at the hand-written medication administration records, it was difficult to determine what medications were to be given on a routine basis and which medications were "as needed" only.


Hospital leadership was asked to provide documentation of the investigation (root cause analysis) of medication administration errors. The hospital had no documentation the pharmacy or the nursing leadership performed analysis of medication errors. The hospital provided a description of the error event. As a result, the hospital had not identified trends with certain staff, shifts, physicians, medications, the medication administration environment or the systems or policies and procedures that may be responsible or may contribute to the opportunity for errors.


The hospital staff provided "medication administration record audits" that looked to see if all the medications written on the administration record had in fact been given. This audit did not include a review to verify the medications on that record were correctly transcribed from the physician's orders.


The hospital staff provided a document titled, "2016 Annual Education Competency Post-Test." The training did not include safe medication administration as a topic for the year.