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Based on interviews and record reviews the facility failed to implement an effective grievance process for one sampled patient (Patient 1).

Findings:

1. Patient 1's record was reviewed with the Director of Clinical Informatics (DCI). Patient 1's record indicated:

a. 92 year old Patient 1 was initially admitted to the facility for GI (gastrointestinal) evaluation and treatment for recurrent esophageal stricture (narrowing of the esophagus) on 2/8/2022. Patient 1's diagnoses included chronic kidney disease stage 4. Patient 1 was discharged home from the facility on 2/11/2022 at around 5 PM.

b. On 2/11/2022 at around 9 PM, Patient 1 returned to the facility ED (emergency department) via ambulance for fever, cough and generalized weakness. Patient 1 tested positive for COVID-19 in the ED and was admitted. Patient 1 was discharged home from the facility on 2/17/2022, discharge diagnoses included acute COVID-19 infection, acute hypoxic respiratory failure and acute pneumonia secondary to COVID-19 infection.

c. On 2/21/2022 returned to the facility ED for difficulty breathing and low oxygen level. In the ED Patient 1 was found to be hypoxic (absence of enough oxygen) with worsening persistent bilateral (both lungs) pulmonary infiltrate (substance associated with pneumonia). Patient 1 was discharged home with hospice care on 3/3/2022 and subsequently passed away on 3/9/2022.

2. The facility's grievance log was reviewed. The grievance log indicated a grievance related to Patient 1 dated 3/28/2022. The grievance was reviewed with the Vice President for Quality (VPQ). The grievance indicated multiple concerns during the patient's admission in the facility from 2/8/2022 through 3/3/2022. The grievance concerns included communication, physician services, discharge, quality of care and treatment plan. The VPQ was unable to provide documentation of Patient 1's grievance analysis and/or investigation, referral for Peer Review, or identified results reported for quality improvement activities. The VPQ stated "None of the leadership that was involved with the case is with the hospital anymore. Considering the grievance information provided by the family the case should have been reported and considered for review through the Peer Review Process and tracked through the ongoing professional practice evaluations as per policy." The VPQ further stated there was an email about the need to bring the case to peer review but there was no documentary evidence of Patient 1's case being brought into consideration for peer review.

3. The facility's policy and procedure titled "Patient Grievance Process" last reviewed 1/21 indicated, "...PURPOSE: To provide a mechanism for receiving and responding to patient and family complaints concerning the quality of care; to analyze patient grievances which relate to their care and the quality of medical services while hospitalized; to identify measures to prevent further grievances of similar nature...Grievance involving licensed independent practitioners will be reported and reviewed through the Peer Review process and tracked through the ongoing professional practice evaluations...It is ultimately the responsibility of the (facility name) leadership team to resolve complaints and or grievances following the policies and procedures established by the hospital. The primary objective is to protect the patient's rights while being a patient advocate. The results are reported to appropriate Director/staff for quality improvement..."

Based on interviews and record reviews the facility failed to immediately protect other patients from alleged abuse healthcare staff perpetrators after allegations of abuse were reported, for two (Patient 2 and Patient 3) out two allegations of abuse reviewed.

Findings:

1. On 1/10/2023 the abuse investigation related to Patient 2 and Patient 3 were reviewed with the Vice President of Human Resources (VPHR). The investigations indicated the following:

2a. On 6/13/2022 at around 9:30 PM Patient 2 reported that she was startled awake to the feeling of someone holding her left breast. Patient 2 stated she was half asleep, a male patient care technician (PCT) was unsnapping her gown was pulling on the tabs on her chest (monitor box leads). Patient 2 stated PCT was cupping her breast and it felt intentional.

2b. The Charge Nurse changed PCT's assignment that night and assigned him to another patient in the unit. The PCT continued to work that night and finished his shift at 7 AM.

2c. The "Punch Detail Report" for PCT on 6/13/2022 indicated time in 18:53 (6:53 PM) , time out 6/14/20222 (7:37 AM) (10 hours after the allegation of abuse was reported by Patient 2).

3a. On 8/26/2022 at around 9 AM Patient 3, who was a vulnerable adult, reported " ...(name of staff sitter - SITTER) he's been texting me and asking me about my dick size, about having a threesome ...has been grooming him ..." The VPHR stated the facility substantiated the allegations.

3b. The SITTER's assignment was switched after the allegation was made on 8/26/2022. The SITTER was moved from the reporting patient to another Baker Act patient (another vulnerable adult).

3c. The "Punch Detail Report" for SITTER on 8/26/2022 indicated time in 7:13 AM, time out 8/26/2022 4:37 PM (7 and a half hours after the allegation of abuse was reported by Patient 3).

4. The VPHR stated PCT and SITTER should have been removed from the floor immediately after the allegations were made to protect other patients in the facility.

5a.The facility policy and procedure titled "Allegation of Sexual Misconduct/Abuse by a Healthcare Worker" approved 11/11/20, was reviewed with the Chief Nursing Officer (CNO). The CNO stated the policy applies to all types and forms abuse allegations by a facility healthcare worker (facility staff to patient abuse). The CNO stated the policy and procedure is specific to all facility staff-to-patient abuse allegations. The CNO stated the facility policy and procedure did not indicate immediate removal of the staff perpetrator from the unit/floor after an abuse allegation was reported.

5b. The policy and procedure indicated, "...PROCEDURE: All health care workers shall be responsible for reporting any allegation or suspicion of sexual misconduct/abuse to the Patient Safety Office. The Healthcare Worker who identifies the allegation of sexual misconduct/abuse, will: 1. Ensure the safety of the patient; 2. Immediately notify their supervisor/chain of command; 3. Notify the patient's physician of the allegation; and 4. Complete an Occurrence report of the incident. The Director of Patient Safety/Designee shall: 1. Notify the Chief Executive Officer...3. Investigate the allegation of sexual misconduct/abuse, which was made against the healthcare worker, who has direct patient contact...7. Healthcare workers involved in the allegation shall be immediately suspended pending investigation..."

Based on review of medical records, review of policy and procedure and staff interview it was determined the facility failed to ensure restraints were discontinued at the earliest possible time for one (#5) of two restrained patients of ten patients sampled.

Findings included:

Review of the facility policy, "Patient Restraint and Seclusion," last reviewed 4/2021 revealed Section (11) Discontinuation of Restraint or Seclusion, (a) the patient in restraint is evaluated frequently and the intervention is ended at the earliest possible time; (b) when an RN (Registered Nurse) determines that the patient meets the criteria for release, the restraint or seclusion are discontinued by staff with demonstrated competence; Section (12) Documentation Requirements: the medical record contains documentation of (n) Restraints or seclusion removal/termination.

Review of the medical record for patient #5 revealed a physician order dated 1/2/2023, at 3:08 AM for non-violent restraint usage of bilateral upper extremity with soft wrist restraints for attempted removal of medical device and handling of wound/dressing. Review of the record revealed the patient remained in bilateral upper extremity restraints until 1/3/2023 at unknown time. The record did not reveal documentation of the time of the restraint removal/termination.

Interview with the Director of Clinical Informatics on 1/11/2023 at 1:50 PM confirmed the above findings.

Based on review of medical records, review of policy and procedure and staff interview it was determined the facility failed to monitor the condition of the patient, per facility policy, for one (#5) of two restrained patients of ten patients sampled.

Findings included:

Review of the facility policy, "Patient Restraint and Seclusion," last reviewed 4/2021 revealed Section (7) Monitoring the Patient in Restraints or Seclusion, (b) an RN (Registered Nurse) will assess the patient at least every two (2) hours. The assessment will include where appropriate: signs of injury associated with restraint, respiratory and cardiac status, psychological status, needs for range of motion, hydration/nutritional needs are being met, hygiene, toileting needs are met, patient's rights, dignity, and safety are maintained, patient's understanding of reasons for restraint and criteria for relase from restraint, and consideration of less restrictive alternatives to restraint.

Review of the medical record for patient #5 revealed a physician order dated 1/2/2023, at 3:08 AM for non-violent restraint usage of bilateral upper extremities with soft wrist restraints for attempted removal of medical device and handling of wound/dressing. Review of the record revealed the restraints were applied on 1/2/2023 at 2:12 AM. Review of the RN assessments revealed an assessment was completed at least every two hours until 6:00 AM. Review of the record revealed the next RN assessment was conducted at 10:45 AM, a total of 4 hours and 45 minutes. The next RN assessment was at 12:09 PM and then at 4:20 PM, a total of 4 hours and 11 minutes. The next RN assessment was at 6:50 PM, a total of 2 hours and 30 minutes. The RN failed to follow the facility policy for assessment of the patient's condition, needs, and patient's rights while restrained.

Interview with the Director of Clinical Informatics on 1/11/2023 at 1:50 PM confirmed the above findings.

Based on review of medical records, review of policy and procedure and staff interview it was determined the facility failed to ensure the 1-hour face-to-face medical and behavioral evaluation was conducted for a patient placed in restraint for violent/self-destructive behavior for one (#5) of two restrained patients of ten patients sampled.

Findings included:

Review of the facility policy, "Patient Restraint and Seclusion," last reviewed 4/2021 revealed Section (9) Face-to-Face Assessment by a Physician or LIP (Licensed Independent Practitioner), (a) a face-to-face assessment by a Physician or LIP, RN (Registered Nurse) or PA (Physician Assistant) with demonstrated competence, must be done within one (1) hour of restraint initiation... to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. At the time of the face-to-face assessment, the LIP/Physician/RN/PA will: work with staff and patient to identify ways to help the patient regain control; evaluate the patient's immediate situation; evaluate the patient's reaction to the intervention; evaluate the patient's medical and behavioral condition; evaluate the need to continue or terminate the restraint or seclusion; and revise the plan of care, treatment and services as needed.

Review of the medical record for patient #5 revealed a physician order dated 1/2/2023, at 12:32 AM for violent restraint usage of bilateral upper extremities with soft wrist restraints for attempting self-harm and removal of medical equipment. Review of the record revealed no documentation of a face-to-face assessment. Staff failed to follow the facility policy for assessment of the patient's condition, needs, and patient's rights while restrained for violent behavior.

Interview with the Director of Clinical Informatics on 1/11/2023 at approximately 1:50 PM confirmed the above findings.

Based on interview and record review the facility failed to ensure a nursing plan that hearing impairment was initiated and implemented for one sampled patient (Patient 1).

This failure resulted in the potential for increased feelings of isolation and decline for Patient 1.

Findings:

1. On 1/6/2022 Patient 1's spouse was interviewed in relation to a complaint. Patient 1's spouse stated Patient 1 was hard of hearing and required the use of a hearing aid to be able to participate in meaningful interactions.

2. Patient 1's record was reviewed with the Director of Clinical Informatics (DCI). Patient 1's record indicated:

a. 92 year old Patient 1 was initially admitted to the facility for GI (gastrointestinal) evaluation and treatment for recurrent esophageal stricture (narrowing of the esophagus) on 2/2/2022. Patient 1's History and Physical dated 2/8/2022 indicated "...This a pleasant elderly white male...awake, alert and oriented..." Patient 1 was discharged home from the facility on 2/11/2022 at around 5 PM.

b. On 2/11/2022 at around 9 PM, Patient 1 returned to the facility ED (emergency department) via ambulance for fever, cough and generalized weakness. Patient 1 tested positive for COVID-19 in the ED, was admitted, and placed on isolation with no visitors allowed. Patient 1 was discharged home from the facility on 2/17/2022, discharge diagnoses included acute COVID-19 infection, acute hypoxic respiratory failure and acute pneumonia secondary to COVID-19 infection.

c. On 2/21/2022 returned to the facility ED for difficulty breathing and low oxygen level. In the ED Patient 1 was found to be hypoxic (absence of enough oxygen) with worsening persistent bilateral (both lungs) pulmonary infiltrate (substance associated with pneumonia). Patient 1 was admitted and placed on isolation with no visitors allowed. Patient 1 was discharged home with hospice care on 3/3/2022 and subsequently passed away on 3/9/2022.

d. The nursing admission assessment on 2/11/2022 indicated patient was "hard of hearing". There were other no documentary evidence Patient 1's hearing was assessed.

e. There is no documentary evidence of a care plan initiated and implemented to address Patient 1's hearing impairment and use of hearing aide during his three admission in the facility between 2/8/2022 through 3/3/2022.

3. Review of the facility policy and procedure titled "Assessment and Reassessment" last reviewed 10/21, indicated "...Each patient admitted to the institution shall receive a complete head-to-toe assessment by a qualified individual so that a plan of care can be developed to best meet the needs of the patient...Care and/or treatment provided by all health-care professionals will be based on each patient's specific needs. Development of plan of care, treatment and services is individualized and appropriate to the patient's needs, strengths, limitations and goals..."

Based on review of personnel files, review of facility policy and interview with staff revealed the facility failed to ensure the director of nursing service provided adequate supervision and evaluation of nursing personnel providing services for one (B) of five personnel sampled.

Findings included:

Review of facility policy, "Competency Assessment," effective 6/15/2022, stated contract staff will be held to the same standards as colleagues and the records must be maintained by the business entity. Responsibilities: the business entity ensures a mechanism exists to identify area-specific competency requirements; creating an environment that promotes timely Competency Assessment and ongoing growth and development; monitoring colleague progress; and participating in evaluation of the competency process. Requirements for ongoing Competency Assessment is an essential process for verifying an individual's ability to perform their assigned job role by evaluating the ability to apply knowledge, perform skills and demonstrate critical thinking. An individual with the same education and licensure and who has the knowledge, and/or experience for the skills being reviewed should assess the validation of competency. Requirements: initial Competency Assessment and Ongoing Competency Assessment.

Review of the facility policy, "Performance Evaluation," effective 10/01/2020, stated the purpose was to provide guidelines to measure performance through formal performance evaluation at specific intervals, in a timely, fair, and equitable manner. Colleagues should receive a formal performance evaluation, at a minimum, on an annual basis.

Review of the personnel file for RN (Registered Nurse) B revealed the nurse was hired by the facility's internal agency on 9/05/2019. Review of the documented competencies revealed the RN conducted a self-assessment of her skills on 8/13/2019. Review of the file revealed no evidence a performance evaluation had been conducted.

An interview was conducted with the CNO (Chief Nursing Officer) on 1/12/2023 between 12:45 PM and 4:05 PM. The CNO stated the agency conducts the competencies of the employees. He confirmed the hospital did not have documentation of RN B's initial or ongoing competencies. The CNO confirmed the agency seeks feedback from the facility via a "feedback form" and stated there is no set timeframe. He stated the feedback form is provided "ad hoc" when facility staff want to provide comments regarding the agency staff's performance. The CNO confirmed the agency will request feedback regarding the agency staff from facility managers on 3 separate requests. If there is no response the agency does not conduct an annual performance evaluation.