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28467

Based on observation, interview and record review, the hospital failed to:

1. Ensure the hospital addressed patient grievances in a timely, organized and consistent manner. (see A118)

2. Ensure the Hospital Governing Body had proper oversight of the hospital grievance process and reviewed patient grievances. (see A119)

3. Ensure the hospital grievance process had a mechanism for timely and proper referrals of quality of patient care. (see A120)

4. Provide patients with written notice of the hospital's decisions and steps taken to resolve patient's grievances. (see A123)

5. Ensure patients had the right to formulate an advance directive. (see A132)

6. Investigate allegations of abuse and ensure that all hospital employees were trained in abuse. (see A145)

7. Ensure orders for seclusion were ordered and signed by the patient's Physician and that Patient seclusion was used in accordance with the hospital's policy and procedure. (see A168)

The cumulative effect of these systemic problems resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation for Patient Rights.

Based on interview and record review, the hospital failed to ensure patient grievances were addressed in a reasonable, organized and consistent manner for three of 17 (4, 9, and 13) sampled patients. These failures violated patients' rights to prompt resolution of grievances.

Findings:

1. During a concurrent interview on 9/24/13 at 9 AM with the Registered Nurse Consultant (RNC) and the Quality Assurance Manager (QAM) regarding the hospital's process in patient grievances and resolutions, the RNC stated, "I have identified large gaps in the grievance process including concerns with assessments, investigation, response, tracking and trending, and monitoring of staff education...it is a broken process." The QAM stated "I know we are out of compliance with the grievance process."

2. During an interview with the QAM and the Customer Service Representative (CSR) on 9/24/13, at 10:40 AM, when asked about the hospital's grievance process, the QAM stated the "Patient Complaint Log" is utilized to document and track patient complaints and grievances. He stated the CSR handles the log. "Yes, we only have one log for the North and South." He stated, CSR 1 and CSR 2 have 72 hours to enter information onto the Patient Complaint Log. "Yes, there is a problem with our system, we haven't been logging within 72 hours and our Nurse Manager hasn't been addressing the complaints. She (Nurse Manager of the unit) kept a big pile of complaints on her desk and the CSR's have been logging them this week." CSR 1 stated, "No, we only have one log for both sites." As he read the complaint log, the QAM stated, "I was not aware that so many complaints were unresolved."

3. During a concurrent interview and document review with CSR 2, on 9/24/13, at 10:55 AM, she stated she "...gets a phone call regarding a patient complaining or upset with food, staff etc." Then she interviews the patient, talks with the manager (of the patient's unit) and logs the information on the Patient Complaint Log. When asked about the resolution of a patient's complaint, she stated managers should provide feedback to her. If she did not receive a response, she verbally reminded the manager and advised the Chief Nursing Officer (CNO). When there was still no response she forwarded the issue to the Nurse Manager, "who is no longer here as of Friday, 9/20/13". She did not offer the current process for ensuring resolution was reached.

4. During an interview with the Social Services Manager (SSM), on 9/25/13, at 3:15 PM, she stated she does the report for Child Protective Services (CPS) or Adult Protective Services (APS). She stated the staff completed a report for any suspicion of abuse or patient complaint issue and forwarded the report to her. There was no indication on the Patient Complaint Log of review by the SSM.

5. During an interview with the Risk Management Director (RMD), on 9/25/13, at 3:55 PM, she stated she maintained the "Incident Log" a separate log from the Patient Complaint Log. She provided a copy of a blank Occurrence Report Form and a blank Occurrence Report Follow-Up Form. When asked how the hospital tracked follow-up action, if indicated, the RMD stated the managers use the "Occurrence Report Follow-up Form" to document follow-up activity. When asked how the RMD tracks follow-up when the log indicated the item was closed, the RMD stated "The QAM and I are in the same office. We discuss the issue at the time and hand the follow-up form back and forth. I think we need to fix our system." There was no evidence of final resolution indicated on the Incident Log. The process of resolution of an incident was unclear.

6. During a review of the "Patient Complaint Log" labeled SW (Southwest hospital) on 9/23/13 at 3 PM, the following was noted: two complaints one from a patient's (Patient 4) mother dated 7/20/13, and another was from Patient 9, on 9/21/13, of an allegation of staff to patient verbal abuse with no correction action taken or resolution noted. There was no documented evidence as indicated in interview with CSR 2. CSR 2 was unable to provide evidence that Patient 4's mother's complaint was ever dealt with.

The Patient Complaint Log indicated on 7/26/13 for Patient 4, "Patient's mother (responsible party for son) states the patient was being bullied by staff. Mother states they were laughing at him and standing behind him mocking him and that's why he went left AMA (against medical advice). Mother states the Bakersfield Police Department was called".

During an interview with the QAM, on 9/23/13 at ,2:30 PM, when asked if he had spoken to the complainant (Patient 4) he stated, "Yes, I talked to her, she's looking for a way to talk about her thirty year old son being bullied by our staff. No, it's not documented."

The "Patient Complaint Form" dated 7/26/13 for Patient 4, indicated, "PROBLEM: the mother states son being bullied...", INVESTIGATION and RESOLUTION: were left blank. The QAM stated, "I haven't done that yet. Yes, we are behind."

7. The "Patient Complaint Log", dated 9/10/13, for Patient 9, indicated, she felt embarrassed by cafeteria staff when they "yelled" at her.

During an interview with the QAM on 9/23/13 at 2:40 PM, regarding Patient 9's grievance documented on the Patient Complaint Log, he stated, "I didn't even see that one, we wouldn't report that though, CSR 2 would be aware of that since she entered it on the log. The QAM was unable to find a Patient Complaint Form for Patient 9.

During an interview with CSR 2 on 9/25/13 at 2:30 PM she stated, I have been helping CSR 1 with her log, I just finished putting all the complaints on the log." When asked if this was her usual process, she stated, "No, I just found a pile of complaints on the nurse managers desk that doesn't work here anymore. She had complaints from June forward on her desk that she hadn't done anything with. If she doesn't return them to me I can't do anything with them."

8. During a review of the clinical record for Patient 13, the "Inventory of Patient Property" form, dated 6/23/13 upon patient's admission to the hospital, indicated the patient received and signed for his belongings as listed upon patient's discharge on 6/26/13. The "Patient Complaint Log", labeled SW (Southwest hospital), indicated an entry dated 8/23/13 at 3:30 PM, for Patient 13 "Patient states he is missing belongings states nursing staff said they'd look for it and would call him to come for it but they never did. He wants his belongings returned." The column on the Patient Complaint Log labeled "Action Taken/Resolution" indicated "Wants belongings reimbursed or returned" and the columns labeled "Pt. Satisfied" and "Resolved in 72 hrs" were blank.

9. The hospital policy and Procedure titled,"Patient Complaint/Grievance", dated effective 8/89 and Board Approved on 5/30/12, indicated, in part, "A patient grievance is a formal or informal written or verbal complaint that is made to the Hospital by a patient, or the patient's representative, when a patient issue cannot be resolved promptly (no later than 72 hours of receipt) by staff or department management...". "All grievances will have a prompt written response, within 7 days if possible... All grievances are followed-up in writing... Grievances regarding situations that endanger the patient shall be addressed immediately." And, "The Board of Governors approves and is responsible for the effective operation of the grievance process. The Board of Governors delegates responsibility of the investigation & resolution of grievances to the Risk Management Department." The RMD could not provide any evidence the grievances had been resolved.

Based on interview and record review, the hospital's governing body failed to be responsible and accountable for ensuring an effective grievance process and it's integration into the Hospital Quality Improvement Program (QAPI), when patient grievances were not addressed in a timely manner and patient concerns were not addressed in a current QAPI process. This failure had violated patient rights regarding timely resolution of grievances.

Findings:

During a concurrent interview with the Chief Executive Officer (CEO) and the Chief Administrative Officer (CAO), on 9/24/13, at 9 AM, the CEO stated he had recently taken on the responsibility and full authority for operations of the hospital and was not familiar with the QAPI program or improvement indicators. The CAO stated he had discussions with the Quality Assurance Manager (QAM), however there were no meeting minutes to document the discussions.

During an interview with the QAM, on 9/24/13, at 10:40 AM, he stated the "Patient Complaint Log" is utilized to document and track patient complaints and grievances. He stated the Customer Service Representative 1 (CSR) handles the log for the hospital's North location and CSR 2 handles the log for the hospital's Southwest location. He stated CSR 1 and CSR 2 have 72 hours to enter information from the "incident report", onto the Patient Complaint Log. When asked about the process for patient complaints and grievances, the QAM stated the CSR receives the incident report, logs it on the Patient Complaint Log, refers it to the QAM. He did not indicate the Risk Management department managed grievances.

During an interview with the QAM on 9/23/13, at 2 PM, he stated he was the individual within the hospital responsible for the QAPI and Grievance programs. He stated he could not produce documentation of current QAPI projects, which reflected an ongoing, data-driven QAPI program. He stated he could not produce minutes from the meetings of the QAPI committee. He stated he could not produce documentation that reflected the involvement of the governing body in the QAPI program. He stated he could not produce documentation that reflected the governing body having assumed responsibility for the QAPI program.

During an interview with the Risk Management Director (RMD), on 9/25/13, at 3:55 PM, she stated she maintained the "Incident Log". She provided a copy of a blank Occurrence Report Form and a blank Occurrence Report Follow-Up Form. She provided a copy of the September 2013 Occurrence Log. When asked how the hospital tracks follow-up activity, if indicated, the RMD stated the managers use the "Occurrence Report Follow-up Form" to document follow-up activity. When asked how the RMD tracks follow-up when the log indicated the item was closed, the RMD stated "The QAM and I are in the same office. We discuss the issue at the time and hand the follow-up form back and forth." There was no indication of final closure or resolution on the Incident Log. The RMD did not indicate the information contained on the Incident Log included grievances.

The hospital policy and procedure titled "Patient Complaint/Grievance", dated 8/89, indicated, in part, "The Board of Governors approves and is responsible for the effective operation of the grievance process. The Board of Governors delegates responsibility of the investigation & resolution of grievances to the Risk Management Department."

Based on interview and record review, the hospital's Governing Body failed to be responsible for the effective operation of the grievance process and it's integration into the Hospital Quality Improvement Program and failed to review and resolve grievances in a timely manner. These failures had the potential for patient concerns and grievances to go un-answered.

Findings:

On 9/23/13, at 3:30 PM, a signed copy of the hospital Performance Improvement Patient Safety Plan dated 9/13 was reviewed. It stated on page 3 "The purpose of the Organizational Performance Improvement, Patient Safety Plan at Good Samaritan Hospital is to ensure that the Governing Body, medical staff and professional service staff demonstrate a focus on providing healthcare services that are continuously improved to meet the needs and expectations of our patients, physicians, employees, and community as a whole... Leaders of the organization determine priorities and the organization designs methods to measure performance in order to improve patient care. Leadership has the responsibility for monitoring every aspect of patient care, from the time the patient enters the hospital through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to continuously improve and facilitate positive patient outcomes. The plan reflects total organizational commitment to continuous improvement in quality of governance, management, clinical and support processes... The Governing Body is responsible for the quality of patient care provided. The Governing Body shall maintain ultimate responsibility for the organization-wide Performance Improvement Program which strives to ensure quality patient care requiring and supporting the establishment and maintenance of an effective organization-wide program. To achieve this goal, the Board of Governors will establish policy, promote the Performance Improvement Program and provide for the function of organizational management and planning. The Governing Body responsibility to the Administrator and the Medical Staff to implement and report on the activities and the mechanisms for process design and performance measurement, analysis and improvement, monitoring, assessing and evaluating the quality of patient care, for identifying and reducing the risk of sentinel events; for resolving problems and for identifying opportunities to improve patient care and services or performance throughout the facility. This process addresses those departments/disciplines that have direct or indirect effect on patient care, including management and administrative functions."

During an interview with the Quality Assurance Manager on 9/23/13, at 2 PM. He stated he was the individual within the hospital responsible for the QAPI (quality assessment and improvement) and Grievance programs. He stated he could not produce documentation of current QAPI projects, which reflected an ongoing, data-driven QAPI program. He stated he could not produce minutes from the meetings of the QAPI committee. He stated he could not produce documentation that reflected the involvement of the governing body in the QAPI program. He stated he could not produce documentation that reflected the governing body having assumed responsibility for the QAPI program.

During an interview with the Registered Nurse Consultant 1 on 9/24/2013 at 9 AM, she stated, "I admit there is very little oversight or involvement by the Governing Body of the grievance process. I have identified large gaps in the hospital's process, in investigating, response and tracking grievances. I concur that items on the grievance log constitute abuse, this is a problem, the hospital did not follow their policy and we are out of compliance."

The hospital policy and procedure titled "Patient Complaint/Grievance", dated 8/89, indicated, in part, "The Board of Governors approves and is responsible for the effective operation of the grievance process. The Board of Governors delegates responsibility of the investigation & resolution of grievances to the Risk Management Department."

Based on interview and record review, the hospital failed to provide a written response to one of 17 sampled patients' (4) grievances in a timely manner and was unable to provide evidence of compliance with these requirements. These failures violated patients' rights and knowledge of grievance resolution.

Findings:

During an interview and concurrent record review with the QAM (Quality Assurance Manager) on 9/23/13 at 3 PM, he stated, "I haven't been able to keep up with this, I haven't sent out response letters after seven days or even after 30 days.

The "Physician Discharge Summary" dated 7/31/13 for Patient 4 was reviewed on 9/23/13. It indicated Patient 4 was admitted on a voluntary status for having increased depression and suicidal ideation's. "On 7/25/13, Patient 4 stated they (staff) were bullying him." The physician was informed the patient wanted to go home.

Further review of the Patient Complaint Log indicated on 7/26/13, "Patient's (Patient 4) mother states the patient was being bullied by staff. Mother states they were laughing at him and standing behind him mocking him and that's why he went left AMA (against medical advice). Mother states the Bakersfield Police Department was called".

During an interview with the QAM on 9/23/13, at 2:30 PM, when asked if he had spoken to the complainant (Patient 4) or the responsible party, he stated, "Yes, I talked to her, she's looking for a way to talk about her thirty year old son being bullied by our staff. No, it's not documented." The QAM was unable to provide a copy of the response to the patient's grievance.

Based on interview and record review, the hospital failed to ensure that two of 17 sampled patients (6 and 1) had the opportunity to provide guidance as to their wishes or their representatives wishes concerning provision of care. This failure had the potential to prevent Patient 6 and Patient 1 to accept or refuse medical treatment and to formulate an advance directive.

Findings:

During an interview with the South West facility Intake Manager on 9/24/13, at 2 PM, he reviewed the clinical records of Patient's 1 and 6 and was unable to find documentation of Advance Directive Acknowledgement forms for Patient's 1 and 6. He stated that he was unable to find any documentation that advanced directives were discussed with the patients or their representatives.

The hospital policy and procedure titled "Advance Directive" dated 5/30/12, indicated, "Every adult patient who is admitted will be asked if they have completed an advance directive." Under the heading, "Required Forms" an Advance Directive Acknowledgement is noted.

Based on interview and record review, the hospital failed to ensure allegations of abuse were identified, investigated, and consistently reported for four of 17 sampled patients (11, 12, 4, and 9) and failed to ensure all employees received training regarding abuse, including reporting requirements, prevention, intervention and detection. These failures had placed all patients at risk for abuse.

Findings:

1A. During a review of the clinical record for Patient 11, the "Social Services Notes", dated 9/17/13, at 2:10 PM, indicated in part, "Pt. did get in to a physical altercation with another Pt. last night. Pt. got punched by a Pt., and the Pt. took swings at the other Pt.". The "Nursing Progress Notes", dated 9/16/13, at 8 PM, indicated, "Pt had a heated argument toward peer and uses racial remarks. hit each other and staff attempted to separate them."

During an interview with the Quality Assurance Manager (QAM), on 9/24/13, at 10:25 AM, regarding the documentation of the patient altercation, he stated the nurse would assess the patient and determine if the incident required a report of violence. He stated the patients would be separated, rooms changed if needed, and the patients would be monitored every 15 minutes. The QAM stated if an incident report was completed it would be on the 24 hour nurse report form. At 10:40 AM, the QAM stated the 24 hour nurse report did not have any information regarding the physical altercation.

During an interview with the Risk Management Director (RMD), on 9/25/13, at 3:55 PM, she stated she maintained the "Incident Log". She provided a copy of a blank Occurrence Report Form and a blank Occurrence Report Follow-Up Form. She provided a copy of the September 2013 Occurrence Log. Patient 11 was entered on the log twice for "escalated behavior" with "physical contact to other", on 9/16/13 and 9/22/13. Both entries are coded as a level 1 A ("No harm - Circumstance had the capacity to cause an unanticipated event/negative outcome"). Manager follow-up was indicated for the event on 9/22/13. Both occurrences indicated "closed" status on the same day they were received in risk management. When asked how the hospital tracked follow-up activity, if indicated, the RMD stated the managers use the "Occurrence Report Follow-up Form" to document follow-up activity. A follow-up form for Patient 11 was not provided. When asked how the RMD tracks follow-up when the log indicated the item was closed, the RMD stated "The QAM and I are in the same office. We discuss the issue at the time and hand the follow-up form back and forth." There was no evidence of final resolution indicated on the Incident Log. The process of resolution of an incident was unclear.

1B. During a review of the clinical record for Patient 12, the "Nursing Progress Notes" form, dated 8/26/13, at 9:15 AM, indicated, "Patient reports being slapped by female peer on unit. Patient then punched female patient four times to head and face. Patient (Patient 12) separated from another female peer by staff. During separation, patient punched staff member."

During a concurrent interview with the QAM and the RMD, on 9/25/13, at 4:15 PM, the RMD stated the occurrence report did not have thresholds for external reporting. The QAM stated he had reviewed the video of the incident regarding Patient 12, on 8/26/13, and due to the diagnoses of both involved patients, no further action or reporting was required.

During an interview with Licensed Vocational Nurse (LVN) 1, on 9/24/13, at 10:35 AM, regarding the process for patient altercation reporting, she stated if one patient hits another patient they would be separated, changed units if needed to de-escalate and she would follow the chain of command reporting. The nurse would report the incident to the Charge Nurse, who would report to the Nursing Supervisor or Manager then to the Chief Nursing Officer. However, the hospital could not provide any evidence this altercation was reported to the Department.

1C. During a review of the "Patient Complaint Log" labeled SW (Southwest hospital) on 9/23/13, at 3 PM, two complaints, one from Patient 4's family member dated 7/20/13, and another from Patient 9 on 9/21/13, of verbal abuse by the hospital staff, were recorded with no action taken or resolution noted.

The Patient Complaint Log indicated on 7/26/13, for Patient 4, "Patient's family member (responsible party for son) states the patient was being bullied by staff. Family member states they were laughing at him and standing behind him mocking him and that's why he went left AMA (against medical advice). Family member states the Bakersfield Police Department was called".

During an interview with the QAM on 9/23/13, at 2:30 PM, when asked if he had spoken to the complainant (Patient 4), he stated, "Yes, I talked to her, she's looking for a way to talk about her thirty year old son being bullied by our staff. No, it's not documented."

The "Patient Complaint Form," dated 7/26/13, for Patient 4, indicated, "PROBLEM: the mother states son being bullied", but the investigation and resolution were left blank.

1D. The "Patient Complaint Log", dated 9/10/13, for Patient 9, indicated, she felt embarrassed by cafeteria staff when they "yelled" at her...

During an interview with the QAM on 9/23/13, at 2:40 PM, regarding Patient 9's grievance, he stated, "I didn't even see that one, we wouldn't report that though, CSR (Customer Service Representative) 2 would be aware of that since she entered it on the log." The QAM was unable to find a Patient Complaint Form for Resident 9.

During an interview with CSR 2 on 9/25/13, at 2:30 PM she stated, "I have been helping (CSR 1) with her log, I just finished putting all the complaints on the log. Yes, even the ones from June forward."

2A. During an interview with the QAM, on 9/24/13, at 10:40 AM, he stated the "Patient Complaint Log" was utilized to document and track patient complaints and grievances. He stated CSR 1 and 2 entered complaints/grievances and maintained the log.

2B. During a concurrent interview with CSR 1 and CSR 2, on 9/24/13, at 10:55 AM, CSR 1 stated if someone reported an allegation of abuse (regarding a patient) she would notify the nurse on the unit and the patients would be separated. CSR 2 stated all abuse allegations would be referred to the Risk Manager when asked if they had received abuse training, they both stated they had not received any since their employment at the hospital.

During an interview with the QAM, on 9/24/13, at 1:45 PM, he stated the hospital's Medical Social Worker teaches abuse annually and on hire. The QAM provided a document titled "Reporting, Abuse Recognition and Reporting" and Investigation, Patient Complaint/Allegation of Abuse While Admitted to GSH", undated, for review. He stated the document has been laminated and is posted throughout the hospital on the nursing units to help the staff know the proper procedure for abuse and patient complaints. The document indicated "Every employee has the obligation to look for, recognize, and report suspected or actual abuse of patients... The person identifying potential abuse will: Contact the On-Call social Services staff member... The Social Service staff on call will guide you through the mandated reporter process: Complete an abuse-reporting form (found on each Unit). Make a verbal report to the appropriate hotline as indicated". "Any complaint/allegation of assault or abuse of a patient while admitted to GSH requires immediate reporting through the chain of command: ... The Department Manager & CNO (Chief Nursing Officer) will notify Quality & Risk to initiate an investigation".

2C. The hospital's personnel records were reviewed on 9/24/13, with the QAM present. CSR 1's personnel record indicated her date of hire was 9/17/12. She had a New Hire Orientation check off list indicating "Adult/Child Abuse Reporting" was a topic covered during new hire orientation. The form titled "Dependent Adult Abuse Reporting Employee Statement", which covered, in part, "California law requires that the employee as a prerequisite to employment sign this statement and that (the hospital) retain it." The form provides the definitions of "care custodian" as referenced in the California Welfare and Institutions Code Section 15632, and 15630. "Health Practitioner" was defined in the form pursuant to "any person who is currently licensed under Division 2 (commencing with Section 500) of the Business and Professions Code, ...Division 2.5 (commencing with Section 1797) of the Health and Safety Code; or a psychological assistant registered pursuant to Section 2193 of the Business and Professions Code,...subdivision (c) of Section 498.03 of the Business and Professions Code...and Section 4980.44. CSR 1 signed this form dated 9/13/12. The hospital form "Child Abuse Reporting Employee Statement" was signed by CSR 1 on 9/13/12. Neither form contained any educational information about abuse and no competencies of abuse training were found in CSR 1's personnel file/educational record. This was confirmed by the Human Resources Manager (HRM).

CSR 2's personnel record was reviewed with the HRM and QAM present. Her date of hire was indicated as 11/2/07. No evidence of abuse training or annual competency for abuse was found in her record. Her personnel record contained the signed form "Employee Statement - Dependent Adult Abuse Reporting", signed 11/9/07 and the form "Employee Statement - Child Abuse Reporting" signed 11/9/07. Her 2010 Hospital Wide Competencies and 2012 Annual Safety Competencies cover sheets did not indicate education/training for abuse.

The QAM's personnel record was reviewed with the HRM. The "Employee Statement - Dependent Adult Abuse Reporting" form and the "Employee Statement - Child Abuse Reporting" forms were signed by QAM on 12/18/05. No evidence of annual or on-hire abuse training records were found in QAM's personnel record as confirmed by the HRM on 9/24/13, at 3:45 PM.

During an interview with the HRM, on 9/24/13, at 2:37 PM, she stated "Clinical people get abuse training. Clinical Departments and anyone that has to do with patients get abuse training." She stated non-clinical staff do not receive abuse training.

During an interview with the Social Services Manager (SSM), on 9/25/13, at 3:15 PM, she stated all staff are trained in abuse reporting. The SSM provided a document for review titled "Abuse Reporting Matrix" that identified the reporting trigger, to whom to report and time frames for child abuse and neglect, elder/dependent adult abuse and injury by firearm or assaultive/abusive conduct. She stated the document was used as a guideline for staff to assist with reporting requirements. SSM stated she handles external abuse, which are reports that are reported outside of the hospital (Police Department, APS, CPS) or occurred outside of the hospital. Internal abuse reports are incidences that are reported within the hospital, such as incident reports that are forwarded to risk management.

During a concurrent interview and document review (Education Tally Sheet for Abuse) with the QAM, on 9/25/13, at 3:45 PM, he stated the education tally sheet indicated all staff. No CSR staff names were found on the tally sheet. The QAM stated "Yes, we've already admitted we did not train non-clinical staff."

2D. During an interview with Housekeeper 1, on 9/25/13, at 2:15 PM, at the North hospital location, she stated she has been employed with the hospital for 15 years. She stated she has not received any abuse training.

2E. During an interview with Respiratory Therapist 1, on 9/25/13, at 2:20 PM, at the north hospital location, he stated he has completed a competency for abuse by reading a document and signing a form of completion. When asked what he would do if he observed a patient striking another patient, he stated "I would restrain them", and report to a supervisor.

The hospital policy and procedure titled "Abuse: Identifying and Reporting", dated effective 7/10 and board approved 5/30/12, indicated "Scope: All ...Hospital employees and medical staff." Under policy it indicated "The facility will provide in-service training annually, designed to assist employee and healthcare providers associated with the facility in identifying patient abuse..." In the section titled "Management of Suspected Abuse or Neglect:.. All cases of suspected abuse or neglect must be reported to authorities... A healthcare provider who fails to report shall be referred by the Department of Health to the individual's licensing board for appropriate disciplinary action."



32276

Based on observation, interview, and record review, the hospital failed to ensure unauthorized individuals could not gain access to patient records, which had the potential to result in unauthorized access to patient records.

Findings:

During a concurrent interview and observation of the medical surgical wing of the North Hospital on 9/23/13, at 11 AM with the Hospital Chief Nursing Officer (CNO), three patient charts (1, 2 and 8) were observed hanging on a hallway handrail easily assessable by passersby's. Easily viewed without opening the chart were the patient's name, age, birthdate, physician's name and medical record number. Upon opening the chart the "24 Hour Patient Care Record" was found. This document indicated the patient's weight, intake, output and nursing notes regarding the patients activity and alertness. The document titled "Patients Property Inventory" indicated an inventory of the patient's possessions on admission. The CNO stated, "the patient charts should not be kept in the hallways".

Based on interview and record review, the hospital failed to get a physician's signature for three instances of seclusion and failed to write an order for seclusion for two documented instances of seclusion for one of 17 sampled patients (5). This failure had the potential to violate patients' rights by placing them in seclusion without a physicians' order.

Findings:

On 9/25/13, during a review of the clinical record for Patient 5, the "RESTRAINT ORDER FORMS", dated 7/24/13, 7/25/13, and 7/27/13, under the section MD (Medical Doctor) were found to be unsigned by the Medical Doctor. The Seclusion Order Form and orders were initiated by a registered nurse. The form indicated, "For RN initiated order, a physician's signature is required within 24 hours of application of medical/surgical restraint." The "Nursing Progress Note", dated 7/21/13, indicated, "MHW (Mental Health Worker) escorted patient to seclusion room." The "Nursing Progress Note", dated 8/1/2013, at 3 AM, indicated "Patient angry, yelling, placed in quiet room."

During an interview with the Quality Assurance Manager (QAM) on 9/25/13, at 3 PM, he reviewed Patient 5's clinical record and was unable to find physician orders for the seclusion restraint used on 7/21/13 and 8/1/13. He stated, I would expect to find a signed order by the physician for each instance of seclusion. Yes, I consider the quiet room a room for seclusion. The QAM stated all instances of seclusion should have a physicians' order signed within twenty-four hours.

The hospital policy and procedure titled, "Restraint, Seclusion...", dated 9/12, indicated, "Each order episode of seclusion shall be initiated upon the order of a licensed practical independent practitioner." The Seclusion Order Form indicated, "For RN (registered nurse) initiated order, a physician's signature is required within 24 hours of application of medical/surgical restraint."

Based on staff interview and administrative document review, the hospital's governing body failed to be responsible and accountable for ensuring an ongoing, hospital wide, date-driven Quality Assessment and Performance Improvement (QAPI) program was established when the hospital's governing body failed to ensure a QAPI program for quality improvement and patient safety was defined, implemented and maintained. The hospital did not provide adequate resources or personnel to implement and maintain a QAPI program. The hospital did not have evidence of substantive on-going and current QAPI projects aimed at quality improvement and patient safety. (Refer to A309)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.



27011

Based on staff interview and administrative document review, the hospital's governing body failed to be responsible and accountable for ensuring an ongoing, hospital wide, date-driven Quality Assessment and Performance Improvement (QAPI) program was established when the hospital did not provide adequate resources or personnel to implement and maintain a QAPI program. The hospital did not have evidence of substantive on-going and current QAPI projects aimed at quality improvement and patient safety.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Findings:

On 9/23/13 at 3:30 p.m., an unsigned copy of the hospital Governing Body Bylaws dated 6/30/11 was reviewed. It indicated on page 18 "ARTICLE VIII QUALITY OF PROFESSIONAL SERVICES Section 1. BOARD'S RESPONSIBILITY. a. Requirement of Patient Care Review and Evaluation. The Board of Governors and the General Partner shall, after considering the recommendations of the Medical Staff and other professional staffs, review and evaluate activities to assess, preserve and improve the overall quality and efficiency of patient care in the Hospital. Through this mechanism, the Board of Governors and the General Partner assures that all patients with the same health problem(s) will receive the same level of care while in the Hospital. The Board of Governors and the General Partner, through the Administrator of the Hospital, shall provide what ever administrative assistance is reasonably necessary to support and facilitate the implementation and the ongoing operation of these review and evaluation activities. The Board of Governors and The General Partner delegate to the Medical Staff the responsibility for the identification of general clinical areas that represent actual or potential sources of patient injury (Risk Management)."

On 9/23/13 at 3:30 PM, a signed copy of the hospital Performance Improvement Patient Safety Plan last dated 9/13 was reviewed. It states on page 3 "The purpose of the Organizational Performance Improvement, Patient Safety Plan at Good Samaritan Hospital is to ensure that the Governing Body, medical staff and professional service staff demonstrate a focus on providing healthcare services that are continuously improved to meet the needs and expectations of our patients, physicians, employees, and community as a whole....Leaders of the organization determine priorities and the organization designs methods to measure performance in order to improve patient care. Leadership has the responsibility for monitoring every aspect of patient care, from the time the patient enters the hospital through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to continuously improve and facilitate positive patient outcomes. The plan reflects total organizational commitment to continuous improvement in quality of governance, management, clinical and support processes... The Governing Body is responsible for the quality of patient care provided. The Governing Body shall maintain ultimate responsibility for the organization-wide Performance Improvement Program which strives to ensure quality patient care requiring and supporting the establishment and maintenance of an effective organization-wide program. To achieve this goal, the Board of Governors will establish policy, promote the Performance Improvement Program and provide for the function of organizational management and planning. The Governing Body responsibility to the Administrator and the Medical Staff to implement and report on the activities and the mechanisms for process design and performance measurement, analysis and improvement, monitoring, assessing and evaluating the quality of patient care, for identifying and reducing the risk of sentinel events; for resolving problems and for identifying opportunities to improve patient care and services or performance throughout the facility. This process addresses those departments/disciplines that have direct or indirect effect on patient care, including management and administrative functions."

The Quality Assurance Manager (QAM) was interviewed on 9/23/13 at 2 PM. He stated he was the individual within the facility responsible for the QAPI program. He stated he could not produce documentation of current QAPI projects, which reflected an ongoing, data-driven QAPI program. He stated he could not produce minutes from the meetings of the QAPI committee. He stated he could not produce documentation that reflected the involvement of the governing body in the QAPI program. He stated he could not produce documentation that reflected the governing body having assumed responsibility for the QAPI program.

Chief Executive Officer (CEO) and Chief Administrative Officer (CAO) were interviewed together on 9/24/13 at 9 AM.

The CEO stated he had recently taken on the responsibility and full authority for operations of the hospital and he had not become familiar with the QAPI program. He stated he had no knowledge of any improvement indicators which were used as a basis for QAPI projects.

The CAO stated he had held discussions with the QAM regarding quality issues, however, there were no meeting minutes to document the discussions. He stated the hospital had a QAPI committee which recently began to hold regular meetings, however, there were no meeting minutes to substantiate that the meetings had taken place. He stated he had no knowledge of documentation which would substantiate current QAPI projects which focused on patient safety. He stated he had no knowledge of improvement indicators which were used as a basis for ongoing, data-driven QAPI projects.

28741

Based on observation, interview, and record review, the hospital failed to follow the policy for fire alarms when an alarm sounded and the announcement was delayed. This had the potential to place all patient's at risk as the location of the alarm was unknown.

Findings:

During an observation on 9/25/13, at 4:25 PM, in the administrative wing of the hospital, a loud alarm began sounding. The Quality Assurance Manager (QAM) ushered the individuals located in the Administrative Conference room into the hospital lobby, where 4-5 visitors were seated. The QAM requested the visitors to exit the lobby out the hospitals front door entrance. After several minutes (while the alarm continued to sound and hospital staff at the front desk were stating they could not identify the location of the fire), the hospital staff member at the front desk announced over the loudspeaker "Code Red Second Floor". The QAM and the Chief Administrative Officer entered the fire doors into the hospital. Additional administrative staff members exited the hospital through the front entrance doors.

During an interview with the Intake Manager, on 9/25/13, at 4:30 PM, when asked who was vacating the hospital and who was taking care of the patients, he stated "Oh, that's just the administrative staff." He stated the staff in the hospital on the units takes care of the patients.

The hospital policy and procedure titled "Code Red - General Instructions", undated, indicated "4-5 personnel with fire extinguishers are to report to the fire area....all personnel not having fire extinguishers shall immediately close all fire doors and patient doors. Remain in the area of the hospital." The policy indicated when a fire alarm is pulled, the signal shows up in the Front Office to indicate the general area of the fire and the PBX operator notes the general area of the fire on the enunciator panel and announces the Code Red Alert.