HospitalInspections.org

Based on interview, record review and policy review, the Governing Body (GB) failed to ensure they reviewed and resolved grievances, or delegated the responsibility in writing to a grievance committee (more than one person). This failure had the potential to endanger all patients if complaints/grievances were not investigated for systemic problems that could lead to patient harm. The hospital census was 24.

Findings included:

1. Review of the hospital's policy titled, "Patient Complaint and Grievance Process," dated 01/31/19, showed the following:
- No designation of a grievance committee.
- All grievances were to be submitted verbally or in writing to the Patient Advocate.
- If a grievance was unable to be resolved, the Performance Improvement Committee would be notified and requested to intervene.
- The patient or his/her representative had the right to appeal a grievance determination. Appealed grievances would be submitted to the Patient Advocate and forwarded to the Performance Improvement Committee or the Utilization Management Committee for review.

Review of the hospital's document titled, "Governing Board Bylaws," dated 2021, showed no designation of a Performance Improvement Committee or a Utilization Management Committee.

During an interview on 04/07/21 at 9:00 AM, Staff I, Patient Advocate, stated that she was the only person responsible for reviewing and responding to grievances, and that there was no committee designated to review grievances.

During an interview on 04/07/21 at 11:35 AM, Staff C, Chief Executive Officer (CEO), stated that he was a voting member of the GB and was aware that there was no Performance Improvement Committee or Utilization Management Committee.

Based on interview, record review and policy review, the hospital failed to ensure nursing staff obtained verbal consent from patients' legal guardians (a person appointed to take care of and manage the rights of a person who is considered incapable), as required for new medication orders, for one current patient (#4) and one discharged patient (#6), of 21 patients reviewed when informed consent was required. This failure had the potential to affect all patients admitted to the hospital who had a legal guardian. The hospital census was 24.

Findings included:

1. Review of the hospital's policy titled, "Consent to Psychotropic (drugs that affect a person's mental state) Medication," dated 01/31/19, showed the following:
- The consent form for medications would be signed prior to administering the medication to the patient.
- Written documentation of the patient's decision to consent would be maintained and the patient was able to withdraw consent at any time.
- If the patient had a legal guardian and the legal guardian gave consent for the medication, a copy would be secured for the medical record.

Review of Patient #4's medical record showed the following:
- She was a 13-year-old female who presented on 03/25/21, for evaluation of anger and aggression.
- On 03/25/21, consent for follow-up contact documentation showed the person responsible for consent was the patient's caseworker, her legal guardian.
- On 03/25/21, documented consent for telephone calls and visitation, showed that the patient's biological mother was the first contact person listed, her biological father was listed second, her foster mother was listed third, and her caseworker was listed fourth.
- On 03/25/21, the patient's caseworker/legal guardian provided verbal telephone consent for her admission, treatment and admitting medications.
- On 03/26/21, a physician's order showed that Lexapro (a medication used to treat depression and anxiety) 5 milligrams (mg, a measure of dosage strength), was ordered for the patient.
- On 03/26/21, informed consent documentation showed the patient's biological mother was contacted, and verbal consent was obtained for administration of the new medication Lexapro.

Staff did not contact Patient #4's caseworker/legal guardian for verbal consent for a new medication, but obtained consent from the patient's mother, who was not the patient's legal guardian.

2. Review of Patient #6's medical record showed the following:
- He was a 14-year-old male who was admitted on 12/23/20, after he had made homicidal (thoughts or attempts to cause another's death) threats toward his peers and teachers at school, as well as his stepmother.
- On 12/22/20, the patient's father/legal guardian provided verbal telephone consent for his admission, treatment and admitting medications.
- On 12/24/20, physician order documentation showed that he was ordered Risperdal (a medication used to manage certain mental/mood disorders) 2mg, twice a day, for aggression. Informed consent documentation showed the patient's stepmother was contacted and gave consent for a new medication order.

Staff did not contact Patient #6's legal guardian for verbal consent for a new medication, but obtained consent from his stepmother, who was not the patient's legal guardian.

During an interview on 04/06/21 at 9:10 AM, Staff F, Registered Nurse (RN), stated that upon admission to the hospital, the Assessment and Referral (A&R) Department gathered information during the admission process and recorded it onto a form titled, "Consent for Telephone and Visit Consent," which listed family members or others who were able to have telephone and visitation rights for the patient. She stated that this form was kept in a binder book at the nurses' station and that staff referred to this when they needed to obtain consent for new medication orders. Staff F stated that inside this book there would also be a yellow sheet that alerted staff if the patient had a legal guardian.

During an interview on 04/05/21 at 3:30 PM, Staff E, RN, stated that she would normally take the first name listed on the form titled, "Consent for Telephone and Visit Consent," when consent was required to give a patient a new medication. She had never seen a legal document for guardianship or custody of the patient in the medical record. The nurse in the admission process would complete the "Consent for Follow up Contact," which included the legally responsible person.

During a telephone interview on 04/07/21 at 4:15 PM, Staff S, RN, stated that the A&R Department determined who the patient's legal guardians were, and that the legal guardian's information was always listed on the face sheet. She stated that at times, multiple parents or caregivers would be listed on the face sheet, which made it confusing to know whom to call. Staff S stated that when a legal guardian was contacted for consent, they would be told the reason for the new medication and possible side-effects. If the guardian agreed to the new medication, another nurse spoke with them to obtain their verbal consent, and the consent form would be completed by both nurses.

During a telephone interview on 04/07/21 at 9:45 PM, Staff T, RN, stated that a consent for a new medication must be obtained prior to administering a medication, unless it was an emergent situation, and that a second nurse or technician could be the second witness. However, they must speak to the legal guardian and also hear them give consent. Staff T stated that it was difficult to determine who the legal guardian was, especially when multiple family members were listed on the face sheet or call sheet.

During a telephone interview on 04/07/21 at 3:04 PM, Staff R, RN, stated she never thought to question if the person she spoke to was the patient's legal guardian, when she witnessed consent for medication.

During an interview on 04/06/21 at 3:30 PM, Staff A, A&R Division Manager, stated that when a child was brought in for admission, the A&R staff would ask the person that brought them in if they were a legal guardian or custodial parent (a parent that a court of law has given primary legal or physical custody). If a guardian had been appointed, then the A&R staff would request a name and contact information. If there was a court order or paperwork for custody or guardianship, A&R staff would request to see the paperwork, but that paperwork was not placed into the medical record. The information would be entered onto the "Consent for Telephone and Visit Consent" form.

During an interview on 04/05/21 at 3:45 PM, Staff D, Director of Nursing (DON), stated that staff should always call the legal guardian or custodial parent for medication consent.



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Based on interview, record review and policy review, the hospital failed to ensure that staff were trained in first aid (the first and immediate assistance given to any person suffering from either a minor or serious illness or injury) related to restraints (application of mechanical restraining devices or manual restraints which are used to limit the physical mobility of a patient), for four staff (E, F, N and O) personnel files of five staff personnel files reviewed. This failure had the potential to result in serious injury or death to patients who required restraints in the hospital. The hospital census was 24.

Findings included:

1. Review of the hospital's policy titled, "Restraint or Seclusion Use," revised 01/31/19, showed that all clinical staff were required to have training and competency prior to patient intervention. These competencies included first aid.

Review of the hospital's untitled, undated document showed 13 entries of physical holds over the previous six months with no applications of restraints.

Review of four personnel records for Staff E, Agency Registered Nurse (RN); Staff F, RN; Staff N, RN; and Staff O, RN, showed no restraint first aid training.

During an interview on 04/06/21 at 10:22 AM, Staff H, RN, stated that staff did not received first aid training specific to restraints. She stated that nursing staff should know what to do because they were nurses.

During an interview on 04/07/21 at 1:20 PM, Staff D, Director of Nursing (DON), stated that since the hospital didn't have a current educator, she was responsible for educating staff and the restraint training provided to staff did not include restraint first aid training.

Based on interview and record review, the hospital failed to ensure personnel records contained documentation that training and competencies were successfully completed initially during orientation, and on a periodic basis, for four staff (E, F, M, and O) personnel records of five staff personnel records reviewed. This failure had the potential to place all patients admitted to the hospital at risk for their health and safety. The hospital census was 24.

Findings included:

1. Even though requested, the hospital failed to provide a policy related to personnel files.

Review of the hospital's personnel file for Staff E, RN, showed no documentation of her job-specific orientation, nursing competencies, Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) certification, infection control or restraint (application of mechanical restraining devices or manual restraints which are used to limit the physical mobility of a patient) training.

During an interview on 04/04/21 at 10:05 AM, Staff E, RN, stated that she was hired in 09/2020, and received nursing orientation and Crisis Prevention Institute (CPI, a type of training where staff learn safe physical holds to restrict a person's movement) training and that she was certified in basic CPR.

Review of the hospital's personnel file for Staff F, RN, showed no documentation of her job description, job-specific orientation, nursing competencies, infection control training, restraint training, or CPI training.

During an interview on 04/06/21 at 9:10 AM, Staff F, Registered Nurse (RN), stated that she was an agency nurse (a nurse that is employed by a business that provides nursing staff to hospitals and other health care institutions) and was on week three of a 13-week contract. She stated that she had received a two-day nursing orientation with competencies and then a one-day CPI training.

Review of the hospital's personnel file for Staff M, Safety Manager, showed a hired date of 12/2019. There was no documentation of CPR certification, annual evaluation, periodic re-training or evidence he was qualified to train staff on CPI training.

During an interview on 04/04/21 at 2:30 PM, Staff M, Safety Manager, stated that he was responsible for the CPI training to all staff. He stated that he was a certified trainer and had received that training in 01/2021.

Review of the hospital's personnel file for Staff O, RN, showed a hire date of 12/2020, and there was no documentation of CPR certification.

Review of an undated, blank hospital document titled, "Employee File Section C Index," showed a listing for professional licenses that included nursing and certifications with boxes to be marked to indicate if that staff member had a specific license or certification.

Review of an undated, blank hospital document titled, "Employee File Section D Index," showed a listing of required documents, that included job descriptions, with boxes to be marked to indicate if that staff member had those documents within their file.

Review of an undated hospital document titled, "Employee File Section E Index," showed a listing of evaluations that included 90-day evaluation and annual evaluation and corrective action form with boxes to be marked to indicate if that staff member had received the evaluations and if they had received any correction action.

During an interview on 04/06/21 at 1:50 PM, Staff B, Regional Human Resources (HR) Director, stated that there was no current HR staff personnel for the hospital, that the position had been vacant since 02/2021, and that she was responsible for the HR duties until someone was hired. Staff B stated that all patient care staff were to be CPR certified and that information was collected at the time of hire and should be in the personnel files along with other required documents. She also stated that she was aware that the personnel files were a "mess" and that they were incomplete.