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Based on record review and interview the hospital failed to follow their policy and procedure for addressing grievances as evidenced by failing to respond in writing to the complainant upon completion of the investigation for 3 of 8 grievances received from 01/01/10 through 04/19/10. Findings:

Review of the 2010 Patient Complaint Log for the time period of 01/01/10 through 04/19/10 revealed 8 grievances had been received by the hospital. Further review revealed the following:
01/27/10 - hospital received a verbal grievance alleging physical abuse by a staff member - no documented evidence a written response had been sent to the complainant. Further review revealed the hospital had sent the complaint to the Department of Health & Hospitals.
02/14/10 - hospital received a grievance concerning treatment of minors - no documented evdience written response had been sent to the complainant;
04/05/10 - hospital received a verbal grievance alleging physical abuse and loss of patient's dentures - no documentation a letter had been sent and the log revealed the matter had been resolved 04/09/10. Further review of the grievance revealed the information had been sent to the Department of Health & Hospitals, an internal investigation performed which revealed the hospital found no evidence to support the grievance and therefore the hospital felt the matter had been resolved; therefore no documentation concerning the results had been sent to the complainant.

In a face to face interview on 04/20/10 at 3:00pm S12, Director of Quality Management indicated she was not aware the hospital was required to send a letter to the complainant when a grievance had been received. Further she indicated a response, if appropriate is sent when the investigation has been completed.

Review of Policy# 670-34B titled "Patient/Family Member Grievance Procedure" last revised January 2009 and submitted as the one currently in use revealed .... "Procedure: 5. The patient/family will be provided with a written response from the Quality Management Department within 30 days of receiving information about the grievance".

Based on observation, record review and interview the hospital failed to follow their policy and procedure by failing to obtain a physical examination in a timely manner for the alleged victim of sexual abuse for 1 of 1 reported cases of alleged sexual abuse of 6 sampled patients (Patient #3).

Review of Policy # 670-308 titled "Adult/Elderly Abuse or Neglect" last revised December 2005 and submitted by the hospital as the one presently in use revealed... "Procedure: B. The patient is assessed. 1. A RN assessment is done and documented. a. Physical assessment to include overall body assessment for suspicion of abuse/neglect. b. Psychological/emotional assessment including mental status, affect, mood, and patient's account of events. 2. Physician assessment is done and documented, a. For alleged sexual abuse/rape, the patient will be referred to the Emergency Department for exam. 3. The patient's medical needs will be managed by the Attending Physician and appropriate departmental Nursing Staff".

Review of the open electronic medical record revealed patient #3 was a 38 year-old female who was admitted to the BHU on 4/12/2010 at 20:20 (8:20 PM) with diagnoses of Polysubstance Dependence especially to Xanax and Lorcet and Bipolar I Disorder, "most recently mixed". The admitting physician ordered "Close Contact Precautions" (every 30 minute observation) and no activity restrictions.

Review of the Incident Report dated 04/17/10 for Patient #3 revealed the alleged incident of sexual abuse happened on a Friday 04/16/10 at approximately 11:00pm Friday night and reported the next day (04/17/10) to the charge nurse. Further review of the medical record revealed the incident was reported by the charge nurse RN S15 to the DON of the Behavioral Unit on 03/17/10; however the DON S4 failed to send Patient # 3 to the Emergency Department for a physical examination until 03/19/10 (the day she came back to scheduled duty).

The hospital could not submit documentation to the survey team of the required report to the Department of Health and Hospitals within 24 hours of the reporting of the incident to administration. Further the COO S13 verified that this had not been reported to the state within 24 hours and the Director of Nursing could offer no explanation as to why she had not followed the policy and procedure and sent Patient #3 to the Emergency Department, notified the physician or notified the State Office.

Based on observation, record review and interview the hospital failed to: a) ensure hospital policy and procedure was followed for nurses not to be assigned to supervise relatives. Findings:

Review of Policy # 670-109 titled "Employment of Relatives" last revised December 2007 and submitted by the hospital as the one currently in use revealed.... "For purposes of this policy, a relative is defined as a family member who is the spouse; birth or adoptive parent; child; sibling; step relative (parent, child, brother or sister); in-law (father, mother, sister, brother, son, daughter); grandparent or grandchild; and spouse of a grandparent or grandchild of an employee; or a person whose relationship is not legally formalized but is similar to that of such relatives. This policy applies to all employees without regard to the gender or sexual orientation of the individuals involved. Procedure: 2. relatives shall not be employed under the direct supervision of a relative".

In a face to face interview on 04/21/10 at 10:00am S13 Chief Operating Officer indicated those employees who were already employed at the time of implementation of this policy (after January 2008) were not required to disclose a relationship. Further these employees were not required to complete a new application form which now includes disclosure of relationships to employees in the hospital. When the COO was asked by the surveyors if it was possible for nurses to be supervising relatives on the Behavioral Unit because of those employees hired before 2008 not required to disclose this information she responded, "I guess it would. I will have to speak with the Human Resource Director about how we will obtain this information from the rest of the employees".

The DON of the Behavioral Unit was not able to produce a list of relatives working together on the unit and their relationship and did she have knowledge of any of the staff being related.

Based on record review and interview the facility non-employee (agency) nurses had been supervised by an RN (Registered Nurse) employed by the hospital as evidenced by assigning agency nurses as the only nurse for the evening and night shifts resulting in 10 shifts in a four month period being covered by one agency nurse. Findings:

Review of the Psychiatric Unit Daily Staffing sheets submitted by the S4, RN DON (Director of Nursing) of the BHU (Behavioral Health Unit) for the time period of 01/01/10 through 04/19/10 revealed the following shifts had been staffed with an agency RN: 01/28/10 3p-11p; 02/13/10 7a-3p (weekend); 02/14/10 7a-3p (weekend); 03/22/10 3p-11p; 04/02/10 11p-7a; 04/03/10 3p-11p and 11p-7a; 04/03/10 3p-11- and 11p-7a; and 04/08/10 11p-7a. Further review of the staffing sheet revealed no documented evidence of any other nurse assigned to those shifts.

In a face to face interview on 04/21/10 at 11:55am S13 Chief Operation Officer and S14 Chief Nursing Officer indicated neither had been aware of the federal regulation concerning supervision of an agency nurse.

In a face to face interview on 04/21/10 at 10:45am S8 Psychiatrist indicated he would prefer not to have agency nurses staffing the unit because things don't always go smoothly because the nurses are not accustomed to BHU routine.

Review of Policy # 670-121 titled "Contract/Agency/Forensic Personnel" last revised September 2009 and submitted as the one currently in use, revealed no documented evidence supervision of agency personnel (Nursing) had been addressed.