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Based on observation and interviews, the hospital failed to ensure that an ice machine had an air gap to prevent backflow of waste water into the ice machine for 1 of 2 ice machines; counters were in good repair in the sterilization area; electrical safety checks were completed; and asset stickers were placed on items to trigger the hospital's computerized preventative maintenance system. In addition, the hospital failed to provide information related to the frequency of preventative maintenance and any items that may be on an alternative maintenance program.

Findings:

1. On 4/23/19 at 9:47 AM, the ice machine, located in the kitchen area, was observed to be lacking an air gap thus creating an opportunity for the back flow of waste water into the ice machine. This finding was confirmed by the Dietary Manager at the time of the observation. This finding was also confirmed by the Plant Operation Manager on 4/23/19 at 10:15 AM.

2. On 4/23/19 at 11:05 AM, the surveyor, with the Nurse Leader of Peri-Operative Services present, observed two counter tops in the sterilization area that had worn down laminate, thus creating potentially uncleanable surfaces. This finding was confirmed at the time of the observation. The Nurse Leader of Peri-Operative Services stated a work order had been submitted to replace the counter tops.

On 4/23/19 at 2:15 PM, the surveyor reviewed the work order provided by the hospital representative, which only referred to repair of the "Decontamination Room"; not the Sterile Room where sterilized surgical instruments were kept and the area that was observed at 11:05 AM. At this time, the surveyor confirmed the finding with the Leader of Peri-Operative Services.

3. The hospital's policy "Electrical Device Safety Checks for Non-Medical Equipment", last reviewed on 4/28/15, indicated the following:

- It is the responsibility of Central Maine Health Care staff to notify Plant Operations Department prior to entering non-medical electrical appliances into service. When notified, Plant Operations Department shall perform electrical safety checks on all non-medical electrical items for use by patients or staff.

- Patient care area non-medical electrical appliances require a one time yellow inspection sticker.

- If successfully inspected, a one time yellow inspection sticker shall be applied to the item, reflecting the date of the inspection and the initials of the inspector.

a. On 4/24/19 between 11:20 AM and 11:47 AM, in the Outpatient Therapy area located at 35 Hospital Drive, surveyors observed the following items without the required yellow inspection sticker. These observatories were made in the presence of the Plant Operations Manager, Plant Operation Supervisor, and the BioMed Supervisor:

- Fans in Therapy Room #323, Bridgton Therapy Office - OT (Occupational Therapy) Hand and Upper Extremity, Office - Physical Therapy (PT) Ms. [staff name], Office - OT [staff name], Room #328 (two fans), Room #420, PT Gym (an old 18 inch Stutter fan attached to the wall and three stand up fans), and the Therapy Services Gym (two fans). These findings were confirmed with the Plant Operation Supervisor at the time of the observations.

- Air Conditioners (ACs) in Therapy Room #323, Bridgton Therapy Office - OT (Occupational Therapy) Hand and Upper Extremity, Office - Physical Therapy [staff name], Office - OT [staff name], the children's area of Speech Therapy (two ACs), and Room #419. It was noted that there were two different types of air conditioners. These findings were confirmed with the Plant Operation Supervisor at the time of the observations.

b. On 4/24/19 at 11:52 AM, surveyors observed a sticker was not attached to an electric Care Fusion Surgical Clipper, located in an examination room of Bridgton Surgical at 35 Hospital Drive. The BioMed Supervisor confirmed this finding and indicated that this item would be considered non-medical equipment.

4. On 4/23/19 at approximately 10:18 AM, the Plant Operations Manager was asked about the preventive maintenance program. He indicated that all items have an asset number, the number is placed on the item, the number is entered into the computerized system, and the contract company determines the frequency of the preventative maintenance checks. His department conducts the maintenance of non-clinical items and Biomed conducts the maintenance on clinical (medical) items. At approximately 10:45 AM, it was explained that the computerized system will send out work orders to each of the maintenance personnel of what needs to be done for preventative maintenance.

The hospital's "Preventative Maintenance Work Orders", policy and procedure last revised 1/2019, indicated the following: "Preventative maintenance procedures will be followed on all pieces of equipment deemed necessary by the Facilities Manager"; "Each piece of equipment will be inspected per requirement and regularity as deemed necessary"; "All equipment that is included in the preventative maintenance program will be entered into the Facilities computerized maintenance program"; "once the equipment information has been entered into the database, the preventative maintenance work orders will be performed on the equipment shall be listed on order on the work order ..."

a. On 4/24/19 between 10:58 AM and 11:15 AM, surveyors observed no asset stickers on the Welch Allyn 70400 Charging Stations for the Cordless Illuminators, Vaginal Spectrum Lighting System, in Exam Rooms #2 and #4 of the Speciality Clinic located at 35 Hospital Drive. These findings were confirmed by the Plant Operation Supervisor at the times of the observations. On 4/24/19 at 11:11 AM, these findings were also confirmed with the BioMed Supervisor.

b. On 4/24/19 between 10:58 AM and 11:15 AM, surveyors observed the Podotronic A300 machine, in Exam Room #1 of the Speciality Clinic located at 35 Hospital Drive. This machine had a sticker on it that indicated that maintenance was due in December 2018. This finding was confirmed by the Plant Operation Supervisor at the time of the observation. On 4/24/19 at approximately 11:11 AM, this finding was discussed with the BioMed Supervisor and he was going to check on this. As of 4/25/19, at the time of the exit conference at approximately 3:30 PM, no further information had been given to the surveyors regarding the maintenance and check of this device.

c. On 4/24/19 between 11:20 AM and 11:47 AM, in the Outpatient Therapy area located at 35 Hospital Drive, surveyors observed no asset stickers on the Air Conditioners (ACs) in Therapy Room #323, Bridgton Therapy Office - OT (Occupational Therapy) Hand and Upper Extremity, Office - Physical Therapy [staff name], Office - OT [staff name], the children's area of Speech Therapy (two ACs), and Room #419. It was noted that there were two different types of air conditioners. These findings were confirmed with the Plant Operation Supervisor at the time of the observations.

On 4/25/19 in the morning, the Plant Operations Manager gave the surveyor a copy of the owner's manual for one type of the air conditioners. This manual indicated "the air filter should be checked at least once a month to see if cleaning is necessary."

On 4/25/19 at 2:15 PM, the Plants Operations Manager indicated that the ACs were not in the preventative maintenance program. When asked how would they know when filters would need to be changed if they were not in the program, he indicated that he was sure that the filters were changed but didn't know how it gets triggered to do the maintenance.

d. On 4/24/19 at 11:55 AM, surveyors observed that an asset sticker was not attached to the Walach LL100 Cryogun located in the store room of Bridgton Surgical at 35 Hospital Drive. This finding was confirmed by the BioMed Supervisor at the time of the observation.

e. On 4/24/19 at 12:00 PM and 12:12 PM, surveyors observed that an asset sticker was not attached to thermometers located in Exam Rooms #5 and #6 (Pediatric side) in the Bridgton Primary Care at 35 Hospital Drive. These findings were confirmed by the BioMed Supervisor at the time of the observation.

f. On 4/24/19 at 11:55 AM, surveyors observed that an asset sticker was not attached to the Welch Allen Universal Charger for Otoscopes located in Bridgton Primary Care at 35 Hospital Drive. This finding was confirmed by the BioMed Supervisor at the time of the observation.

g. On 4/24/19 at 12:13 PM, surveyors observed that no asset sticker or electrical sticker was attached to the exam table in Exam Room #6 Bridgton Primary Care - Pediatric Side. This finding was confirmed by the BioMed Supervisor at the time of the observation.

On 4/24/19 at 12:14 PM, the Clinical Coordinator of Bridgton Primary Care stated that they (maintenance) were there last Wednesday and they ran out of stickers.

h. On 4/24/19 at 1:25 PM, surveyors observed that no asset sticker was attached to the overhead ceiling lift located in Inpatient Room #112. This finding was confirmed by the BioMed Supervisor at the time of the observation.

The failure to have asset stickers on the above findings means that these items would not be logged into the computerized system; therefore, a work order would not be generated to conduct any potential maintenance on the items.

5. On 4/25/19 in the morning, a surveyor inquired multiple times with the Plant Operations Manager regarding the items that were on the preventive maintenance program, the frequencies of the checks, and what items that they may have determined to be on an alternative Equipment Management (AEM) Program if any.

In the morning, the Plant Operations Manager gave the surveyor a spreadsheet that had a hand written title of "Plant Ops - PMs (Preventative Maintenance)". The surveyor and the Plant Operations Manager reviewed this spreadsheet which had a column titled "Int". The Plant Operations Manager indicated that this was the interval of the maintenance. When reviewing the spreadsheet further, the surveyor noted that some items had an interval number of "1", which the Plant Operation Manager indicated meant monthly, yet the spreadsheet did not indicate that the maintenance was done monthly. The surveyor asked about same and the Plant Operation Manager indicated that he would need to check on this.

On 4/25/19 at 2:15 PM, a document from the contracted company titled "Maintenance Strategies and Frequencies" was given to the surveyor by the Plant Operations Manager. He indicated that he was still looking for material that had been requested.

The document titled "Maintenance Strategies and Frequencies" indicated that an AEM may be utilized if it is determined to be optimum for equipment reliability and life cycle cost; "the department identifies in writing the frequencies for inspecting, testing and maintaining of operating components of utility systems in the inventory"; the criteria for establishing the activity frequency; "determine election for AEM equipment based upon the selection matrix, appendix 1, sheet 1"; the Facility Director would enter the info into the computer system; and "if an AEM strategy is utilized for a specific piece of equipment an annual evaluation of that strategy must be completed". The review would be done utilizing the matrix.

On 4/25/19 at approximately 2:55 PM, the surveyor made the President/Chief Executive Office aware that she had not received information related to the preventative maintenance program.

On 4/25/19 at 3:15 PM, the President/Chief Executive Officer indicated that the hospital was unable to provide the information.

As of approximately 3:30 PM, at the time of the exit conference, no further information was received, including the matrix referred to in the document.

Based upon the inability of the hospital to provide information, the surveyor was unable to determine if the hospital had placed items on an AEM program and the frequencies in which items would be checked.

Based on interviews and observation, the hospital failed to ensure that the floor of a patient's room was clean for 1 of 13 patient rooms observed (Patient #13).

Finding:

On 4/24/19 at 9:45 AM, Patient #13 indicated, to the surveyor, that the floor of the room had not been cleaned since giving birth in the room on 4/23/19 at 7:30 PM. The patient and two visitors pointed to an area, on the right side at the foot of the bed, that was approximately 12 inches, that was splattered with dried dark red spots.

On 4/24/19 at 11:30 AM, the Nurse Manager of the In-patient Unit was interviewed. She indicated the following: the blood splatters on Patient #13's floor were not cleaned up yet as the floors are cleaned by the housekeeping department daily; housekeeping had not gotten to that room yet; the hospital does not have 24-hour housekeeping services; and the Registered Nurses had other important priorities on the evening of 4/23/19.

Based on the survey conducted by life safety code surveyors, the hospital failed to ensure that 11 life safety code requirements were met K161, K211, K222, K271, K321, K351, K353, K363, K372, K761, and K919).

Findings:

During the life safety code survey, the following life safety code requirements were not met: K161, K211, K222, K271, K321, K351, K353, K363, K372, K761, and K919. Please see the CMS Form 2567 for Event ID NTPK21 for details.

Based on records reviewed and interviews, the Condition of Participation (COP) for Organizational Structure was not met as evidenced by the failure of the Governing Body to ensure a system was in place to ensure hospital policies were implemented in relation to an allegation of neglect, grievances, checking crash carts, and ensuring electrical devices were checked for safety.

Findings:

§485.627(a) Standard: Governing Body or Responsible Individual also known as C-0241 - Based on record review and interviews, the Governing Body failed to ensure hospital policies were implemented in relation to an allegation of neglect, grievances, checking crash carts, and ensuring electrical devices were checked for safety. Please see C-0241 and C-0381 for details.

The cumulative effect of the deficient practices resulted in noncompliance with this Condition of Participation.

Based on record review and interviews, the Governing Body failed to ensure hospital policies were implemented in relation to an allegation of neglect, grievances, checking crash carts, and ensuring electrical devices were checked for safety.

Findings:

1. The hospital's policy titled, "Abused, Assaulted or Neglected Children, Adults, Patients, Reporting of Suspected Cases", revised 5/21/18, was not implemented when an allegation of neglect was reported by a patient on 12/21/18. Please see standard §485.645(d)(3) Freedom from abuse, neglect and exploitation also known as C-0381 for details.

2. The hospital's policy titled, "Patient Complaints and Grievances", revised 6/25/17, indicated the following:

- "Resolution: A written letter from the Patient Relations Specialist at [Hospital #2] and Guest Relations personnel at [Hospital #1] and [Hospital #3] summarizing the actions taken, shall be provided to the Grievant at the conclusion of the investigation. Resolution of most grievances should be completed within seven business days of receipt but not more than 30 days. Upon resolution of a grievance, the Grievant will be provided with written notification of the decision that includes the contact person, steps that were taken on behalf of the patient to investigate the grievance, the results of the review and the date of the completion. If it will take more than thirty days to conclude the investigation, the Grievant shall be notified in writing with an approximate date of resolution. Attempts to communicate with the grievant are to be documented in Midas."

This policy was not implemented as evidenced by the following:

a. Two incident reports for a patient grievance involving Patient #1G were entered into the hospital's tracking system on 12/21/18. The surveyor requested to review the letter that was sent to the patient. On 4/25/19 at 8:40 AM, the Director of Nursing (DON) stated a letter had not been sent to the complainant.

b. An incident report for a patient grievance involving Patient #2G was entered into the hospital's tracking system on 12/14/18. A letter, dated 10/29/18, had been submitted by the patient and this letter was stamped, at Hospital #2, as being "Received on 11/1/18". On 11/01/18 at 5:24 PM, documentation showed that the letter was forwarded to Hospital #1. On 2/14/19, a response letter was sent to the patient. However, this response letter did not indicate the date of completion as required by this regulation. On 4/25/19 at 8:40 AM, the DON confirmed this finding.

c. An incident report for a patient grievance involving Patient #3G was entered into the hospital's tracking system on 1/19/19. The surveyor requested to review the letter that was sent to the patient. On 4/25/19 at 8:40 AM, the DON stated a letter had not been sent to the complainant.

d. An incident report for a patient grievance involving Patient #4G was entered into the hospital's tracking system on 1/23/19. The surveyor requested to review the letter that was sent to the patient. On 4/25/19 at 8:40 AM, the DON stated a letter had not been sent to the complainant.

e. An incident report for a patient grievance involving Patient #5G was entered into the hospital's tracking system on 2/5/19. The surveyor requested to review the letter that was sent to the patient. On 4/25/19 at 8:40 AM, the DON stated a letter had not been sent to the complainant.

3. The hospital's "Code Cart Adult/Pediatric Checking Inventory" policy and procedure indicated, the following under the procedure:

- 1. Code Carts are checked and documented daily for lock integrity and 02 [oxygen] tanks with adequate supply.
- 2. Document that appropriate locks/seals are intact on the Code Cart List.
- 3. Code Cart contents must be reviewed and expiration dates assessed Tuesday of each week."

This policy was not implemented as evidenced by the following:

a. A review of the the "Bridgton Hospital Code Cart Checklist" for the crash cart located on the Post Anesthesia Care Unit (PACU) indicated the checks were not completed for 21 out of 31 days in March 2019 and 5 days as of 4/23/19.

On 4/23/19 at 10:47 A.M., in an interview with the Nurse Leader for Peri-Operative Services, he/she stated the code carts were checked only on days when there are scheduled surgeries.

On 4/23/19 at 2:00 P.M., in an interview with the DON, she confirmed Surgical Services perform both elective and emergency surgeries. The surveyor confirmed this finding with the DON at this time.

b. A review of the the "Bridgton Hospital Code Cart Checklist" for the crash cart located on the Medical/Surgical/Special Care Unit indicated the checks were not completed on the following dates: 1/25/19, 2/2/19, 2/10/19, 2/18/19, 2/19/19, 3/24/19, 4/6/19, and 4/7/19.

On 4/23/19 at 10:50 A.M., in an interview with the unit Registered Nurse, she stated the code cart was supposed to be checked every day and weekly. She indicated that sometimes the acuity of patients is so high they may not always get to complete these code cart checks.

4. The hospital's policy "Electrical Device Safety Checks for Non-Medical Equipment", last reviewed on 4/28/15, indicated the following:

- It is the responsibility of Central Maine Health Care staff to notify Plant Operations Department prior to entering non-medical electrical appliances into service. When notified, Plant Operations Department shall perform electrical safety checks on all non-medical electrical items for use by patients or staff.

- Patient care area non-medical electrical appliances require a one time yellow inspection sticker.

- If successfully inspected, a one time yellow inspection sticker shall be applied to the item, reflecting the date of the inspection and the initials of the inspector.

This policy was not implemented as evidenced by the following:

a. On 4/24/19 between 11:20 AM and 11:47 AM, in the Outpatient Therapy area located at 35 Hospital Drive, surveyors observed the following items without the required yellow inspection sticker. These observatories were made in the presence of the Plant Operations Manager, Plant Operation Supervisor, and the BioMed Supervisor:

- Fans in Therapy Room #323, Bridgton Therapy Office - OT (Occupational Therapy) Hand and Upper Extremity, Office - Physical Therapy (PT) Ms. [staff name], Office - OT [staff name], Room #328 (two fans), Room #420, PT Gym (an old 18 inch Stutter fan attached to the wall and three stand up fans), and the Therapy Services Gym (two fans). These findings were confirmed with the Plant Operation Supervisor at the time of the observations.

- Air Conditioners (ACs) in Therapy Room #323, Bridgton Therapy Office - OT (Occupational Therapy) Hand and Upper Extremity, Office - Physical Therapy [staff name], Office - OT [staff name], the children's area of Speech Therapy (two ACs), and Room #419. It was noted that there were two different types of air conditioners. These findings were confirmed with the Plant Operation Supervisor at the time of the observations.

b. On 4/24/19 at 11:52 AM, surveyors observed a sticker was not attached to an electric Care Fusion Surgical Clipper, located in an examination room of Bridgton Surgical at 35 Hospital Drive. The BioMed Supervisor confirmed this finding and indicated that this item would be considered non-medical equipment.

Based on document review and interviews, the hospital failed to ensure that all services furnished under arrangement was maintained on a list which described the nature and scope of the service for 1 of 1 services identified.

Finding:

On 4/23/19, surveyors requested and received a list of services furnished under arrangement or agreement.

On 4/24/19 between 2:30 and 2:55 PM, the Environmental Services Manager stated that cleaning of patient curtains, employee lab coats and employee uniforms was performed by Service Provider #1.

A review of the list of services furnished under arrangement or agreement was conducted and it was determined that Service Provider #1 was not on the list provided.

On 4/24/19 at 3:15 PM, it was discussed, with hospital staff, that Service Provider #1 and others identified were not on the list provided.

On 4/25/19, a revised list was provided to surveyors. It was again noted that Service Provider #1 was not on the list.

On 4/25/19 at 11:22 AM, the surveyors discussed, with the President/CEO, that they were looking for service agreement for Service Provider #1.

On 4/25/19 at 1:29 PM, the Clinical Project Manager confirmed that the hospital did not have a contract with Service Provider #1.

Based on record reviews and interviews, the hospital failed to ensure that medications were administered as ordered by the authorized practitioner for 2 of 20 patients reviewed (Patient #7 and #10).

Findings:

1. Patient #7 had an order, dated 2/20/19, for "Ritalin 50 mg [milligrams] po [by mouth] every day".

There was no evidence in the patient's record to indicate that Ritalin was administered on 11/13/18, 11/14/18, and 11/15/19.

On 4/25/19 at 8:30 AM, the Associate Nurse Leader confirmed this medication was not administered as ordered.

2. Patient #10 had an order, dated 2/20/19, for Combivent Respimat (an inhaler) to be administered four times per day.

There was no evidence in the patient's record to indicated that the Combivent Respimat inhaler was administered on 2/20/19 and 2/21/19.

On 4/25/19 at 10:30 AM, the Associate Nurse Leader confirmed the Combivent Respimat inhaler was administered as ordered.

Based on record review and interview, hospital failed to ensure a record contained dated signatures for 1 of 5 sampled Surgical Services records reviewed (Surgical Service Record #2).

Finding:

Surgical Services Record #2 contained a "History and Exam Pre-Procedure with Sedation" form which was signed by a Provider. However, there was no date to indicated when this form was completed and signed by the Provider.

On 4/24/19 at 8:50 AM, the Director of Nursing confirmed this finding.

Based on record reviews and interviews, the hospital failed to ensure that a swing bed patient was free from neglect for 1 of 1 incidents reviewed. In addition, the hospital failed to ensure that their policy and procedure was implemented in relation to reporting and investigating an allegation of neglect for 1 of 1 incidents reviewed.

Findings:

On 12/21/2018 at 10:30 AM, a Physical Therapy Aide (PTA) entered the following into the hospital's computer system for grievances in relation to Patient #1G: "PTA arrived to pt. [patient] room 107 at 8:07 [AM] to find pt. seated in [his/her] chair without a gown on, with a feces covered pad on [his/her] bed, and urine filled commode. Pt. states [he/she] was incontinent in bed and [his/her] nurse got [him/her] on the commode. [He/she] then sat on the commode for a bit of time, then used [his/her] call bell to ask for help with personal care and was informed that [his/her] nurse was on their way. Pt. stated [he/she] then sat on the commode for a long period of time with no arrival of nursing therefore [he/she] rang [his/her] bell again. Pt. reports that after pressing the call bell [he/she] was informed that they are on their way again in what the pt. described as an angry tone. Pt. sat on commode for extended period of time again and still had not had a nurse arrive so [he/she] decided to transfer to [his/her] chair due to commode hurting [his/her] bottom. Pt. stated from the time [he/she] was placed on the commode until the time the PTA had arrived was 2 hours without the arrival of a nurse/tech. [He/she] was in the chair without a gown, but managed to grab a blanket next to [him/her] for cover/warmth. After questioning pt, and PTA stating he will talk to nursing about it, pt. states [he/she] doesn't want to make anyone mad or it'll just get worse."

On 12/21/2018 at 11:25 AM, Lead Occupational Therapist (OT) entered the following into the hospital's computer system for grievances in relation to Patient #1: "Upon working with Pt. [patient] this AM [morning] I was abruptly informed of [his/her] HORRIFIC experience this morning with [his/her] lack of care. Pt. described that this AM [he/her] was incontinent in [his/her] bed and stated [he/she] needed to use the commode. Per the Pt when NSG [Nursing] staff arrived they informed [him/her] that [he/she] was independent in the room and [he/she] was encouraged to complete on [his/her] own. When Pt vocalized that [he/she] would still require help [he/she] said [he/she] was hastily attended to and assisted to the bedside recliner and left there naked. Pt stated [he/she] called/rang for TWO HOURS (5:30ish-7:30ish) where during that time [he/she] managed to grab a blanket off the bed to minimally cover [him/herself] up. [His/her] bed still covered in feces, [his/her] commode still full and was left in the recliner without a Johnny on or anything to cover up? Upon 8 the NSG tech [Certified Nursing Assistant - CNA #2] and PTA found the pt. haphazardly wrapped in a blanket in the chair with feces in the already described places - bed, commode and all backside of Pt still. Both [CNA #2] and PTA having witnessed the aftermath of the situations - attended to and reported event. I came on around 10:30 to Pt and was informed of all of this. The Pt ashamed of the event and afraid to call out for help as [he/she] states 'I can tell they don't want to. Even the women answering the call is mean about me asking for help'. I relayed this event to [his/her] current nurse [RN #1] to which she took no ownership for any of it and simply stated 'Well it must have been the overnight staff'. I attempted to find NSG supervisor - or RN Manager of In-patient Unit both of which were unavailable."

Documentation indicated an email was sent, on 12/24/2018, to the RN Manager of In-patient Unit from the Controller stating, "Two events for same patient, same situation. Please follow up. Thanks. [Controller]."

Documentation indicated an email was again sent, on 1/10/2019, to the RN Manger of the In-patient Unit from the Controller stating, "[RN Manager of In-patient Unit], please document follow up. Thanks. [Controller]".

Documentation indicated an email was again sent, on 1/21/2019, to RN Manager of the In-patient Unit from the Controller stating, "[RN Manager of In-patient Unit] - would you please investigate and document your findings there are two entries for this same complaint".

Documentation indicated an email was again sent, on 1/21/2019 at 8:15 AM, to the RN Manager of the In-patient Unit from the Secretary of Controller indicating a reminder was sent to RN Manager of In-patient Unit to look into this matter and she was asked her to document her findings.

Documentation indicated an email again was sent, on 1/29/2019 at 2:24 PM, to the RN Manager of the In-patient Unit from the Secretary of Controller regarding this incident.

On 2/4/2019, an email was sent to the Controller from the RN Manager of the In-patient Unit indicating the following: "2/4/19 [RN Manager of In-patient Unit-initials], Call made to patient and apologized for delay in response to [his/her] calling for assistance. [He/she] stated that the girl said that she did not get the call that [he/she] needed help. Pt. was very understanding and I told [him/her] that I would look into why they may not have gotten the call. Pt. is doing well other. Additionally, I contacted PT to please let me know real time when there is a concern like this so that it can be handled immediately. I also followed up by email to all staff that were assigned to that patient during the time period that this occurred to make them aware of the event".

On 2/4/19 at 12:43 PM, an email regarding this event was sent from the RN Manager of the In-patient Unit to six staff. The email indicated the following: "Hey everyone, I [in] digging through ... and quite behind on following up on Midas events. I have copied and pasted an actual Midas event that was filed, and at this late date there is not much that I can do with regard to identifying the reason or 'story' of this occurrence, but I feel the need to make you aware of the content of this event. Given the timing of the event, it seems to have crossed over from the night shift into the day shift, so have included those of you that were assigned to the patient that night/day. Please take a look at this. All I ask is that you ask yourself, is there something that we could have done or should have done to make this patient's experience better? My responsibility is to follow up with this patient and my regret is that I did not respond to this event more promptly. Let me know if you have any feedback that may help improve a situation like this. [RN Manager of In-patient Unit]."

On 4/25/19 at 11:25 AM, an interview was conducted jointly with the Lead OT and the PTA and the following was obtained:

- Both individuals confirmed what they wrote in each of their grievances.

- Both the Lead OT and PTA confirmed that neither of them reported this event to the Department of Health and Human Services.

- The PTA stated that the patient told him he/she didn't want to make a big deal of it for fear of retaliation.

-The PTA stated that, "[he/she] is well known for being dependent so for [him/her] to move on [his/her] own [he/she] must have been pretty uncomfortable".

- The Lead OT stated, "[he/she] looked ashamed, embarrassed, and was fearful of the repercussions by staff if [he/she] complained". She added, he/she asked them not to report the situation to anyone.

- The Lead OT stated that Patient #1G is supposed to use his/her bariatric walker for transfers. She shared her concern stating, "[he/she] very unsafely moved himself from the commode to the chair [by himself]."

On 4/25/19 at 12:10 PM, the Manager of the In-patient Unit was interviewed and the following information was obtained:

- Any Midas reports, involving her Unit, are sent to her as soon as they are entered.

- She confirmed she received the Grievance report regarding Patient #1G on 12/21/18.

- She confirmed that she did not report this event to the Department of Health and Human Services.

- She confirmed that she did not respond to the event until 2/4/19.

On 4/25/19 at 2:00 PM, RN #1 was interviewed and the following information was obtained:

- She worked the day shift, 7:00 AM- 7:00 PM, on 12/21/18.

- During rounding (when they receive report from the off-going shift patient room to room) the night nurse RN #2 told her that "Room #107 [Patient #1G] had complained of not being attended to... someone didn't help him ...took a while to get him off of the commode".

On 4/26/19 at 1:55 PM, CNA #2 was interviewed and the following information was obtained:

- Patient #1G did need help to get out of bed and transfer.

- On 12/21/18 at 8:00 AM, she entered the patient's room to find a mess in his/her room - the bed pad was full of feces (stool); he/she was sitting in his/her chair naked with a sheet on him/her; stool was smeared on him/her; and he/she was upset that he/she had been left like this for so long.

- She approached the Unit Secretary asking her who she contacted when Patient #1G called out for help. She found out that RN #2 had been contacted and that she went in to assist the patient.

- Patient #1 was visibly upset and he/she verbally shared his/her upset about being left without being helped for so long.

On 4/26/19 at 2:20 PM, Patient #1G was interviewed and the following information was obtained:

- He/she had a diagnosis of C-Difficile so he/she was incontinent frequently and was weak.

- There was a mess (incontinent of stool) on him/her and on his/her bed.

- He/she sat in the chair for a long time.

- He/she was afraid to complain as he/she feared that they (staff) would retaliate against him/her. "They really wouldn't respond when I called them".

- When someone finally came in to help him/her, they told him/her that they didn't know someone else hadn't already help him/her.

The hospital's policy titled, "Abused, Assaulted or Neglected Children, Adults, Patients, Reporting of Suspected Cases", revised 5/21/18, indicated the following:

- "Neglect - Failure to provide adequate food, clothing, shelter, supervision, or medical care when that failure causes or is likely to cause injury including accidental injury or illness ..." The policy further describes neglect as, "'Neglect' means a threat to an adult's health or welfare by physical or mental injury or impairment, deprivation of essential needs or lack of protection from these."

- "Mandated Reporters - While acting in his/her professional capacity, a medical or osteopath physician, resident, intern, emergency medical services person, medical examiner, physician's assistant, dentist, dental hygienist, dental assistant, podiatrist, registered or licensed practical nurse, social worker, homemaker, home health aide, medical or social services worker, psychologist, child care personnel, or mental health professional who knows or has reasonable cause to suspect abuse, assault or neglect."

Under Section C. Suspected Patient Abuse or Neglect:

- "1. Any employee or member of the Facility Medical Staff who witness or receives an allegation of sexual or physical abuse, neglect or assault of any patient or other individual in [Hospital] facilities will intervene immediately and ensure actions stop and that the patient or individual is safe from further neglect, abuse or assault. The first person becoming aware of an allegation of suspected abuse/neglect/assault will notify the applicable Department Manager or House Supervisor, who ensures that any immediate measures are taken for patient safety, then notifies the following: a. Administrator-on-call (AOC); b. Department Manager or Director; c. Attending Physician; Human Resources ..."

- "2. The individual will also create an event report in Midas prior to the end of the current work shift."

- "3. Investigation:

a. The Department/Unit Manager, or House Supervisor, will ensure the patient is placed in a secure area and take any necessary steps to ensure their safety from any other injury by the alleged perpetrator ...
Any employee of [Hospital] having reasonable cause to suspect that an adult or child has suffered abuse, neglect, or assault, shall report or cause reports to be made in accordance with state law ...

b. The House Supervisor or Risk/Quality/Compliance designee obtains detailed statement from the patient and /or family member(s) making the allegation.

c. Human Resources and Risk Management interview the employee against whom the allegations are being made, then interview any witnesses.

d. The Vice President, or designee, reports the allegation to local law enforcement, as appropriate.

e. An employee suspected of, or whom an allegation of abuse is made, will be immediately removed from patient care and placed on suspension, or leave of absence as appropriate, pending further investigation ..."

There was no evidence provided to the surveyor that indicated that the hospital identified this incident as an allegation of neglect and followed their own policy. The incident was entered into computerized system on 12/21/18 by two individuals; the report was received by the the Manager of the In-patient Unit on 12/21/18 and despite five reminders (12/24/18, 1/10/19, two on 1/21/19 and on 1/29/19) the report was not acknowledged until 2/4/19 (45 days later), and no investigation was ever conducted into the incident. In addition, multiple individuals had knowledge of the alleged incident of neglect and failed to report the allegation to the Department as required by state law.

The hospital also failed to ensure Patient #1G was free from neglect. According the patient, he/she attempted to obtain assistance from staff after being incontinent of feces and waited a lengthy period time before assistance was received despite calling for assistance. Hospital staff documented on 12/21/18 the patient expressed he/she didn't want to make anyone mad or it'll just get worse and the patient was ashamed of the event and was afraid to call out for help as he/she had stated the following: "I can tell they don't want to. Even the women answering the call is mean about me asking for help". In addition, during interviews with the surveyor staff indicated the patient looked ashamed, embarrassed, and was fearful of the repercussions by staff if he/she complained and asked that the staff not report the situation to anyone; he/she didn't want to make a big deal of it for fear of retaliation; and the patient was visibly upset about the incident.