HospitalInspections.org

Based on review of Governing Body Bylaws, Governing Body meeting minutes for the past year, and staff interviews, the Governing Body failed to:


a. provide oversight of the quality of care provided throughout the Mental Health Unit (MHU) of the hospital. See Tag A-0115 and Tag A-0386;


b. ensure there were mechanisms that effectively measured, assessed and improved clinical care and service for the MHU of the hospital. See Tag A-0263 and;


c. ensure compliance with all Medicare Conditions of Participation at 42 CFR 482. See 2567 Statement of Deficiencies.


Findings:


1. On 01/06/2016, at 8:30 a.m., surveyors requested governing body meeting minutes for the past year. Surveyors reviewed the governing body meeting minutes. There was one documented entry in the Governing Body meeting minutes for the past year specific to the MHU. The one entry in the Governing Body meeting minutes documented the MHU with minimal information. The Administrator of the MHU was asked what the information meant. The Administrator was unable to provide the surveyors with details based off the Governing Body meeting minutes.


2. On 01/06/2016, at 8:30 a.m., surveyors requested governing body bylaws. Governing Body Bylaws were provided by administrative staff. The Governing Body Bylaws documented, "...provide oversight of the quality of care provided throughout the Hospital and require mechanisms for effectively measuring, assessing and improving clinical care services...To approve and ensure compliance with a program of continuous performance improvement for the Hospital...and comprehensive review of the Hospital's program to assess and improve the quality and performance of patient care and services provided in the Hospital..." and "...regulatory oversight..."


3. On 01/07/2016, at 10:00 a.m., surveyors asked the Administrator of the MHU to provide documented evidence where the MHU was reporting information to the Governing Body of the hospital. The Administrator told surveyors that the MHU was recently invited to provide quantitative data to the hospital's Governing Board's 4th quarter meeting. The Administrator of the MHU told surveyors she had not been asked/attended QAPI meetings. The Administrator of the MHU told surveyors that the Administrator had been working for the hospital in the MHU for over 12 years.

Based on hospital policy and procedure review, grievance review, injury report review, and staff interview, the hospital failed to:


a. protect all patients from all forms of abuse; (see tag A-0145)


b. appropriately identify complaints and grievances; (see tag A-0118)


c. ensure the governing body was responsible for all grievances; (see tag A-0119)


d. ensure all patient's who filed a grievance was provided written notice with the decision of the hospital and all investigative steps taken on the patient's behalf. (see tag A-0123)

Based on policy and procedure review, grievance review, injury report review, and staff interview, the hospital failed to ensure complaints, grievances and injuries were appropriately identified.


Findings:


1. On the afternoon of January 6, 2016, administrative staff told surveyors Staff B was the staff responsible for grievances.


2. On the afternoon of January 6, 2016, Staff A told surveyors if a patient wanted to file a grievance they would fill out a grievance form or they could talk with Staff B and he would assist the patient in filling out the form.


3. On January 7, 2016, at 11:20 a.m., a grievance policy was reviewed. The policy titled, "Patient Grievance Policies and Procedures," references the Office of Client Advocacy (OCA) requirements for grievances but failed to ensure that the Medicare requirements for hospital grievances were met.


4. On January 7, 2016, at 12:50 p.m., Surveyors reviewed a binder that contained hospital grievances for the past year.


The binder contained multiple grievance forms that alleged abuse of some sort. There were allegations of threatening physical abuse from staff. There were allegations of verbal abuse and yelling from staff. There were allegations of name calling by staff and allegations of physical exercise being used for punishment. There was no documentation of complete investigative actions taken on any of these allegations.


5. On the afternoon of January 6, 2016, surveyors reviewed hospital "injury reports." There were multiple injury reports that alleged some form of abuse from staff. None of the injury reports where abuse was alleged were taken through the hospital's grievance process.


6. On the morning of January 7, 2016, Staff B told surveyors he did not have access to all the injury reports that go to Risk Management.


7. On the morning of January 7, 2016, Staff B told surveyors that all grievances come in the form of a written grievance and is put on a grievance form. Staff B told surveyors that he did not send written notice to any patient that outlined the decision of the hospital regarding the grievance or that included the investigative steps taken on behalf of the patient.

Based on hospital grievances review, grievance policy and procedure review, staff interview, and Quality Review Committee of the Board of Directors meeting minutes review, the hospital failed to ensure the governing body was responsible for the effective operation of the grievance process.


Findings:


1. On the afternoon of January 6, 2016, administrative staff told surveyors Staff B was the staff responsible for grievances.


2. On the afternoon of January 6, 2016, Staff A told surveyors if a patient wanted to file a grievance they would fill out a grievance form or they could talk with Staff B and he would assist the patient in filling out the form.


3. On January 7, 2016, at 11:20 a.m., a grievance policy was reviewed. The policy titled, "Patient Grievance Policies and Procedures," references the Office of Client Advocacy (OCA) requirements for grievances but failed to ensure that the Medicare requirements for hospital grievances were met.


4. On January 15, 2016, at 11:10 a.m., surveyors requested and reviewed the grievance policy for the hospital wide system. The policy titled, "Receiving and Responding to Patient Complaints and Grievances," documented, "...Every patient or patient representative will be given appropriate notice of the grievance process... All written responses will be signed by the Hospital President, the Chief Operating Officer of {name omitted} health or the Chief Executive Officer of {name omitted} or his/her respective designee (s)..." On January 7, 2016, at 10:15 a.m., Staff B told surveyors that he had not sent a written letter to any patient who filed a grievance.


6. On January 7, 2016, at 10:00 a.m., surveyors reviewed the Quality Review Committee of the Board of Directors meeting minutes dated November 12, 2015. The meeting minutes documented 5 grievances on the mental health unit with 100% reviewed. The meeting minutes did not document any other data related to the grievances. On the morning of January 7, 2016, Staff I told surveyors that numbers are the only thing reported in the meetings.


7. On January 7, 2016, at 12:50 p.m., Surveyors reviewed a binder that contained hospital grievances for the past year.


The binder contained multiple grievance forms that alleged abuse of some sort. There were allegations of threatening physical abuse from staff. There were allegations of verbal abuse and yelling from staff. There were allegations of name calling by staff and allegations of physical exercise being used for punishment. There was no documentation of complete investigative actions taken on any of these allegations. There was no documentation these grievances had been reviewed in Quality Review Committee. There was no documentation these grievances had been reviewed in Governing Body. On January 7, 2016, at 10:30 a.m., Staff B told surveyors the grievances had not been taken to Risk Management.


8. On the afternoon of January 6, 2016, surveyors reviewed hospital "injury reports." There were multiple injury reports that alleged some form of abuse from staff. None of the injury reports where abuse was alleged were taken through the hospital's grievance process.

Based on hospital grievances review, hospital grievance policy and procedure review, and staff interview, the hospital failed to provide each patient who had a grievance with a written notice of the hospital's decision on the grievance and steps taken on behalf of the patient to investigate the grievance.


Findings:


1. On the afternoon of January 6, 2016, administrative staff told surveyors Staff B was the staff responsible for grievances.


2. On the afternoon of January 6, 2016, Staff A told surveyors if a patient wanted to file a grievance they would fill out a grievance form or they could talk with Staff B and he would assist the patient in filling out the form.


3. On January 7, 2016, at 10:15 a.m., Staff B told surveyors when a patient wanted to file a grievance they would fill out a grievance form. Staff B told surveyors he had never sent a written letter to any patient. Staff B told surveyors he would resolve grievances face to face.


4. On January 7, 2016, at 11:20 a.m., a grievance policy was reviewed. The policy titled, "Patient Grievance Policies and Procedures," references the Office of Client Advocacy (OCA) requirements for grievances but failed to ensure that the Medicare requirement for hospital grievances were met.


5. On January 15, 2016, at 11:10 a.m., surveyors requested and reviewed the grievance policy for the hospital wide system. The policy titled, "Receiving and Responding to Patient Complaints and Grievances," documented, "...The patient or the patient's representative will be infomed by written response..." The policy further documented, "...written responses shall include notice of the decision, the name of the contact person, the steps taken to investigate the grievance, the results of the investigation, and the date of completion of the process..."


6. On January 7, 2016, at 12:50 p.m., Surveyors reviewed a binder that contained hospital grievances for the past year. The grievance binder contained no documentation a written letter was sent to any patient that filed a grievance. The grievance binder did not contain documentation of a complete investigation into all grievances.


The binder contained multiple grievances forms that alleged abuse of some sort. There were allegations of threatening physical abuse from staff. There were allegations of verbal abuse and yelling from staff. There were allegations of name calling by staff and allegations of physical exercise being used for punishment. There was no documentation of complete investigative steps taken on any of these allegations.


7. The Policy titled, "Receiving and Responding to Patient Complaints and Grievances," documented "...Complaints or grievances about situations that are perceived to endanger the patient will be addressed immediately..."


The policy further documented, "...the Risk Management office may be notified of any complaint or grievance as indicated by the nature of the issue involved..." On January 7, 2015, at 10:30 Staff B told surveyors that grievances do not go to the Risk Manager.

Based on policy and procedure review, hospital grievance review, hospital reports, and staff interview, the hospital failed to protect patients from all forms of abuse.


Findings:


1. On January 6, 2016, at 8:30 a.m., surveyors requested all patient incidents and grievances with investigations and responses for the last year and patient abuse and neglect policies and procedures. Administrative staff provided surveyors with multiple binders that contained documents titled, "Patient Injury Reports."


2. Surveyors reviewed the binders that contained Patient Injury Reports. Surveyors identified multiple allegations of verbal and physical abuse. Not all Patient Injury Reports with allegations of abuse were investigated.


There was no documented evidence that staff had been removed from patient care after the allegations of verbal and physical abuse occurred.


3. On January 6, 2016, at 2:15 p.m., surveyors asked Administrative Staff what the process was for any allegation of abuse/neglect. Staff A told surveyors that any allegation of abuse would be called into the Office of Client Advocacy (OCA) if the Nurse on the unit determined it should be called in. Staff A told surveyors that the Nurse on the unit where the allegation of abuse was alleged should have completed a Patient Injury Report and would have reassigned the staff member to different patients. Staff A told surveyors any allegation of abuse would go to the Risk Manager and the Director.


4. On January 6, 2016, at 2:15 pm., Staff E told surveyors that the Nurse would ask the patient alleging abuse their side of the story and write it on a Patient Injury Report. Staff E then would talk to the staff member who the patient identified as the alleged abuser their side of the story. Staff E told surveyors that the Nurse would make the decision if abuse occurred. Staff E told surveyors that the staff member would be reassigned to different patients depending upon the allegation.


5. On January 6, 2016, at 2:15 pm., surveyors asked the Administrator of the Mental Health Unit (MHU) and Clinical Directors of the Licensed Practical Counselors (LPCs) and Nursing if they were aware of the multiple allegations of verbal and physical abuse. The Administrator of the MHU and the Clinical Directors of the LPCs and Nursing told surveyors they were not aware of the multiple allegations of verbal and physical abuse.


The Administrator of the MHU verified that all allegations of abuse had not been investigated. The Administrator of the MHU told surveyors that depending what the allegation of abuse was would determine if the staff member would remain at work or be sent home.


6. On January 7, 2016, at 12:50 p.m., surveyors reviewed a binder that contained hospital grievances for the past year. The binder contained multiple grievance forms that alleged abuse of some sort. There was no documentation of completed investigative actions taken on any of these allegations.


7. On January 7, 2016, at 10:15 a.m., surveyors received and reviewed hospital documents titled, "Patient Abuse and/or Neglect" and "Alleged Sexual Assault" policies and procedures.


The patient abuse and or neglect policy and procedure documented:


"...immediately remove the employee from direct patient care duties and all patient contact, as appropriate, during the pendency of the investigation of the alleged abuse, exploitation and/or neglect..."


"...Upon learning of a reportable incident, the Nurse in Charge on the Unit or House Supervisor...will immediately ensure the safety of any patient(s) named in the alleged incident..."


"...Patient abuse and/or neglect includes any incident of physical, sexual or verbal abuse, patient neglect, or mistreatment..."


The alleged sexual assault policy and procedure documented:


"...In all alleged sexual assault incidents involving oral, anal or vaginal penetration, a report will be made to the local police...


8. The Administrator of the MHU and the Clinical Directors of the LPCs and Nursing told surveyors that the MHU failed to follow the hospital's policies and procedures for allegations of patient abuse.

Based on review of quality assessment performance improvement (QAPI) program meeting minutes for the past year, review of QAPI Plan 2015 and 2016, review of performance improvement (PI) projects 2015 and 2016, hospital reports, and staff interviews, the hospital failed to ensure that the Mental Health Unit (MHU) was included in QAPI.


Findings:


1. On 01/06/2016, at 8:30 a.m. surveyors requested QAPI meeting minutes for the past year. Surveyors reviewed QAPI meeting minutes for the past year. There was no documented evidence that the MHU reported any information to QAPI program.


2. On 01/06/2016, at 8:30 a.m. surveyors requested QAPI Plan 2015 and 2016. Surveyors reviewed the QAPI Plan for 2015. There was no documented evidence that the MHU was included into the QAPI Plan in 2015. The QAPI Plan for all 2016 does not describe a proactive, coordinated, systematic approach to improving patient safety, patient care and health outcomes for the MHU as documented in the Hospital's QAPI Plan 2016.


3. On 01/06/2016, at 8:30 a.m. surveyors requested PI projects for 2015. Surveyors reviewed PI projects for 2015. There was no documented evidence that the MHU had projects that were conducted.


4. On 01/07/2016, at 10:00 a.m. the Regulatory Compliance Clinical Consultant for Nursing Quality told surveyors that the MHU was not included in QAPI.


5. On 01/07/2016, at 10:00 a.m. the Administrator of the MHU told surveyors that she had not been asked/attended QAPI meetings. The Administrator of the MHU told surveyors that she had been working for the hospital in the MHU for over 12 years.