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Based on observation, record review, policy review, and interviews the facility failed to:

- ensure the governing body was responsible for the operation of the grievance process including the review and resolution of grievances and the delegation of their responsibilities to a grievance committee
- ensure a timely response to patients and/or guardians of patients who filed grievances
- ensure patients admitted with suicidal ideation and/or a history of suicidal ideation, were provided care in a safe setting when it failed to provide an environment aimed at preventing looping and hanging hazards, failed to ensure staff documented the actual time of patient observations when ordered every 15-minutes and failed to include psychiatric environmental safety checks for looping and hanging hazards as part of behavioral health environmental inspections

The facility admits patients with suicidal ideations and a history of suicidal ideations.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with CFR 482.13, Condition of Participation: Patient's Rights.

The facility census was 36.

Based on observation, interview and record review, the facility failed to inform patients of their rights in advance of providing care in the outpatient Wound and Skin Management Clinic for 100% of patients.

Findings included:

During an interview on 06/16/11 at 9:10 AM, Staff S, clinic receptionist, provided a copy of the patient's rights the clinic provided to patients. The document titled, "Notice of Privacy Practices" describes how medical information about the patient may be used and disclosed and how the patient can access that information. The document did not include any other patient's rights such as patient privacy, the right to file a complaint or grievance, the right to make informed decisions regarding their care or the right to formulate advance directives.

Record review for current patients #17, #18 and #19 showed no evidence in the records that the patients received information regarding their rights and responsibilities.

Based on review of the acute hospital's patient bill of rights, review of the behavioral health patient bill of rights and review of the facility's policy on patient rights the hospital failed to include the state contact grievance information in the patient bill of rights. This affected 100% of the facility's patients. The facility census was 36.

Findings included:

Review of Patient Right's policy Index Number 950.805, Effective Date, 11/07, showed no documentation that the patient has a right to contact the state agency regarding grievances and also failed to include the state agency hotline number.

Review of the hospital wide patient bill of rights showed no documentation that the patient has the right to contact the state agency regarding grievances and also failed to include the state agency hotline number.

Review of psychiatric admission packet information provided to the patients on admission showed on page nine, "The State of Missouri has a representative who is responsible for investigating serious complaints." This statement instructs patients to limit complaints made to the state to "serious" complaints only and also failed to include that it is a right of the patient to make grievances to the state.
-Pages three through five of the admission packet titled "Patient Rights" showed the patient has a right to voice complaints and suggest changes in service or staff without fear of discrimination. The information failed to include it is the right of the patient to make grievances to the state agency and failed to include the state agency phone number.

Based on interview, policy review, review of grievances, review of the facility's grievance log and review of the governing body minutes the facility's governing body failed to be responsible for the operation of the grievance process, failed to review and resolve grievances and failed to delegate their responsibility to a grievance committee. This affected 100 percent of the facility's patients. The facility's census was 36.

Findings included:

Record review of the facility's policy titled, "Complaints/Grievances, Patient/Family/Visitor" dated 08/10 showed the Board of Directors has awarded the authority and responsibility for reviewing and resolving patient grievances to the Hospital's Operations Team.

During an interview on 06/15/11, at 10:56 AM, Staff B, Administrative Officer for Case Management, Risk Management and Quality stated that:
- He/she reviews and resolves the complaints and grievances,
- The hospital does not have a grievance committee, the facility's Operations Team does not function as a grievance committee and
- The governing body does not process the complaints or grievances.

Three grievances filed with the facility were reviewed. The steps taken to resolve the grievances were phone calls to the patients or their representative, review of the medical records and letters and/or phone calls to the patients or representatives. These steps were completed by Staff B without involvement from a committee or evidence of involvement from the governing body.

Review of the facility's complaint log for 2011 and the governing body minutes for 2011 showed the governing body failed to review and resolve grievances.

Review of the governing body minutes failed to include written delegation of the grievance process to a grievance committee.

Based on record review, interview and policy review the facility failed to ensure two patients and/or guardians of patients (#35 and #36) who filed grievances, received a timely response to those grievances. Three grievances were reviewed. The facility census was 36.

Findings included:

1. Record review of the facility's policy titled, "Complaints/Grievances, Patient/Family/Visitor" dated 11/07, showed direction that feedback to the patient or others concerned should occur within seven (7) days by the Administrative Officer or their designee.

2. Record review of a grievance by Patient #35 showed the following:
-The facility received a grievance from Patient #35 on 06/04/10;
-The facility sent a letter to the patient on 07/02/10 regarding the resolution of the grievance.

The facility resolved the grievance with the patient 28 days after receipt of the grievance from Patient #35.

3. Record review of grievance filed by the guardian of Patient #36 showed the following:
-The facility received a grievance from the guardian of Patient #36 on 08/10/10;
-The facility sent a letter to the guardian on 08/26/10 regarding the resolution of the grievance.

The facility resolved the grievance with the patient's guardian 16 days after receipt of the grievance from the guardian of Patient #36.

4. During an interview on 06/16/11 at 10:20 AM , Staff B, Administrative Officer for Case Management, Risk Management and Quality stated that the responses to Patient #35 and the guardian of Patient #36 were not completed within seven days per their policy.

Based on observation, interview and record review the facility failed to ensure privacy for any patients placed in a seclusion room on the New Beginnings behavioral health unit. The facility census was 36 and the unit census was 22.

Findings included:

1. Record review of the facility New Beginnings inpatient handbook revised 04/08 showed the following:
-The patient has the right to privacy and safety, including the freedom to be free of all forms of abuse or harassment;
-For safety and security purposes, the entrance door, hallways and seclusion room of this unit are monitored with the assistance of video cameras.

2. Observation in the nurses' station on 06/14/11 at 1:15 PM showed a television like monitor mounted on the wall. The monitor had images of hallways, a day room area and one seclusion room. The monitor could be viewed from the hallway and anytime a patient is in the seclusion room, any person walking down the hallway would view that patient. At the time of the observation no patients were in the seclusion room.

3. During an interview on 06/15/11 at 2:52 PM, Staff B, Administrative Officer for Case Management, Risk Management and Quality stated that visitors to the unit could view the monitor from the hallway and would be able to see any patient in the seclusion room.

Based on observation, interview and record review the facility failed to ensure patients admitted with suicidal ideation, history of suicidal ideation, and/or attempts to harm self or others were provided care in a safe setting when it failed to:
-provide an environment aimed at preventing looping and hanging hazards for suicidal patients
-ensure staff documented the actual time of patient observations when ordered every 15-minutes,
-include psychiatric environmental safety checks for looping and hanging hazards as part of three different types of behavioral health environmental inspections, and
-ensure plastic trash can liners are not accessible to patients who had sucidal ideations.

These failures could potentially affect 100% of the facility's behavioral health patients. At the start of the survey the behavioral health unit had three patients on suicidal precautions and three patients on assault precautions. Total behavioral health patient capacity is twenty two adult patients. The behavioral health unit census was 21 and the facility census was 36.

Findings included:

1. Observation of the patient multipurpose room on 06/14/11 at 9:37 AM, showed exposed TV and VCR electrical cords ranging in length from two to approximately five feet. The same area had a metal vertical blind hardware over the windows that mounted to the wall with metal brackets. The electrical cords and blind hardware/brackets presented a looping and hanging hazard.

2. Observation on 06/14/11 at 9:32 AM showed Staff I, Mental Health Technician (MHT) rounding on patients (observation of patients locations and activities) in the hall of the behavioral health unit.

Review of the rounding documentation sheet showed all the times of the rounds were pre-printed on the form and Staff I initialed next to the pre-printed rounding times. Staff I did not document the actual rounding time for each patient.

During an interview on 06/14/11 at 9:32 AM Staff I stated that he/she initialed next to the pre-typed times and the actual times are not documented. He/she stated that all patients are on 15-minute observation.

3. Observation on 06/14/11 at 1:15 PM on the New Beginnings (behavioral health) unit showed four trash cans in the nurses' station. Each trash can was lined with a plastic liner (bags). The plastic liners were accessible and could be removed from the trash cans by reaching over the nurses' station counter. The presence of plastic liners/bags created choking and suffocation hazards for patients at risk for suicide.

4. Observation on 06/14/11 at 2:00 PM, with Staff F, Director of Integrated Services (this included environmental services) showed a table at the end of the patient hallway with two desk phones with telephone receiver cords approximately 10 feet long. The receiver cords were removable by unclipping the receiver cords from the phone and the phone receiver. The area is open to all patients and presented a looping and hanging hazard.

5. Review of the Behavioral Health Census Database document provided by Staff H, Director of Behavioral Health on 06/14/11 showed Patient #10 assigned to Room 331 was on suicide precautions.

Observation of room 331 on 06/14/11 at 2:09 PM, with Staff F, Director of Integrated Services showed the following potential looping and hanging hazards
-Large wrist hot and cold faucet handles (4.5 inches long) and high goose neck faucet (11 inches above the sink);
-Two metal doors under the sink with protruding metal handles, which were 27 inches above the floor;
-Exposed hot and cold water shut off valves under the sink, which were 21 inches above the floor;
-Exposed sink drain under the sink, which was 12.5 inches above the floor at the lowest point;
-Exposed toilet plumbing, which was 16 inches above the floor at the lowest point;
-All the furniture in the room was unsecured and moved easily. The furniture included two platform beds, a desk, a chair, and two 4-drawer chests. There is a potential the patient(s) can move/position the furniture under a looping and hanging hazard to aid the patient in reaching a hanging position.

6. Review of the Behavioral Health Census Database document provided by Staff H, Director of Behavioral Health on 06/14/11 showed Patient #8 and Patient #9 assigned to Room 325. Both patients were on suicide precautions.

Observation of room 325 on 06/14/11 at 2:13 PM, with Staff F, Director of Integrated Services showed the following potential looping and hanging hazards:
-Large wrist hot and cold faucet handles (4.5 inches long) and high goose neck faucet (9.5 inches above the sink);
-Two metal doors under the sink with protruding metal handles, which were 27 inches above the floor;
-Exposed hot and cold water shut off valves under the sink, which were 22 inches above the floor;
-Exposed sink drain under the sink, which was 14 inches above the floor at the lowest point;
-Exposed toilet plumbing, which was 16 inches above the floor at the lowest point;
-Metal brackets located in two of two closets. Each bracket had two open areas measuring approximately 1.5 inches. The brackets were 68 inches from the base of the closet. The openings in these brackets allow for an item to be looped through the openings and create a hanging hazard.
-The bathroom door had three flat top hinges with the top hinge measuring 89 inches from the floor and the middle hinge 52 inches from the floor. The hinges left a gap in the doorway and created a ligature, or looping hazard. Gaps or openings created an opportunity for injury and presented an additional hazard to patients with suicidal ideations.
-All the furniture in the room was unsecured and moved easily. The furniture included two platform beds, a desk, a chair, and two 4-drawer chests. There is a potential the patient(s) can move/position the furniture under a looping and hanging hazard to aid the patient in reaching a hanging position.

7. During an interview on 06/14/11 at approximately 2:20 PM Staff F, Director of Integrated Services, stated that the remaining behavioral health patient rooms are designed and constructed the same way as rooms 325 and 331 and have the same looping and hanging hazards. Staff F also confirmed no furniture on the unit is secured to the walls or the floor. This included the following rooms: 302, 303, 322, 323, 326, 327, 328, 329, 330 and the seclusion room/including the seclusion bathroom.

Observation of the seclusion shower showed a single water control handle approximately four inches long and had a narrowed plumbing point where the metal comes through the wall providing a looping and hanging hazard.

8. Observation on 06/14/11 at approximately 3:00 PM, of the two patient shower rooms in the hall on the behavioral health unit showed both showers with hot and cold water knobs with a narrowed metal plumbing point where the plumbing comes out of the wall creating a looping and hanging hazard.

9. During an interview on 06/14/11 at approximately 10:00 AM, Staff H, Program Director of Behavioral Health stated that he/she performs monthly inspections of the behavioral health unit; Staff F, Director of Integrated Services performs bi-annual inspections of the behavioral health unit; and a contracted behavioral services management company provides bi-annual inspections of the behavioral health unit.

Review of the monthly inspections of the behavioral health unit performed by Staff H lacked the year of the monthly inspections for January through May and there is no signature of the person who conducted the inspection. The monthly inspections included:
-Exit lights working;
-Exit doors clear and unblocked;
-Fire extinguisher checked monthly;
-Multipurpose room and dining room clear of clutter and unsafe issues;
-Ceiling tiles clean;
-Laundry room clean;
-Washer and Dryer vent clean;
-Refrigerator logs current;
-Patient rooms tidy and in good order;
-Nurses station in good working order and
-Medication room/refrigerator in good order.
The monthly check failed to inspect for behavioral health safety hazards such as looping and/or hanging hazards or items that could be used to harm a patient or others.

Review of the "Hazard surveillance Program Survey" dated 05/20/11, performed by Staff F included the following categories:
-Life Safety;
-General Safety;
-Staff Knowledge;
-Cosmetic and
-Other.
The inspection was based on life safety code issues including fire extinguishers, floor maintenance, equipment maintenance, electrical maintenance, bed and cabinet maintenance, sharps containers, cleaning supplies, material safety data sheets, safety manual, medication carts locked, gait belts available, lifts available, rooms neat and clean, waiting areas neat and clean, walls in good repair, nursing areas neat and clean, storage areas neat and clean, work surfaces in good repair, ceiling tiles in good repair, emergency equipment available and in working order and refrigerators used as designated with temperature charts current.

The inspection does not include inspection for behavioral health safety hazards such as looping and/or hanging hazards or items patients could use to harm themselves or others.

-Review of the most current contracted "Environmental Walk through Findings of Inpatient Services" by the contracted behavioral health management entity dated October 2010 included inspection of:
-Large day room showed stained ceiling tiles;
-Patient art work on the door;
-No loose paper to be on the doors or walls;
-Ensure light fixtures and vents are lent free;
-Laundry room showed clean dryer vents;
-Ensure cleaning of washers between patient uses with logs up to date;
-Chart room showed staff drinks on table;
-Linen room showed linen shelf not covered;
-Pillows stored in cardboard box on floor;
-Patient hall showers showed dirty patient clothes on the floor, ensure floor is cleaned between patient use;
-Handicap shower with long spray shower head - make sure no patients are in this shower without staff present;
-Medication supply room showed no expired items and medication log current;
-Staff lounge and nurses station showed holiday decorations, paper taped on walls and counters.

Other than identification of the long shower spray hose in the handicap shower, looping and hanging hazards in the patient rooms failed to be identified.










19957

Based on interview and observation in the outpatient orthopedic specialty clinic the facility failed to ensure medical records of patients discharged from care were maintained in a manner to protect against unauthorized access. The facility census was 36.

Findings included:

Observation of the outpatient orthopedic clinic on 06/16/11 at 1:15 PM showed approximately 100 to 110 cardboard boxes of medical records from discharged patients stored on the top floor of the building accessed through a home care oxygen company located next door to the clinic. The door to the steps leading up to the storage area had no lock. The storage area contained items stored by the home care oxygen supply company. Staff of the oxygen supply company had access to the medical records.

During an interview on 06/16/11 at 1:20 PM, Staff W, orthopedic clinic receptionist, stated that the door to the storage area is not locked and that staff from the oxygen supply company can access the area. Staff W stated that the oxygen supply company staff stored items in the same area where the medical records were stored.

Based on interview and record review the facility failed to require and provide appropriate first aid training related to restraints and seclusion. This has the potential to affect any patient in the facility needing restraint or seclusion. The facility census was 36.

Findings included:

During an interview on 06/15/11 at 1:20 PM, Staff H, Program Director Behavioral Health, stated that he/she was not familiar with first aid training for the staff as related to restraints and seclusion. Staff H stated that he/she had been in his/her position for eight years and is unaware of the need for first aid training related to restraints and seclusion. He/she stated that first aid training is not included in staff orientation or annual educational training. Staff H stated that the facility did not have a policy requiring staff first aid training related to restraints and seclusion.

Review on 06/15/11 at 2:05 PM of the facility's on-line psychiatric training regarding restraints and seclusion showed no first aid training related to restraint and seclusion.

Review of orientation documentation and educational records for Staff I, Mental Health Technician (MHT); Staff K, Behavioral Health Charge Nurse, and Staff L, Behavioral Health Registered Nurse (RN); showed no first aid training related to restraints and seclusion.