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Based on document review and interview the facility failed to ensure the implementation of the policy related to patient complaints for 1 of 1 patient whose family filed a complaint, patient #8.

1. Review of the policy: Patient Complaint and Grievance Process, policy number I-A.30, issued/approved 5/2015, indicated in the policy section: NeuroPsychiatric Hospital of Indianapolis shall provide a system whereby patients and/or their significant others or representatives, can voice a grievance/complaint about the quality of care and/or services received at NeuroPsychiatric Hospital of Indianapolis...Upon notification of a patient grievance, information sufficient to identify the individual registering the concern will be recorded: The name of the patient (if not the individual submitting the information) Date of receipt Nature of the concern Patient's attending physician Hospital location of the patient. The Chief Compliance Officer or designee will conduct an investigation of the grievance reviewing the patient's medical record, to obtain information regarding the patient's clinical condition.

2. Review of patient and/or family complaints/grievances for May, June and July 2016 indicated none could be found related to patient #8.

3. At 6:55 PM on 7/18/16, telephone interview with family member #60, a family member of patient #8, confirmed that this family member phoned the facility and spoke with a social worker on one phone call and the assistant director of nursing on another call to ask how patient #8's pressure ulcer occurred and why the family had not been notified of the skin breakdown.

4. At 10:25 AM on 7/19/16, interview with staff member N5, a social worker, confirmed that:
A. This staff member had a phone message from #60 asking about skin breakdown that was found at the time of arrival at the LTC (long term care) facility patient #8 had been transferred to.
B. A written note of the conversation was made by this staff person and placed in a personal file of patient documentation/notes that this staff member keeps.
C. No complaint record was completed by this staff member.

5. Review of the document "Social Services - Family Communication Log", indicated family member #60 called at 5:11 PM on 6/14/16 and left a voice mail message requesting to speak with the social worker and that on 6/15/16 at 9:41 AM the call was returned and that family member #60 "wants to know why patient has a sore on [their] hip."

6. At 12:30 PM on 7/19/16, interview with the assistant director of nursing, staff member #52, confirmed that:
A. This staff member spoke with family member #60 regarding the pressure ulcer for patient #8 that was documented as having physician orders for wound care on 6/9/16 prior to discharge on 6/13/16.
B. It was explained that the patient was a high risk for skin breakdown due to inactivity (patient liked to sit in a wheelchair all day) and due to incontinence.
C. No complaint record was completed as family member #60 was not the POA (power of attorney) for the patient and complaints are only taken from POAs.
D. There is no documentation of any investigation of the caller's concerns regarding patient care/assessments/precautions and the development of a pressure ulcer for patient #8.

7. At 12:45 PM on 7/19/16 interview with the chief executive officer, staff member #50, confirmed that complaints may be taken from anyone and the policy is not restrictive to only POAs of patients. Anyone may file a complaint on behalf of a patient, or in concern of patient care. The phone complaint by caller/family member #60 should have been recorded and investigated.

Based on document review and interview, it was determined that the hospital failed to protect patients by failing to ensure the implementation of facility policy regarding general safety and fall prevention (Refer to A 0395) and failed to ensure the wound nurse was a licensed nurse (Refer to tag 397). The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the nursing services be supervised by a registered nurse.

Based on document review and interview the nursing staff failed to supervise and evaluate their patients by failing to implement policies related to fall risk identification and precautions for 10 of 10 patients (patients #1 through #10), and related to skin risk identification for 7 of 10 patients (patients #1, #2, #5, #6, #8, #9 and #10); nursing failed to implement a physician order for an OT (occupational therapy) and PT (physical therapy) evaluation for 1 of 6 current patients, patient #1, and nursing failed to write an order for transfer to the ER (emergency room) for 1 of 3 fall patients, patient #3.

Findings Include:
1. Review of the policy Fall Risk Identification and Precaution, policy number II-A.9, revised/approved 2/2016, indicated in the policy statement: It is the policy of NeuroPsychiatric Hospital of Indianapolis to assess, appropriately identify and re-assess patients who are at risk for possible falls while hospitalized. All patients presenting for admission will be assessed and identified for fall risk...2. SCUBA will be followed: S Socks (non-skid) or non-skid footwear in place C. Clutter free...U Unnecessary/unsafe medications or equipment...B Bed in safest position...A Alerting systems initiated or activated (tab/sensor alarm, call light, room monitor)...3. Fall Precautions will be documented on the patients Q 15 minute observation form. 4. The Nurse in collaboration with the Physician/LIP (licensed independent practitioner) will assign Fall Precaution as needed for the safety of the patient...".

2. Review of the Nursing Admission Database form indicated in the section "Fall Risk Factor Assessment" that Low Risk = score of 0 - 3 with SCUBA and 15 minute checks to be done on all patients; Medium Risk = 4 - 5 with "Line of Sight, Bed/Chair Alarms, Stand By Assist when Ambulating, Exercise class (sic)" to be implemented. High Risk = scores of 6 - 7 with staff to: "Assess for 1:1, PT Consult, room (sic) close to Nurses Station, Toileting Schedule" to be implemented.

3. Review of medical records indicated:
A. Patient #1 was a current patient who was admitted on 6/24/16. On admission, the Nursing Admission Database form was completed and indicated the patient scored a "Total Fall Risk Score" of 4 with the form indicating 4 to 5 was a "Medium Risk" for falls and that "Line of Sight, Bed/Chair Alarms, Stand By Assist When Ambulatory, Exercise class" were to be implemented on admission.
a. The "Patient Observation Monitoring Rounds" form completed by NAs (nurse aides) from 6/25/16 to 7/17/16 failed to indicate the patient was a fall risk on 7/12/16.
b. The NA form "Daily Nursing Record" lacked documentation for the AM (morning) shift that the patient had a fall risk band on for: 6/25/16, 6/28/16, 6/29/16, 7/4/16, 7/12/16 and 7/13/16 and for the PM (evening) shift on: 6/28/16, 6/29/16, 6/30/16, 7/1/16, 7/3/16, 7/5/16 and 7/6/16.
c. The NA form "Daily Nursing Record" indicated that a bed alarm and personal alarm were "N/A" (not applicable) on 6/26/16, 6/30/16, 7/1/16, 7/3/16, 7/4/16, 7/5/16, 7/6/16, 7/8/16, 7/9/16, 7/10/16, 7/11/16, 7/12/16, 7/13/16, 7/15/16, 7/16/16 and 7/17/16, and the area was blank on 6/25/16, 6/27/16, 6/28/16, 6/29/16 and 7/2/16.
d. On the "Daily Nursing Record" form for nurses, the patient scored at 3 or 4 for risk of falls from 6/24/16 to 7/3/16.
e. At 3:50 PM on 7/4/16, nursing documented: Pt. slid from w/c (wheelchair) on to buttocks, no injury noted. Pt. returned to bed per request.
f. Nursing continued to score the patient at 3 or 4 fall risk after the 7/4/16 fall, night shift on 7/10/16, 7/14/16 and 7/16/16 scored the patient at 6 and the day shift for 7/14/16 and 7/15/16 scored at 5, both a high risk for falls, but no further fall precautions were noted to have been implemented after the fall.

B. Patient #2 was admitted on 6/17/16 who had documentation in the psychiatric evaluation that the patient had fallen 6 times in the last 2 days. There was no nursing admission database form in the medical record so that no admission fall risk was noted. There was also no "Daily Nursing Record" form for 6/17/16 for this patient (for nurses). Further documentation in the medical record included:
a. The first nursing notes were the day shift on 6/18/16 with the nurse scoring the patient at 4 for fall risk on the daily nursing form.
b. The NA form "Daily Nursing Record" lacked AM and PM documentation that the fall band was on the patient and lacked documentation in the area to mark that a bed alarm and personal alarm was utilized for the patient.
c. Nursing noted at 10:15 PM on 6/18/16 that: "Nurse came to this RN (registered nurse) to check patient following a fall. Patient in bed. Patient PERLLA (sic) (PERRLA = pupils equal round reactive to light and accommodation), able to move all extremities, bruising noted on buttocks. Patient's nurse concerned about [pt's] respiratory status due to respiratory rate of 44. Oxygen saturation is 93%, lungs auscultated and patient has wheezes throughout. Nurse practitioner called and orders received for oxygen at 2 L/NC (nasal canula), duoneb treatments q (every) 6 hrs prn (as needed) and a chest x-ray. PA & lateral. Patient is able to move lower extremities and no shortening or rotation noted upon assessment."
d. The day nurse on 6/19/16 had no fall score noted on the "Daily Nursing Record" form, failed to indicate the patient was a fall risk and failed to indicate extra precautions had been implemented after the fall on 6/18/16.
e. No time was documented with the notation: "Nurse called into patients room by another nurse patient's left shoulder noted to be swollen patient unable to move arm large purple bruise also noted to outside left thigh patient unable to abduct left leg, patient yelled out in pain while assessing. Writer gave prn pain medication Charge nurse notified. NP (nurse practitioner) on call order obtained to send patient to ER (emergency room) family notified as well as administrators."

C. Patient #3 was an 82 year old who was admitted on 6/14/16 and discharged 7/7/16. The Nursing Admission Database form was completed and indicated the patient scored as a medium fall risk with a score of 4. The nursing care plan failed to indicate fall precautions and risk for this patient. Further documentation in the medical record indicated:
a. The NA form "Daily Nursing Record" lacked documentation for the AM (morning) shift that the patient had a fall risk band on for: 6/17/16, 6/18/16, 6/19/16, 6/20/16, 6/21/16, 6/22/16, 6/23/16, 6/24/16, 6/25/16, 6/28/16, 6/29/16, 7/4/16, 7/5/16 and 7/6/16 and failed to document the fall risk band was on for the PM shift on: 6/20/16, 6/24/16, 6/26/16, 7/4/16, 7/5/16 and 7/6/16.
b. The NA form "Daily Nursing Record" lacked documentation indicating a bed and personal alarm was initiated on 6/24/16, 7/4/16, 7/5/16 and 7/6/16 when the area was left blank and on 6/15/16, 6/1/16, 6/17/16, 6/18/16, 6/19/16, 6/20/16, 6/21/16, 6/22/16, 6/23/16, 6/25/16, 6/26/16, 6/28/16, 6/29/16, 6/30/16, 7/1/16 ad 7/4/16 when it was documented that bed and personal alarms were "N/A".

D. Patient #4 was a current patient admitted 7/10/16 who scored a 4 (4 to 5 = medium risk) on the fall risk portion of the Daily Nursing Record form for nurses. The following days nursing scored the patient at 2 or 3 for fall risk until the night shift on 7/14/16 when nursing scored the patient at a 5. The Daily Nursing Record form for NAs lacked documentation for both the AM and PM shifts on 7/14/16 that a fall ID band was on, and was blank in the area to check that a bed and personal alarm had been activated.

E. Patient #5 was admitted on 7/6/16 and was a current patient who scored 1 for fall risk (low risk) on admission and 2 or 3 on subsequent days until the night shifts of 7/10/16 and 7/14/16 when the patient scored at a 6 (high risk for falls). Nursing failed to document any implementation of the high risk precautions recommended. The NA Daily Nursing Record form for 7/10/16 had no documentation that the fall ID (identification) band was on and the personal and bed alarm sections were checked as N/A. The NA Daily Nursing Record for 7/14/16 was missing from the medical record.

F. Patient #6 was admitted on 7/1/16 and was a current patient who scored a 2 (low risk) on admission for falls until 7/3/16 when nursing scored the patient at 4 (medium risk) and on 7/10/16 when the patient scored 6 (high risk). Nursing failed to document that any of the medium and high risk precautions were implemented. The NA form on 7/10/16 lacked documentation of a fall ID band being in place on the AM shift, and the area indicating utilization of a bed and/or personal alarm was blank. On 7/14/16, nurse aides lacked checking that the patient had a fall ID band on for the AM shift and had N/A noted for the bed and personal alarms.

G. Patient #7 was a current patient admitted on 7/7/16 who scored 4 on admission for fall risk and again scored 4 on the night shift of 7/17/16. On the night shift for 7/10/16 and 7/14/16, the patient scored 6 (high risk). No nursing documentation indicated that either medium or high risk precautions were implemented. There was no fall risk score completed by nursing on the night shift of 7/11/16. NAs failed to document on 7/11/16 that alarms were being utilized, on 7/14/16 there was no NA form that would indicate that the fall ID band was on and that alarms were on, and on 7/17/16, the NAs indicated alarms were N/A.

H. Patient #8 was admitted on 5/26/16 and discharged on 6/13/16. The admission fall score was 6 with later scores of 4 and then 5 on 6/9/16 (night shift) and 5 on the day shift of 6/8/16. NAs indicated no fall ID band was on and the bed/chair alarms area was blank on 5/26/16. NAs failed to indicate any alarms were on for the patient on 6/9/16 as the form was blank.

I. Patient #9 was admitted on 5/24/16 and discharged on 6/7/16. The Nursing Admission Database form indicated the patient was a 10 for fall risk on admission and lacked any documentation that skin precautions were implemented. The patient scored 4 on the following days: Days on 5/24/16, 5/26/16, 5/28/16, 5/30/16, 6/1/16, 6/2/26, 6/3/16, 6/4/16, and on Nights: 5/28/16, 5/29/16, 5/30/16, 5/31/16, 6/1/16, 6/4/16 and 6/5/16. There was no fall risk done by the night nurse on 6/3/16. The only fall precaution noted by nursing was on the care plan where it was noted: encourage pt. (patient) mobility and repositioning--about unit independently. NAs failed to document that the fall ID band was on for the AM shift on 5/24/16, 5/25/16, 5/28/16, 5/29/16, 6/3/16 and 6/7/16, left the area blank on 5/26/16, 5/30/16, 5/31/16, 6/1/16, 6/2/16, 6/4/16, 6/5/16 and 6/6/16.

J. Patient #10 was a current patient admitted on 7/6/16 who scored 4 for falls on the day shifts for 7/8/16, 7/11/16, 7/14/16, 7/16/16 and 7/18/16 and on nights 7/7/16, 7/8/16, 7/9/16, 7/10/16, 7/11/16, 7/12/16, 7/13/16, 7/15/16, 7/17/16 and 7/18/16. NAs failed to indicate the patient had a fall ID band on the AM shifts of 7/7/16 and 7/16/16, failed to indicate a fall ID band was on for the night shifts on 7/7/16, 7/10/16 and 7/16/16, and had neither shift documented on 7/9/16, 7/14/16 and 7/17/16. Alarms were either noted as N/A or were blank for the night shifts of 7/7/16, 7/9/16, 7/12/16, 7/13/16, 7/14/16, 7/16/16 and 7/17/16. There was nno NA page for checking fall bands and alarms on 7/8/16 and 7/11/16.

4. At 11:45 AM and 1:12 PM on 7/18/16, interview with the assistant director of nursing, staff member #52, confirmed that:
A. After the fall for patient #1, staff were allowing the patient to "choose a chair of their choice" to hopefully keep the patient from falling again.
B. No other fall precautions were noted as implemented after the fall of patient #1 and NAs checked incorrectly that bed and chair alarms were not applicable on 7/5/16 and 7/6/16 after the 7/4/16 fall.
C. Nurses are responsible for "applying" bed/chair alarms but did not document the implementation of bed/chair alarms for any of the patients listed in 3. above who scored 4 or higher.
D. Fall bands are no longer used, but a yellow dot on the patient's name band is the process to indicate a patient is at risk for falls. Nurse aides should still check the box for a fall ID band on their form.

5. At 12:35 PM on 7/18/16, interview with the charge nurse, staff member #51, confirmed that:
A. Nurses and nurse aides are not documenting that fall precautions were being implemented for patients who scored at medium or high risk for falls.
B. The Nursing Admission Database form does not use the Braden skin scoring tool, as the skin assessment policy indicates, making scoring different from the daily skin scoring that is done per the Braden scoring tool.

6. Review of the policy Skin Care Prevention/Pressure Ulcer Risk Assessment: Braden scale, policy number II-D.27, issued/approved 05/2015, indicated in the policy statement: To identify and monitor patients at risk for skin breakdown through out hospitalization. Identify nursing measures needed in the care of patients with potential for alteration in skin integrity. All patients will have an integumentary assessment and Braden Scale completed upon admission for their risk of development of skin breakdown according to overall physical condition, mental status, activity level, mobility level, nutrition/fluid intake and incontinence status...Braden Risk Assessment Scale is completed at time of admission. Per the policy, 13-14 = moderate risk and 12 or below = high risk with the moderate and high risk patients to have nursing: "A...Refer to Wound Care Nurse...B. Establish and record an individualized turning schedule if the patient is immobile. Frequency of position change is titrated for the individual patient...".

7. Review of the Nursing Admission Database form indicated in the section "Patients at Risk to Develop Skin Ulcer (RN)": "Identify any patient at risk to develop pressure sores by assessing the seven clinical condition parameters and assigning a score. Patients with intact skin, but scoring 8 or greater, should have the Nursing Diagnosis "Potential Impairment of Skin Integrity."

8. Review of medical records indicated:
A. Patient #1 was a current patient who was admitted on 6/24/16 and scored 9 on the Nursing Admission Database form with the form indicating that a score of 8 or greater should have implementation of precautions for the potential impairment of skin integrity. Nursing daily Braden scale skin assessments indicated the patient scored 10 (high risk for skin impairment) on the night shift for 7/7/16, 12 (high risk) on the day shifts for 7/8/16, 7/9/16 and 7/10/16, and 14 on the night shift of 7/10/16 and day shift of 7/14/16. No skin precautions were noted by nursing as having been implemented.

B. Patient #2 was admitted on 6/17/16, had a fall on 6/11/16 with transport to a local ER (emergency room) for x-rays and evaluation, returned to the facility and was discharged on 6/24/16. The patient had no nursing admission database form in the medical record so that no admission skin risk was noted. The first nursing notes were the day shift on 6/18/16 with documentation of a bruise 11 x 5 cm on the inside left thigh. Nursing also wrote: "...Writer noted large purplish bruise to inside of left thigh near groin area...Patient also has multiple bruises on upper and lower extremities in various stages of healing. Writer spoke with [family] on the phone. [Family] called for an update. [Family] told this writer that patient has had multiple falls and patient is unable to walk at all anymore...". Documentation was lacking that would indicate skin precautions were implemented for patient #2.

C. Patient #5 was a current patient admitted on 7/6/16 who lacked completion of a Braden skin scoring on the Daily Nursing Record form for nurses on the day shift for 7/14/16.

D. Patient #6 was a current patient admitted on 7/1/16 who lacked completion of a Braden skin scoring on the Daily Nursing Record form for nurses on the night shift for 7/10/16.

E. Patient #8 was admitted on 5/26/16 and discharged on 6/13/16. The admission skin risk score was 12 (greater than 8, as per the Nursing Admission Database with precautions to be implemented). Other skin risk scores were: 11 on night shifts of 6/2/16 and 6/8/16, 8 on night shift of 6/7/16, 10 on the day shift of 6/7/16, 13 on the night of 5/27/16, 6/8/16 day shift, and on the 6/9/16 night shift. On 6/7/16, the day nurse noted; "Sore on left saccral (sic) area" and at 6:20 PM: "...CNA (certified nursing assistant) noticed a nickel sized sore to L saccral (sic) area. NP (nurse practitioner) [named] made aware. Area covered for protection with foam dressing to prevent opening...". On 6/7/16 nights, nursing wrote: "Open area to saccal (sic) area" and at 7:30 AM: "Pt. (patient) resistant to repositioning throughout the night." On 6/8/16 nights, nursing wrote: "See open area left sacrum". Orders for wound care were written on 6/9/16. Nursing documentation failed to indicate what, if any, skin precautions were implemented for the patient until 6/9/16 when nursing noted on the care plan: "W/C (wheelchair) cushion in place" and on 6/10/16; reposition q (every 2 hours, down in bed after meals. Every 2 hour repositioning was not documented in the record by nursing staff.

F. Patient #9 was admitted on 5/24/16 and discharged on 6/7/16. The skin assessment on the Nursing Admission Database form scored the patient at 10 and nursing noted a rash in the right groin area. No skin precautions were noted as implemented. The patient had no Braden skin scoring done on the night shift for 5/24/16 and 6/6/16. The patient scored 14 on the Braden scoring tool on nights 5/23/16, 5/25/16, the day shift of 5/27/16, both the day and night shift of 5/30/16, and the night shift of 5/31/16. On 6/7/16, the patient scored 12. The only skin precaution noted by nursing was on the care plan where nursing noted: "provide barrier cream prn" (as needed).

G. Patient #10 was a current patient admitted on 7/6/16. On admission, the patient was noted as having open areas on the shin of the left leg and top of the left foot (0.5 x 0.5) and an open area on the side of the right ankle. Nursing scored the patient at 14 on the Braden scale on the day shift of 7/16/16 and 14 on the night shift of 7/18/16. The nursing care plan indicated nursing was to consult with the wound nurse, monitor skin weekly, and notify the physician of complications but no further skin precautions/interventions were noted in the medical record as being implemented.

9. Interview with staff nurses #56 and #57 at 11:15 AM on 7/19/16 confirmed that:
A. If a patient scores at risk for skin problems, nursing does daily skin checks, repositions the patient and gives any wound treatment ordered.
B. Usually only a barrier cream for skin protection, or redness from incontinence, is required.
C. There is no specific place on the daily nursing record forms, or fllowsheets, to note that the patient has skin precautions, that routine repositioning occurred, or that any other skin precautions have been implemented.
D. Floor nurses are not allowed to contact the wound nurse, only the charge nurse or director of nursing may do this.
E. The physicians and nurse practitioners give any orders needed for skin/wound care.

10. At 11:55 PM on 7/19/16, interview with staff member #53, the corporate compliance officer, confirmed that:
A. The wound nurse is a corporate employee and may be called for a consult at any time needed.
B. Nursing staff should be able to call the wound nurse and not have to go through a charge nurse or director of nursing.
C. It was not known what the expectation for response by the wound nurse to a referral was as there is no policy regarding this, and it was unknown what the contract may indicate the time frame to be.

11. Review of the medical record for Patient #1 indicated:
A. After the patient's fall of 7/4/16, an order was written at 4 PM on 7/10/16 for an "OT/PT evaluation for mobility."
B. There was no documentation in the medical record to indicate that OT/PT had been contacted or had performed evaluations of the patient between 7/10/16 and 7/18/16.

12. At 11:50 AM on 7/18/16, interview with the assistant director of nursing, staff member #52, confirmed that:
A. OT/PT orders were written non 7/10/16 for Patient #1 and no documentation by OT and/or PT staff was in the medical record.
B. Staff thought the patient was going to be discharged on the 10th and did not follow through with the order for an OT/PT evaluation.

13. Review of medical records indicated Patient #3 was sent to the ER on 6/24/16, after sustaining a fall, but had no order to transfer the patient written in the physician order section of the record.

14. At 1:10 PM on 7/18/16, interview with the assistant director of nursing, staff member #52, confirmed that there was no order written for Patient #3 to be transferred to the ER for evaluation after their fall.

Based on document review and interview the facility failed to ensure that the staff member hired as a wound nurse was in fact a nurse licensed in Indiana and that they had certification to present themselves as a wound nurse, for staff member #61.

Findings Include:
1. Review of the medical record for Patient #10 indicated staff member #61 made notes of wound size, wound care needs and dressing changes and completed the "Wound Report" forms on 7/11/16 for no less than two wounds for the patient.

2. Review of the documents provided for staff member #61 was a "Pending Application", as of 7/21/16, for this staff member as a Licensed Practical Nurse through the Indiana Public Licensing board.

3. At 11:55 AM on 7/19/16, interview with the corporate compliance officer confirmed that the "wound nurse" was a corporate "nurse" who goes to any of the facilities when a referral for wound care is made.

4. Review of an e-mail from the COO (chief operations officer), staff member #62 confirmed that staff member #61 was hired 4/12/16, terminated (resigned) on 7/18/16, and was not an Indiana licensed nurse nor was there any documentation of wound expertise.

5. No further documentation of Indiana licensure or wound care training, education, or certification for staff member #61 was provided.

6. On 7/27/16 at 1630 hours, Indiana Professional Licensing Agency (IPLA) lacked documentation that staff member #61 was a licensed nurse in Indiana.