HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the patient's right to have a complete, individualized treatment plan and to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure the patient /patient representative was included in the development and implementation of a complete and individualized patient plan of care for 1 (#3) of 3 (#1- #3) sampled patient records reviewed.
Findings:

Review of the hospital's policy titled, "Patient Rights", revised 09/01/2023, revealed in part: Policy, in part: The organization supports the patient's right to care, treatment and services within its mission and applicability to law and regulation, and supports and protects the fundamental human, civil, constitutional and statutory rights of each patient. Treatment, in part: ...You have the right to an individualized treatment plan ...You have the right to be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care. If you are unable to make decisions about the care, treatment, and services, the rights of involvement of family/surrogate decisions maker instated on the patient's behalf will be respected in accordance low and regulations.

Review of Patient #3's medical record revealed an admission date of 07/21/2024 at 5:50 p.m. and discharge date of 07/27/2024. Diagnoses included autism with poor impulse control, Suicidal Ideation, Major Depressive Disorder, Mood Disorder, and Medication Non-Compliance.

Review of Patient #3's Interdisciplinary Treatment Plan, dated 07/21/2024 at 6:07 p.m. failed to reveal Problem: Autism. Further review failed to reveal short term/long-term goals, outcomes and interventions pertaining to Autism. Continued review failed to reveal discharge plans, patient strengths and assets, labilities and special needs, diagnosis, and observation levels. Further review failed to reveal a physician signature indicating the physician participated in the development of this treatment plan. Additional review failed to reveal the patient's or patient representative's signature indicating Patient #3's participation in this treatment plan.

Review of Patient #3's Interdisciplinary Treatment Plan-Update, dated 07/25/2024 at 10:25 a.m. failed to reveal Problem: Autism. Further review failed to reveal short term/long-term goals, outcomes and interventions pertaining to Autism.

In an interview on 07/30/2024 at 3:47 p.m., S3QD confirmed Patient #3's Treatment Plans dated 07/21/2024 and 07/25/2024 failed to reveal the problem Autism and the short term/long-term goals, outcomes and interventions pertaining to Autism.

In an interview on 07/30/2024 at 4:03 p.m., S3QD confirmed Patient #3's Treatment Plan dated 07/21/2024 failed to reveal the patient's or patient representative's signature indicating participation in this treatment plan. S3QD verified the treatment plan was incomplete as above.

Based on record review and interview the hospital failed to protect patients from neglect as evidenced by failing to investigate and report allegations of neglect in 1 (#1) of 3 (#1-#3) sampled patients.
Findings:

Review of the hospital's policy titled, "Abuse and/or Neglect of Patients by Staff Members, Students, Interns," effective date 01/11/2016, revealed in part: Policy: Patients have the right to be free from neglect, exploitation, and verbal, mental, physical and sexual abuse. Definition of "Abuse" is the infliction of physical or mental injury ... to the extent that his health or mental or emotional well-being is endangered. Definition of "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. No employee or student will mistreat and/or neglect a patient. Examples of actions/inactions which could be considered mistreatment/abuse include: ...Failing to or refusing to attend to necessary care and treatment; implementing actions contrary to the prescribed treatment of the program; failing to intervene to protect a patient from abuse and/or mistreatment. Any staff suspected of any infractions will be investigated under this policy.

Review of the hospital's policy titled, "Transportation of Patients/Prospective Patients," revised 11/01/2023, revealed in part: Purpose: To outline guidance for the provision of safe and effective transportation to prospective or currently admitted patients. Policy: All Transportations provided by the facility for prospective patient or a currently admitted patient will be provided according to the assessed security needs of the individual. Transportation could include ... Outpatients requiring transport to program. Outpatient Transports: 2. Arrangements to Attend Program: ...forwards directions to transportation coordinator. 3. Transportation Coordinator: Assigns driver to transport patient to and from outpatient program. 4. Drivers: Transports patients to and from program unless otherwise specified by Program Administrator.

Review of Patient #1's medical record revealed a diagnosis of Intellectual Disability, Bipolar Disorder, and Impulse Control. Patient #1 was admitted to the Intensive Outpatient Program (IOP) on 06/17/2024 after inpatient treatment. Patient #1 lives at Location A and is transported to IOP via Transport C which is contracted with the IOP facility.

During an interview on 07/30/2024 at 9:50 a.m. S5IOPLPN stated she communicates to the driver of Transport C regarding which patients to transport. S5IOPLPN enters information into System D which communicates specifics about the patients regarding transport needs.
Patient information is entered before 3 p.m. so the drivers are aware of any precautions/notes for the next morning.

During an interview on 07/30/2024 at 12:05 p.m. S5IOPLPN stated that Patient #1 has specific instructions that have been conveyed to Transport B drivers in regards to drop off locations. S5IOPLPN stated that Patient #1 is not to be dropped off at Location A until after 3 p.m. and is to be dropped off at Location B prior to 3:00 p.m. This was arranged because staff are not available to receive patients before 3 p.m. at Location A. S5IOPLPN explained that once a message is entered by her for a patient, the drivers are able to see it on their end.

During an interview on 07/30/2024 at 12:10 p.m. S5IOPLPN was able to navigate System D used to communicate with the drivers regarding patients who are picked up and brought to IOP.

A review of system log for Patient #1 for 06/17/2024, 06/24/2024, and 07/24/2024 revealed the following:
Patient being dropped off before 2:30 p.m. patient needs to be dropped off at location B. If after 3:00 p.m. patient is to be dropped off at location A.
Further review revealed that looking at the calendar view, the note was visible for the Patient #1.

During an interview on 07/30/2024 at 12:15 p.m. S5IOPLPN stated the notes usually transfer over on an excel sheet for patients, but the note for Patient #1 did not transfer over during review of system with S5IOPLPN. S5IOPLPN confirmed that the drivers have access to this view and should have seen the note.

During an interview on 07/30/2024 at 12:20 p.m. S5IOPLPN confirmed she had been notified of 2 incidents (06/19/2024 and 06/24/2024) involving Patient #1. Both incidents have notes documented in Patient #1's medical record.

Review of Patient #1's medical record revealed a progress note entered by S5IOPLPN from 06/19/2024 at 8:39 a.m. stating "Patient was involved in an incident on the bus, she fell on another patient, was informed by S11SD."

During an interview on 07/30/2024 at 12:25 p.m. S5IOPLPN confirmed that the patient was transported via ambulance for further evaluation post fall on 06/19/2024.

Review of Patient #1's medical record revealed a progress note entered by S5IOPLPN from 06/24/2024 at 2:19 p.m. stating: Was informed by S4DIOP that one of the patients on the bus called her and stated the bus driver dropped Patient #1 off at Location A alone and no one was there. S5IOPLPN immediately called the S11SD at 2:19 p.m. and told him S12D just dropped off a MR patient home alone and no one was there. S11SD told me he was going to call the driver immediately and have them return to pick the patient back up until proper drop off time.

Further review of Patient #1's medical record revealed the following progress notes entered by S5IOPLPN from 06/25/2024: at 11:28 a.m. - Received a call from Director of Location B, he was calling to make sure the psychiatric hospital was aware of the patient being left at the group home alone. I let Director of Location B know the moment I was made aware I notified the S11SD.
11:38 a.m. - Received call from Supervisor of Location B, she again informed me of what happened when the driver left the patient home alone, she stated the patient was dropped off 2:06 p.m. on 06/24/2024 with temps at 93 degrees outside, and when the driver returned it was 25-30 minutes later the staff had arrived home by that time. She requested the contact information for the transportation supervisor. She also stated she will be filling a complaint of neglect with state against Transport C. I notified the interim administrator.

During an interview on 07/30/2024 at 2:35 p.m. with S5IOPLPN, she does not keep a log of complaints that come through to her. She documents a note in the patient chart regarding the issue. S5IOPLPN also notifies the clinical director of complaints (including those involving Transport C).

Review of the incident log failed to reveal a documented incident involving Patient #1.
Review of the self-report log failed to reveal a documented incident involving Patient #1.
Review of the complaint/grievance log failed to reveal a documented incident involving Patient #1.

During an interview on 07/30/2024 at 2:37 p.m. S3QD confirmed that there was no incident on the log for incidents involving Patient #1 for 06/19/2024 or 06/24/2024.

During an interview on 07/31/2024 at 10:07 a.m. S9RVP confirmed that the incidents involving Patient #1 should have had an incident report completed.

Based on record review and interview the hospital failed to identify, measure, analyze, and track adverse patient events. This deficient practice is evidenced by failure of the hospital staff to identify 2 incidents involving harm to Patient #1.
Findings:

Review of the hospital policy titled, "Quality Assessment and Performance Improvement Plan," Revised 02/01/2019, revealed in part: ...the organization is dedicated to providing safe, compassionate and quality care ...The Governing Board ensures the QAPI plan reflects the complexity of the hospital's services, including ...contract services, and focuses on indicators related to improved health outcomes ...and corrective actions as indicated. Procedure, in part: 1 ....Provide for a facility-wide program that ensures the facility designs processes well and systematically measures, assesses, analyzes, and improves its performance to achieve optimal patient health outcomes in a collaborative and interdisciplinary approach. These processes include mechanisms to assess the needs and expectations of patients ... Ensure that Improvement process is organization-wide, monitors, assesses and evaluates the quality and appropriateness of patient care and clinical performance to identify changes that will lead to improved performance and reduce the risk of sentinel events. Corrective actions are taken and evaluated when problems or improvement opportunities are identified ... Provide appropriate reporting of information to the Governing Board to furnish it with the information it needs in fulfilling its responsibility for the quality of patient care and safety. 2. Important key aspects and processes of care to health and safety of patients are identified. Included are those that ... place patients at risk or serious consequences if care is not provided correctly or not provided when indicated ... b. Performance of patient care and quality control activities in the following services are monitored assessed and evaluated, in part: Contracted Services.

Review of the hospital policy titled, "Incident Reporting," effective date 02/01/2024, revealed in part: Purpose: To document any potential or adverse incidents within the facility or on the facility grounds/property/vehicle, with the facts available at the time, recorded by persons involved either in the incident or in the discovery of the incident. Policy: Facility staff will report all patient incidents using the facility's electronic incident reporting system (EIRS) or a paper incident report. Definitions: Patient Incident - anything that is out of the expected norm for the patient ... Incident Reporting Investigation: 1. Upon completion of entry into the EIRS, the system will send an email to the identified hospital leadership for notification and investigation. 2. Each department Director is responsible for reviewing incidents that occur in their area, investigating and completing follow-up. 7. The Quality Director and Hospital Administrator are mandatory reviewers of all incidents. 9. The Quality Director shall track and trend all incident types. 10. All aggregated data should be brought forward to the appropriate committee for performance improvement activities.

Review of the hospital policy titled, "Patient Grievance Process," revised 07/01/2024, revealed in part: Policy: The Governing Body is responsible for effective operation of the complaint/grievance resolution process. Each facility has identified an individual to serve as the facility Patient Advocate who is responsible for the investigation, follow-up and response to grievances submitted by a patient or caregiver. Definitions: Complaint: An expression of dissatisfaction, however made, about the standard of service, actions or lack of action by staff or regarding the facility and is resolved by staff present at the time the complaint is made, requiring no further resolution. Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, and/or patient's rights. Grievance Procedures: 1. The Patient Advocate logs the grievance allegation onto the "Complaint/Grievance Log" and opens an investigation to determine the validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation. If the grievance is regarding an allegation of abuse or neglect, the patient advocate escalates the concern to the hospital leadership immediately and appropriate state mandatory guidelines for reporting will be followed ... Role of the Patient Advocate: 1. Maintains a complete "Complaint/Grievance Log" along with files and results of all grievances ... 2. Complete a thorough investigation of all grievances ... 3. Responsible for reporting all grievance investigation findings and resolutions to QAPI committee and ensuring the Governing Board receives an updated and accurate Complaint/Grievance log. Role of the Administrator: 1. Ensure appropriate policies and procedures are followed for grievances alleging abuse and neglect of patients. 3. Updates the Governing Board on the Complaint/Grievance log.

Review of Patient #1's medical record revealed a diagnosis of Intellectual Disability, Bipolar Disorder, and Impulse Control. Patient #1 was admitted to the Intensive Outpatient Program (IOP) on 06/17/2024 after inpatient treatment.

During an interview on 07/30/2024 at 12:20 p.m. S5IOPLPN confirmed she had been notified of 2 incidents (06/19/2024 and 06/24/2024) involving Patient #1. Both incidents have notes documented in Patient #1's medical record.

Review of Patient #1's medical record revealed a progress note entered by S5IOPLPN from 06/19/2024 at 8:39 a.m. stating "Patient was involved in an incident on the bus, she fell on another patient, was informed by S11SD."

During an interview on 07/30/2024 at 12:25 p.m. S5IOPLPN confirmed that the patient was transported via ambulance for further evaluation post fall on 06/19/2024.

Review of Patient #1's medical record revealed a progress note entered by S5IOPLPN from 06/24/2024 at 2:19 p.m. stating: Was informed by S4DIOP that one of the patients on the bus called her and stated the bus driver dropped Patient #1 off at Location A alone and no one was there. S5IOPLPN immediately called the S11SD at 2:19 p.m. and told him S12D just dropped off a MR patient home alone and no one was there. S11SD told me he was going to call the driver immediately and have them return to pick the patient back up until proper drop off time.

Further review of Patient #1's medical record revealed the following progress notes entered by S5IOPLPN from 06/25/2024 at 11:28 a.m. - Received a call from Director of Location B, he was calling to make sure the psychiatric hospital was aware of the patient being left at the group home alone. I let Director of Location B know the moment I was made aware I notified the S11SD.
06/25/2024 at 11:38 a.m. - Received call from Supervisor of Location B, she again informed me of what happened when the driver left the patient home alone, she stated the patient was dropped off 2:06 p.m. on 06/24/2024 with temps at 93 degrees outside, and when the driver returned it was 25-30 minutes later the staff had arrived home by that time. She requested the contact information for the transportation supervisor. She also stated she will be filling a complaint of neglect with state against Transport C. I notified the interim administrator.

During an interview on 07/30/2024 at 2:35 p.m. S5IOPLPN confirmed that she does not keep a log of complaints that come through to her. She documents a note in the patient chart regarding the issue. S5IOPLPN also notifies the clinical director of complaints (including those involving Transport C).

Review of the current quality indicators being monitored in the QAPI program failed to reveal documented evidence of quality indicators for contracted transportation services.

During an interview on 07/30/2024 at 1:23 p.m., S3QD confirmed contracted transportation services are not included and monitored in the QAPI program and should be part of the QAPI program moving forward.

Review of the incident log failed to reveal any documented incidents involving Patient #1.

Review of the self-report log failed to reveal any documented incidents involving Patient #1.

Review of the complaint/grievance log failed to reveal any documented incidents involving Patient #1.

During an interview on 07/30/2024 at 2:37 p.m. S3QD confirmed that there was no documented incident on the logs involving Patient #1 for 06/19/2024 or 06/24/2024.

During an interview on 07/31/2024 at 9:29 a.m. S8CD confirmed that both incidents involving Patient #1 occurred prior to her hire date. S8CD confirmed they have not been logging incidents/complaints for IOP. S8CD confirmed there are no open complaints on the complaint log at this time.

During a 07/31/2024 at 10:07 a.m. S9RVP confirmed that the incidents involving Patient #1 should have had an incident report completed.

Based on record review and interview, the hospital's governing body failed to ensure the Quality Assessment and Performance Improvement (QAPI) program reflected the complexity of the hospital's services as evidenced by failing to include all contracted services in the QAPI program.
Findings:

Review of the hospital policy titled "Quality Assessment and Performance Improvement Plan" Revised 02/01/2019, revealed in part: ...the organization is dedicated to providing safe, compassionate and quality care ...The Governing Board ensures the QAPI plan reflects the complexity of the hospital's services, including ...contract services, and focuses on indicators related to improved health outcomes ...and corrective actions as indicated. Procedure, in part: 1 ....Incorporate quality planning throughout the facility that includes, but is not limited to, high risk, high volume, high cost, and potentially increased patient safety risk priorities ...Provide appropriate reporting of information to the Governing Board to furnish it with the information it needs in fulfilling its responsibility for the quality of patient care and safety. b. Performance of patient care and quality control activities in the following services are monitored assessed and evaluated, in part: Contracted Services.

Review of the current quality indicators being monitored in the QAPI program failed to reveal documented evidence of quality indicators for contracted transportation services.

In an interview on 07/30/2024 at 1:23 p.m., S3QD agreed contract services providing services affecting the health and safety of patients should be part of the QAPI continuous monitoring activities. S3QD verified contracted transportation services are not included and monitored in the QAPI program and should be part of the QAPI program moving forward.