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Based on interview and record review, the facility in its resolution of the grievance, the hospital failed to provide the patient with written notice of its decision that contains name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for one out of 13 Sampled Patients (SP) #11.

Findings include:

Record review of sampled patient (SP) #11 Nursing Notes dated 2/11/2017 at 2:24 pm showed (Charge Nurse) CN - B received a call from the patient relationship (Patient Guest Relations /PGR) regarding patient complaint of SP #11.

Record review of Policy Name: Patient Complaint & Grievance Resolution 4. Grievance Response. f. Patients in BHU can present grievances as designated in this policy, or as specified in Behavioral Health Department policies, in conjunction and with the oversight of the Patient Relations Department. g. a grievance is considered resolved when the patient is satisfied with the actions taken on his/ her behalf. The Patient Relations Department will maintain documentations of its efforts to resolve the issue for at least six (6) years. Record review of SP #11Nursing Notes dated 2/11/2017 at 2:24 pm showed that Patient Guest Relations (PGR)is aware of the patient's complaint. There were no documentation about this complaint.

Record review of Policy Name: "Patient Complaint & Grievance Resolution" V. Procedure. 4. Grievance response: An acknowledgement of the grievance/ complaint response will be provided to the patient within 7 days. when resolution or investigation will not be completed within 7 days, the individual investigating the grievance will notify the pt. that the Medical Center is still working to resolve the issue and will provide time frame for the final response when it will be given. There were no documentation or evidence about this complaint.

On 4/13/17 at 12:29 pm, Director of Risk Management stated that if there is an abuse related allegation, the PGR will refer this to the Risk Management. And if the complaint about abuse happened in (Behavioral Health Unit) BHU, the investigation is done by Behavioral Health Unit itself.

Interview with Director of Behavioral Health on 4/13/2017 at 12:30 pm revealed the following about her investigation: The Director of Behavioral Health admitted she did not write about or document about this because she was satisfied with her investigation.

Record review of (Sampled Patient) SP #11 Nursing Notes dated 2/11/2017 at 2:24 pm showed Charge Nurse - B received a call from patient guest relations regarding pt. complaint. SP #11 stated, I was beat-up by staff member yesterday. The Patient had complained of pain on rib cage. On assessment, it was notice diffused ecchymosis area on left lower quadrant and left cheek.

The Discharge Summary Provider Notes dated 02/15/2017 showed a final report of SP #11 chest X-ray. The release date of 02/13/2017. The final impression has noted that again seen acute fracture of the right posterio-lateral ninth rib. Previous acute fracture is noted involving the posterior right 11th and 12 ribs are not well seen on the current plain film examination, best seen on the 02/12/2017 CT.

Interview of Charge Nurse-B on 4/13/2017 at 11:35 am, she stated that she also recalls that she received a call from a representative of Pt. Guest Relations about SP#11 complaining he was "mishandled". She said that after she received the call, she and the assigned nurse went to see SP#11 in the room. She recalls SP#11 and stated, "he was angry because he was mishandled".


Record review of SP #11 Care Management notes by LCSW (Licensed Certified Social Worker) at 2/13/2017 2:22 PM revealed the social worker MSW spoke with patient in detail regarding complaint that he was assaulted while hospitalized in this facility inpatient psych unit per patient nursing staff members.

Based on interview and record review, the staff failed to follow the policy and procedure to ensure immediate reporting of suspected internal/external abuse of one sampled patient #11.


Findings include:

Record review of sampled patient (SP) #11 Nursing Notes dated 2/11/2017 at 2:24 pm showed (Charge Nurse) CN - B received a call from the patient relationship (Patient Guest Relations /PGR) regarding patient complaint of SP #11.


On 4/13/17 at 12:29 pm, Director of Risk Management stated that if there is an abuse related allegation, the PGR (Patient Guest Relations) will refer this to the Risk Management. And if the complaint about abuse happened in (Behavioral Health Unit) BHU, the investigation is done by Behavioral Health Unit itself.

Interview with Director of Behavioral Health on 4/13/2017 at 12:30 pm revealed the following about her investigation: The Director of Behavioral Health admitted she did not write about or document about this because she was satisfied with her investigation.

Review of Policy NO: 16.4.015 Subject: "Abuse Reporting: External and Internal Events" showed that staff should follow the policy guidelines in proper procedures in reporting suspected cases of abuse at the Behavioral Health Department. Suspected cases of battery, neglect or exploitation committed against an endangered adult shall be reported to the Abuse Registry at 1800 96-Abuse immediately after the Chairman of the Department or Nurse Director are informed of the matter. Further review of the policy showed that documentation in the patient medical record shall indicate the time of call, supportive information, and any follow-up contact.

The policy " Victims of Abuse, Assault or Neglect" (review/revised 08/2014) state The criteria for identifying possible abuse and neglect includes, but is not limited to, the following: Physical sign: multiple fractures.

Record review of (Sampled Patient) SP #11 Nursing Notes dated 2/11/2017 at 2:24 pm showed Charge Nurse - B received a call from patient guest relations regarding pt. complaint. SP #11 stated, I was beat-up by staff member yesterday. The Patient had complained of pain on rib cage. On assessment, it was notice diffused ecchymosis area on left lower quadrant and left cheek.

The Discharge Summary Provider Notes dated 02/15/2017 showed a final report of SP #11 chest X-ray. The release date of 02/13/2017. The final impression has noted that again seen acute fracture of the right posterio-lateral ninth rib. Previous acute fracture is noted involving the posterior right 11th and 12 ribs are not well seen on the current plain film examination, best seen on the 02/12/2017 CT.

Interview of Charge Nurse-B on 4/13/2017 at 11:35 am, she stated that she also recalls that she received a call from a representative of Pt. Guest Relations about SP#11 complaining he was "mishandled". She said that after she received the call, she and the assigned nurse went to see SP#11 in the room. She recalls SP#11 and stated, "he was angry because he was mishandled".


Record review of SP #11 Care Management notes by LCSW (Licensed Certified Social Worker) at 2/13/2017 2:22 PM revealed the social worker MSW spoke with patient in detail regarding complaint that he was assaulted while hospitalized in this facility inpatient psych unit per patient nursing staff members. When asked about events which occurred patient stated to MSW (Social Worker) "Yes, I was assaulted".

Review of the medical records of SP#11 did not show documentation of reporting to the Abuse Registry Hotline.