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Based upon the review of medical records, the list of contract services, contracts, and staff interviews, the Governing Body failed to ensure the list of contract services included all contracts and the scope and nature of the services provided. Findings:

Review of patient #4's medical record revealed on 5/25/14, Contract A was notified for placement of a Thoracic-Lumbar-Sacral Orthosis (TLSO Brace). On 5/27/14, the patient was placed on a specialty bariatric bed (Contract D), and on 5/28/14, the patient was transferred to a local imaging facility for an open air MRI (Magnetic Resonance Imaging), (Contract C).

Review of the list of contract services revealed Contract A, Contract C, and Contract D failed to be identified. Interview with S5 General Counselor on 12/04/14 at 10:10 a.m. revealed Contract B provided the services of Contract A, C and D; however, review of Contract B revealed the other contracts were not identified. Interview with S20 RN, Director of Quality Assurance revealed the hospital had a contract with Hospital A to provided patient care services that were not available at the hospital, such as the open air MRI. Further review of the list of contract services revealed Hospital A was not identified.

Based on record review and staff interviews, the hospital failed to ensure the effective implementation of the grievance process by failing to initiate the grievance process relative to a grievance filed for Patient #3 involving UPD (University Police Department). Findings:

Review of the Hospital Grievance presented by S14 Patient Relations Manager from May 2014 to November 2014 revealed no documented evidence of a Grievance filed for Patient #3.

In an interview on 12/04/14 at 10:15 a.m., S29 RN Manager indicated that on 10/24/14 after learning of the incident that occurred on 10/23/14, he visited Patient #3. S29 RN Manager indicated that upon entering the room Patient #3's significant other was present. S29 RN Manager indicated Patient #3 and significant other informed him that on 10/22/14 Patient #3 was tased after resisting arrest. Patient #3 and significant other verbally alleged that Patient #3 was abused & handled roughly by UPD causing bruises to both knees. According to S29 RN Manager they both alleged that the bruising of both knees were not caused by the local police department but by UPD. S29 RN Manager indicated that S14 Patient Relations Manager was contacted and arrived while he was still present the room.

In an interview on 12/0414 at 10:45 a.m., S14 Patient Relations Manager indicated on 10/24/14, S29 RN Manager contacted her and requested her presence in Patient #3's room. S14 Patient Relations Manager indicated that the patient and significant other indicated an alleged abuse by UPD on 10/23/14 after the patient tried to leave the hospital. S14 Patient Relations Manager confirmed that no Grievance was filed for Patient #3 after he alleged being abused by UPD.

Based on record review and staff interview, the hospital failed to have an established grievance process in place which clearly provided directions and instructions on filing a grievance for patients, families and or visitors. Findings:

Review of the Hosptial's Policy & Procedure titled,"Patient Rights & Responsibilities" approved by the Governing Body effective 10/01/13 presented by S2 RN/CNO (Chief Nursing Officer) as being current revealed in part: "12. Complaint Process- The patient has the right to file a complaint regarding services and is entitled to information regarding the hospitals mechanism for the initiation, review and resolution of such complaints."

Review of the Hospital's Policy & Procedure titled, "Patient /Visitor Complaints" approved by the Governing Body effective 10/01/13 presented by S2 RN/CNO as being current revealed in part: "1. All patient complaints, written or verbal (including telephone complaints), and regardless of point or origin, are forwarded to the Patient Relations Representative, or the Patient Relations Manager."

Review of a booklet titled "Patient Guide" presented by S14 Patient Relations Manager as being current for patient information revealed in part: "Most problems or questions you may have can be answered by your nurse or doctor. You may also call the Patient Relations department by dialing .....(number listed). Patient Relations staff are available to discuss your concerns privately. The staff of (name of facility) are fully committed to addressing your concerns and providing you with a timely response to your complaint. Continued review of the booklet read in parts: "If you have a problem or concern which you feel Hospital Administration has not addressed, you may contact our accrediting body, (name of agency at (website listed).

In an interview on 10/02/14 at 2:50 p.m., S14 Patient Relations Manager confirmed the policy & procedures presented by S2 RN/CNO were the Hosptial's grievance policy. S14 Patient Relations Manager also confirmed the contact number listed in the patient handbook was the contact number to report complaints directly to her office. S14 Patient Relations Manager confirmed after the number was dialed by the Surveyor that the contact number was still connected to the old system (Previous Provider) and messages on the answering system were not able to be retrieved.

In an interview on 10/20/14 at 3:30 p.m., S13 Tele-Communication confirmed that the hospital had 2 communication systems and S14 Patient Relations Manager had the capability to retrieve messages on the answering system.

In an interview on 10/02/14 at 3:50 p.m., S2 RN/CNO confirmed DHH-HSS (Department of Health & Hospitals Health Standards Section) contact information was not provided to patients/families and/or visitors for filing a complaint. S2 RN/CNO confirmed that the hospital had no policy & procedure which listed the steps for patients/families and/or visitors which provided them with the grievance process.

Based on record review and interview, the hospital failed to ensure that a patient's representative who filed a grievance on behalf of a patient was provided a written notice of its decision that contained the 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. This was evidenced by the hospital failing to provide a written response to a patient and/or representative for 1 (Patient #R3) patients' grievances from a total of 8 grievances reviewed. Findings:

Review of the Hospital's Policy & Procedure titled, "Patient /Visitor Complaints" approved by the Governing Body effective 10/01/13 presented by S2 RN/CNO as being current revealed in part: " Manager shall generate a letter to the complainant stating that their complaint has been received and is being investigated, providing a follow-up contact name. 14. Upon resolution, and not later than thirty (30) days, the individual filing the complaint shall be sent a follow-up letter from the responsible Administrator. Every effort will be made to resolve the complaint within 7 days understanding that some complaints require interdisciplinary investigation which may involve a greater length of time than 7 days. The letter shall provide assurance to the individual that appropriate steps have been taken to address the issues in the complaint and outline the resolution of the situation."

Review of a document presented by S14 Patient Relations Manager as a resolution letter to Patient #R3 revealed the document was typed on plain paper, dated 12/03/14, and addressed to Patient #R3. The document revealed in part: "This letter is in follow up to the complaint filed on your behalf by your daughter (name of daughter), regarding the care provided to you during your admission to (name of Hospital). It is my understanding that the administrative nursing director, S30 Clinical Nurse Director (name of Director),discussed (name of daughter) concerns immediately upon being notified and took appropriate steps to better address the issues concerning pain control."
The letter continued to reveal in parts: "If you would like to pursue this complaint further, you may do so my submitting your request in writing within 30 days of the date of this letter. You may also contact the Department of Health and Hospitals Health Standards Line if you are dissatisfied with the outcome of the this complaint. The phone number for the Health Standards office is toll free (number listed)." The letter was noted to have the Vice President of Clinical Support Services name typed and was not signed him. There was no documented evidence on the resolution letter which provided Patient # R3 and/or representative with the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
Review of the Hospital's Complaints indicated on 10/01/2014 a complaint was filed by a family on behalf of Patient #R3 for lack of care provided by Nursing Services and the Medical Staff for Patient #R3 not having pain medication and/or improper medication prior to a surgical orthopedic procedure.
In an interview on 12/04/14 at 4:20 p.m, S14 Patient Relations Manager confirmed the letter addressed to Patient #R3 was the final resolution and would be mailed out to the patient.

Based on record reviews and interviews, the hospital failed to ensure least restrictive measures were implemented as evidenced by allowing two UPD (University Police Department) officers to handcuff and escort Patient #3 in an elevator from the hospital's lobby to the Telemetry Unit on the 7th floor. Findings:

Review of the closed medical record for Patient #3 revealed the patient was a 36 year old admitted to 7KE from the ED (Emergency Department) on a PEC (Physician Emergency Certificate) after an attempted suicide by ingestion of a large amount of prescription medications. Review of the electronic Physician's progress notes written on 10/24/14 at 6:32 p.m. by S23 MD (Medical Doctor) read in parts: "Pt (as written) refused medical treatment yesterday all day. Then eloped as I was explaining to him the need for the treatments and lab tests ordered. He walked off the floor saying "Try me" and appeared as if he would hit someone. Nursing staff then called UPD." Review of the electronic Nurses' Notes written on 10/23/14 at 12:20 p.m. by S27 RN (Registered Nurse) read in parts: "Pt (as written) became very upset -stormed out of room, left floor-UPD was called. Charge nurse & other staff members attempted to follow patient."

In an interview on 12/03/14 at 1:30 p.m., S2 RN/CNO indicated on 10/23/14 UPD Officer was called by the Nursing Staff on 7KE after Patient #3 attempted to leave the hospital. S2 RN/CNO confirmed that Patient#3 was restrained by S24 UPD with metal handcuffs, escorted back to his room accompanied S26 UPD in an elevator without the presence of a clinical staff member.

In an interview on 12/03/14 at 2:30 p.m., S24 UPD Officer confirmed that on 10/23/14 at approximately noon a call came over the radio from the UPD dispatcher of a PEC'd patient who escaped from 7KE. S24 UPD Officer indicated that he responded to the call and discovered Patient #3 in the hospital lobby after a staff (7KE) yelled "there he is." S24 UPD Officer confirmed that Patient #3 attempted to run toward him and there was a collision of the two resulting in him falling on the patient. S24 UPD Officer indicated that Patient #3 was yelling, cursing, kicking and resisting him and added " I was not sure if he would go for my weapon and there was a lot of people (visitors & staff) in the main corridor." S24 UPD Officer stated he made the decision at that time to place Patient #3 in metal handcuffs because back-up was not immediately in the areas at that time. S24 UPD Officer indicated S26 UPD Officer arrived after he attempted to place the last hand cuff on the patient and confirmed that Patient #3 was escorted back to his room handcuffed, on an elevator without being accompanied by a member of 7KE Nursing Staff and/or any other licensed medical staff only 2 UPD Officers (S24 and S26).

In a telephone interview on 12/03/14 at 3:10 p.m., S25 RN stated that on 10/23/14 she was the assigned Charge Nurse on 7KE. Patient #3 was PEC'd with a sitter at his bedside, walked out of his room and attempted to leave the hospital. S25 RN indicated that the patient took the stairs and she instructed S27 RN to call UPD and she got on the elevator in an effort to follow the patient. When she arrived on the 1st floor, S25 RN stated Patient #3 was on the floor and UPD Officers (2) were telling him "calm down". S25 RN further added that Patient #3 was escorted by 2 UPD Officers onto an elevator and no clinical staff member accompanied the patient. S25 RN indicated " I was not going to get on the elevator he was kicking."

In an interview on 12/03/14 at 3:25 p.m. S26 UPD Officer confimed that he assisted S24 UPD Officer in an attempted elopement of Patient #3 on 10/123/14 which resulted in the patient being handcuffed in the main corridor of the hospital. S26 UPD Officer confirmed that he and S24 UPD Officer escorted Patient #3 to his assigned room and there was no Nursing Staff (7KE) and/or any other member of the medical staff who accompanied the patient on the elevator.

Interview on 12/03/14 at 4:45 p.m. S28 RN 7KE Clinical Nurse Supervisor confirmed that she was present in the main corridor of the hospital when Patient #3 was handcuffed and escorted back to 7KE on an elevator accompanied by 2 UPD Officers.

Based on record review and interview, the hospital failed to ensure staff members (UPD-University Police Department) were trained and educated on the safe implementation of restraints and in the use of least restrictive restraints. This was evidenced by Patient #3 being placed in metal handcuffs by UPD after being placed on a PEC (Physician Emergency Certificate) and attempting to elope from the hospital. Findings:

Review of the closed medical record for Patient #3 indicated he was a 36 year old admitted to 7KE from the ED (Emergency Department). Patient #3 was PEC'd (Physician Emergency Certificate) after an attempted suicide by ingestion of a large amount of prescription medications. Review of the medical record revealed the patient attempted to elope on 10/23/14 and UPD was called to assist.

In an interview on 12/03/14 at 1:30 p.m., S2 RN/CNO indicated on 10/23/14 UPD Officer was called by the Nursing Staff on 7KE after Patient #3 attempted to leave the hospital. S2 RN/CNO indicated that Patient#3 was restrained by S24 UPD with metal handcuffs, escorted back to his room accompanied S26 UPD in an elevator without the presence of a clinical staff member.

Review of the Personnel Files for S24 UPD Officer and S26 UPD Officer revealed there was no documented training and/or education relative to the use of restraints.

In an interview on 12/ 10/14 at 1:05 p.m., S2 RN/CNO confirmed that S24 UPD Officer & S26 UPD Officer had no documented training and/or education for proper application of restraints on patients and/or the use of less restrictive restraints.

Based upon review of medical records, policy and procedure, and staff interviews, the Registered Nurse (RN) failed to evaluate the nursing care of each patient as evidenced by: 1) failure to evaluate patient #1's bowel elimination from 11/26/14 to 12/4/14 and identify the patient had not had a bowel movement for 7 days, 2) failure to perform an initial shift assessment on Patient #3 upon admission to 7KE after elopement (restrained with hand cuffs) and prior to application of 4 point restraints, 3) failure to follow physician order for cardiac monitoring (Telemetry) of patient #3, and 4) failure to evaluate patient #4's bowel elimination from 5/24/14 to 6/6/14 and identify the patient had not had a bowel movement for 12 days. Findings:

1) Review of the medical record for Patient #1 revealed she had been admitted to the hospital on 11/26/14 with the diagnoses of 33.5% coverage of burns to the chest, back, neck, buttocks, and upper & lower extremities with 29% 2nd degree and 4.5% 3rd degree. Review of the RN's documentation on the nursing flow sheets from the date of admit on 11/26/14 to 12/04/14 revealed there failed to be documented evidence patient #1's bowel elimination was evaluated and identified that the patient had not had a bowel movement for 7 days.

Interview on 12/04/14 at 11:20 a.m., S33 RN revealed the nurses should have evaluated patient #4's elimination and identify the patient had not had a bowel movement for 7 days.

2) Review of the closed medical record for Patient #3 revealed he was a 36 year old admitted to 7KE on 10/23/14 from the ED (Emergency Department). He was PEC'd (Physician Emergency Certificate) after an attempted suicide by ingestion of a large amount of prescription medication. Review of the Nurses Notes dated 10/23/14 revealed there was no documented evidence of an assessment of Patient #3 by a Nurse after an attempted elopement in which the patient was restrained with handcuffs by UPD Officers.

Interview on 12/04/14 at 11:20 a.m., S33 RN revealed the nurses should have assessed Patient #3 after the attempted elopement and prior to application on 4 point restraints

3) Review of Patient #3's e physician's admit orders dated 10/23/14 at 0626 revealed an order for cardiac event monitor. Review of the nurses notes documentation on 10/23/14 revealed no documented evidence of cardiac monitor until 1500 (3:00 p.m.).

Interview on 12/03/14 at 3:50 p.m. with S27 RN confirmed that on 10/23/14, she was the nurse assigned to Patient #3 and she failed to perform an assessment at time of admission to 7KE, after elopement and/or removal of handcuffs and prior to application of nylon restraints(4 points). S27 RN confirmed that Patient #3 had an order for Telemetry monitoring and was not on Telemetry at the time of elopement and was placed on Telemetry at 3:00 p.m. on 10/23/14.

Review of the Hospital's Policy titled "Minimal Required Daily EHR(Electronic Health Record) Documentation approved by the governing body effective 10/01/13 presented by S2 RN/CNO as being current, revealed in part: "1. Initial and Daily Documentation A. The Shift Assessment will be initiated daily at the beginning of each shift. 3. Patient Profile 9. Head to toe (Follow unit specific requirements, to be done every shift or with every change in RN Assignment) 10. Intake & Output (Unmeasured output-the nurse shall document the number of stool occurrences, if there are no stool occurrences for that shift, a ZERO must be documented.) 14. Shift note (Completion of all Doc (as written) Flow sheets, Narrative Notes, Care Plans and Education should reflect any changes in patient's condition as well as any additional information showing an accurate detailed depiction of the patient's situation/condition ."

Interview on 12/03/14 at 4:00 p.m. with S2 RN/CNO confirmed that a Nursing Assessment should have been performed upon arrival to the floor, after elopement and prior to application of restraints.

4) Review of patient #4's closed medical record revealed on 5/24/14, the patient presented to the emergency department after a motorcycle accident. The patient was admitted to the hospital's Surgical Intensive Care Unit (SICU) and on 5/27/14 transferred to the Burn Unit. Review of the RN's documentation on the nursing flow sheets from the date of admit on 5/24/14 to 6/06/14 revealed there failed to be documented evidence patient #4's bowel elimination was evaluated and identified that the patient had not had a bowel movement for 12 days.

Interview with S2 RN/CNO on 12/9/14 at 1:30 p.m. revealed the nurses should have evaluated patient #4's elimination and identify the patient had not had a bowel movement for 12 days.





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