HospitalInspections.org

Based on observation, interview, review of recorded video footage, review of medical record documentation for a quadriplegic patient (Patient 14), review of event documentation for 7 of 9 patients who received hospital services (Patients 1, 2, 3, 4, 5, 14, and 15), review of grievance documentation for 5 of 5 patients selected from the grievance log (Patients 6, 8, 9, 12 and 14), and review of policies and procedures, it was determined that the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital that complied with the Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.

2. Refer to the findings cited under Tag A263, CFR 482.21 - CoP Quality Assessment and Performance Improvement.

Based on observation, interview, review of recorded video footage, review of medical record documentation for a quadriplegic patient (Patient 14), review of event documentation for 7 of 9 patients who received hospital services (Patients 1, 2, 3, 4, 5, 14, and 15), review of grievance documentation for 5 of 5 patients selected from the grievance log (Patients 6, 8, 9, 12 and 14), and review of policies and procedures, it was determined that the hospital failed to enforce policies and procedures to ensure patients' rights were protected and promoted as follows:
* Hospital staff failed to ensure patients were provided care in a safe environment. Patient 14, a quadriplegic patient, was taken outside by hospital staff, and left alone unmonitored and unsupervised for periods of time with no way to contact staff if needed, including for emergencies; and then discharged home where there was nobody to care for the patient. The hospital additionally failed to conduct an investigation and follow up actions to ensure these events did not recur.
* The hospital failed to conduct thorough and timely investigations to allegations of abuse and neglect including those with potential or actual harm related to patient behaviors, elopement, medication errors, skin care, and ostomy/incontinence management; and failed to develop follow up actions to ensure they did not recur.
* Responses to and investigations of patient complaints and grievances were not timely or complete, including those related to allegations of abuse.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag 123, CFR 482.13(a)(2)(iii) Patient's Rights - Standard: Notice of Grievance Decision. Those findings reflect the hospital's failure to provide written notice of follow-up investigation and resolution that contained the required elements, including responses and investigations to grievances related to allegations of abuse or neglect.

2. Refer to the findings cited at Tag 144, CFR 482.13(c)(2) Patient's Rights - Standard: Care in a Safe Setting. Those findings reflect the hospital's failure to ensure the patient's right to receive care in a safe setting; and to ensure investigations of allegations of abuse or neglect were timely, clear, complete and accurate to prevent recurrence.

3. Refer to the findings cited at Tag 145, CFR 482.13(c)(3) Patient's Rights - Standard: Free from Abuse/Harassment. Those findings reflect the hospital's failure to ensure investigations of allegations of abuse or neglect were timely, clear, complete and accurate to prevent recurrence.

Based on interview, review of grievance documentation for 5 of 5 patients selected from the grievance log (Patients 6, 8, 9, 12 and 14), and review of policies and procedures, it was determined that the hospital failed to fully implement policies and procedures that ensured patients' rights were recognized, protected and promoted as follows:
* Responses to and investigations of patient complaints and grievances were not timely or complete, including those related to allegations of abuse.
* A written grievance notice that contained the required elements including 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 was not provided to each patient/patient representative who filed a complaint or grievance with the hospital.

Findings included:

1. The policy and procedure titled "Managing Patient Complacints (sic) and Grievances" dated last revised "07/17" was reviewed. It stipulated:
* "A grievance is a statement of concern, communicated by a patient or the patient's representative...about patient care...Examples of Grievances include...A complaint that cannot be resolved at the time of the complaint, by staff present. Whenever the patient or the patient's representative requests that his or her statement of concern be handled as a formal grievance or when the patient requests a response from the hospital, the concern is considered a grievance and all the requirements apply...Any written statement of concern communicated by a patient or the patient's representative...regarding care...Any verbal or written statement of concern alleging the failure of the hospital to comply with one or more of the CMS Conditions of Participation...or other CMS requirement...Statements of concern that are expressed after a patient leaves the hospital..."
* "Manage a Grievance...Grievances are investigated by the affected Unit, Department or Service Manager or Director. Patient Relations manages compliance with timeframes, the content of the mandatory response letter and documentation of the grievance...Grievances will be investigated and managed within a reasonable timeframe determined by the complexity of the grievance and the investigation and decision making required. If the grievance cannot be resolved, or if the investigation is not or will not be completed within seven (7) days, the hospital should inform the patient or the patient's representative (verbally or in writing) that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within thirty (30) days...When a final resolution has been reached, a written response will be provided to the patient/designated representative...The written response will include the following...Patient name and location of services...Name of the hospital contact person...A restatement of the patient's/representative's complaint...Steps taken to investigate the grievance...Results of the investigation...Actions taken based on results of the investigation...Completion date...A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf..."
* "Trending and Analysis of Complaints and Grievances: Management reports will be available for managers and leadership to identify opportunities for improvement.
* The "Definitions" section reflected "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect is considered a form of abuse and is defined as a failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness."

2. Patient 6: Grievance documentation for the patient was reviewed and reflected the "Date Complaint Received" was 06/10/2019. The grievance was categorized as "Complaint Type Care Issues." The "Initial Complaint Description" notes reflected "[Patient] stated [he/she] had a baby...Doctor...came in and assessed [him/her] and then did a rectal exam without telling [him/her] and [he/she] felt violated...I apologized and said I would send for review and respond within 30 days."

A written response submitted to the patient in response to the grievance related to the patient's complaint, was reviewed. The written response was dated 07/31/2019, 51 days after the complaint was received. There was no documentation that reflected the hospital contacted or attempted to contact the patient either verbally or in writing after 06/10/2019, including no written notice of follow-up investigation and resolution submitted to the patient or patient representative within 30 days.

3. Patient 8: Grievance documentation for the patient was reviewed and reflected the "Date Complaint Received" was 06/17/2019. The grievance was categorized as "Complaint Type Care Issues." The "Initial Complaint Description" notes reflected "Family angry that patient was DNR..." The undated "Case Narrative" notes reflected "...family members appeared and demanded to have [patient] changed to full code...[Family member] called to ask for help...[He/she] said...[he/she] has to fight because we have not been caring for [patient]...[He/she] wants [patient] transferred to another hospital and I confirmed that they must find an accepting physician who will contact Legacy and we can go from there..." There was no documentation that reflected the hospital contacted or attempted to contact the patient or patient representative either verbally or in writing after 06/17/2019, including no documentation that reflected a written notice of follow-up investigation and resolution was submitted to the patient or patient's representative.

4. Patient 9: Grievance documentation for the patient was reviewed and reflected the "Date Complaint Received" was 06/24/2019. The grievance was categorized as "Complaint Type...Lost Damaged Items" and "Complaint Sub Type...Glasses." The "Initial Complaint Description" and "Case Narrative" notes reflected "7-1-19 Pt called to report that [he/she] had ordered glasses and paid upfront (sic)...7/15/19...received the bill for glasses. Sent check request..." There was no documentation that reflected a written notice of follow-up investigation and resolution was submitted to the patient, and no documentation that the hospital contacted or attempted to contact the patient either verbally or in writing to inform the patient or the patient's representative that the hospital was still working to resolve the grievance.

5. Patient 12: Grievance documentation for the patient was reviewed and reflected the "Date of Occurrence" and the "Date Complaint Received" were 06/28/2019. The grievance was categorized as "Complaint Type...Risk Management" and "Complaint Sub Type...Physical/Sexual abuse allegation." The "Initial Complaint Description" reflected [parent] of patient alleged that [RN] was physically abusive when [he/she] used techniques to arouse [his/her] [son/daughter] from sedation...[He/she] also complained that [RN] spoke excessively loud to [his/her] [son/daughter] and used [his/her] arm across [his/her] chest to keep [him/her] from sitting up (while intubated). Referred to Risk Management." Additional documentation provided and reviewed included staff interviews and an investigation summary document. The top portion of the investigation summary reflected "Incident Date 6/28/19" and "Closed." The space following "Conclusion" was blank. The "Summary & Analysis of findings" section had an undated handwritten note that reflected "Investigation incomplete." The "Standard of Care" section unclearly had checked boxes next to "Yes" and "No." Interview documentation provided reflected two interviews were conducted on 06/28/2019. No further investigation information was provided.

A written response dated 07/26/2019, a month after the grievance was submitted, was reviewed and reflected "This letter is in response to concerns your [parent] brought to our attention June 28, 2019...[He/she] did not feel your bedside nurse on the day shift provided safe and effective care. I had an appointment to meet with your [parent] to learn more about [his/her] concerns on the morning of 7/1/19 but your [parent] was not on the unit...I attempted to reach you by phone on 7/3/19, 7/10/19 and 7/15/19 to determine if you wanted me to continue the investigation by speaking with your [parent] about your care...We began our review of your care but cannot continue without further contact from you. Your case remains open. If I do not hear from you by August 28th, I will conclude you are not interested in further contact and I will consider the matter closed."
* There was no documentation that reflected a written notice of follow-up investigation and resolution was submitted to the patient or the patient's representative.
* There was no documentation that reflected the hospital contacted or attempted to contact the patient or patient representative either verbally or in writing to inform the patient or the patient's representative that the hospital was still working to resolve the grievance and that the hospital would follow-up with a written response within thirty (30) days.
* The investigation of this allegation of physical abuse received by the hospital approximately six weeks previous to the date of this review, was not completed and the unclearly reflected it "cannot continue" and "the matter closed" if the hospital did not hear from the patient.

6. Patient 14: Grievance documentation for the patient was reviewed and reflected the "Date of Occurrence" was 07/13/2019 and the "Date Complaint Received" was 07/15/2019. The grievance was categorized as "Complaint Type...Risk Management" and "Complaint Sub Type...Physical/Sexual abuse allegation." The "Initial Complaint Description" notes reflected "Patient alleged [RN] intentionally pressed on [his/her] right shoulder causing pain. Referred to Risk Management." The "Actions Taken:" reflected [none]." A written response submitted to the patient in response to the grievance related to the patient's complaint, was reviewed and reflected "This letter is in follow up to a complaint you made on 7/13/19 regarding care you received by one of our nurses..." The written response was dated 07/26/2019, 13 days after the complaint was made. There was no documentation that reflected the hospital contacted the patient either verbally or in writing within 7 days to inform the patient or the patient's representative that the hospital was still working to resolve the grievance and that the hospital would follow-up with a written response within thirty (30) days.

Refer to the findings cited at Tag A 145, CFR 482.13(c)(3) Patient's Rights - Free from Abuse/Harrassment that reflects the hospital's failure to conduct a thorough investigation of Patient 14's grievance.

7. The grievance documentation related to patients 6, 8, 9, 12 and 14 was reviewed with CRM and PRS on 08/07/2019 at 1655 and 08/08/2019 at 1100. The PRS confirmed the findings related to Patients 8, 9 and 12 during the grievance reviews on 08/07/2019 at 1655 and 08/08/2019 at 1100.

Based on observation, interview, review of recorded video footage, review of medical record documentation for a quadriplegic patient (Patient 14), review of event documentation for 7 of 9 patients who received hospital services (Patients 1, 2, 3, 4, 5, 14, and 15), and review of policies and procedures, it was determined that the hospital failed to enforce policies and procedures that ensured patients' rights were protected and promoted as follows:
* Hospital staff failed to ensure patients were provided care in a safe environment. Patient 14, a quadriplegic patient, was left alone outside, unmonitored and unsupervised for periods of time with no way to contact staff if needed, including for emergencies and then discharged home where there was nobody to care for the patient; and an investigation and follow up actions were not conducted to ensure these events did not recur.
* The hospital failed to conduct thorough and timely investigations to allegations of abuse and neglect including those with potential or actual harm related to patient behaviors, elopement, medication errors, skin care, and ostomy/incontinence management; and failed to develop follow up actions to ensure they did not recur.

Findings include:

1. Refer to the deficiency cited at Tag 145, CFR 482.13(c)(3) Patient's Rights: Standard - Free from Abuse/Harassment. Those findings reflect the hospital's failure to ensure investigations of allegations of abuse or neglect were timely, clear, complete and accurate to prevent recurrence.

2. Policies and procedures provided in response to a request for policies and procedures related to observation, monitoring and response to ED patients, including those related to patient behaviors included:

a. The policy and procedure titled "Care of the Adult Patient In The Emergency Department, dated last revised "June 2018," was reviewed. It stipulated:
* The "Expected Patient Outcomes: The RN coordinates the interdisciplinary plan of care and applies the nursing process.
- "Immediate identification and intervention of potential or actual life-threatening or disabling problems."
- "Maintain, improve, or restore physiological function. In select circumstances, the goal may be to simply provide comfort measures/palliative care."
- "Promotion of a safe environment that maintains patient dignity and privacy, and incorporates emotional support."
- "Enhance in knowledge of patient condition and signs and symptoms to report."
- "Opportunity to discuss pain history, current pain status, future expectations, and concerns."
- "Education regarding pain relief measures, realistic expectations, and the pain rating scale."
- "Involvement in establishing a goal for pain relief and in developing, implementing, and revising the plan for achieving the goal."
- "Involvement in care including transition planning and lifestyle changes."
- "Support the family-centered model to meet psychosocial needs."
- "Optimal communication."
* "Multidisciplinary Plan of Care: Patient treatment and care will be done in collaboration and coordination with the multidisciplinary team, to include...primary care physicians...and other identified community/healthcare team members. Within each discipline's scope of practice, the interdisciplinary team collaborates in providing the following care as warranted by patient condition and caregiver judgment based on critical thinking skills."
* "During the visit RN will perform a focused nursing assessment and document findings. A focused nursing assessment is a detailed assessment of any area or system that has an abnormality or injury...Secondary Assessment is performed after the primary assessment...Following the...focused nursing assessment the multidisciplinary team will plan and implement interventions...Provide for interventions and care as patient condition indicates...Provide patient safety measures as indicated...Initiate appropriate nurse initiated order sets and protocols...Provide clear communication to patient and family around provision of care, treatment/interventions medications and discharge planning..."
* "Pain management: Assessment of a patient's pain begins at the time of arrival in the ED and continues throughout the patient's ED stay, with the frequency of reassessment determined by the patient's condition and the interventions provided for pain relief...Partner with the patient...to establish realistic pain management expectations...The nurse will perform pain assessment and document findings...including...Pain intensity...Location of pain...Character of pain...A behavioral assessment tool can be utilized to assist in the evaluation of pain in patients unable to rate pain intensity and to quantify behaviors that may be indicative of pain...Pain should be suspected in the presence of known painful pathology or procedures. Behavioral indicators such as grimacing, writhing, restlessness may confirm the presence of pain..."
* "Re-assessment as indicated per patient condition...Each patient is reassessed related to the patient's course of treatment, response to treatment, and/or changes in the patient's condition...Evaluation and ongoing monitoring is the determination of whether the desired responses to interventions have been achieved. If positive outcomes are not demonstrated, further assessment is indicated, along with reevaluation of the plan of care and specific interventions...Focused reassessment as indicated by conditions and/or interventions."
* "Vital Signs: reassessment is based on nursing judgement, physician order, or patient acuity...ESI level 4: Based on nursing judgement, but no less frequently than every 4 hours...Patients being discharged: Should be current and based on acuity..."
* "Consults for social services and specialty services may occur in the ED as necessary..."
* "Discharge...The discharge planning assessment includes identifying a primary decision maker for planning purposes. Most often, patients and their family members can make their own decisions about continuing care plans, based upon their needs, resources and personal preferences...Discharge needs, including discussion of the results of the assessment with the patient, lay caregiver or individual acting on patient's behalf, is documented in the patient's EHR...All patients will receive discharge education and printed After-Visit Summary (AVS) pertinent to their diagnosis or condition...Give written discharge instructions and validate patient/family understanding of instructions."

b. The policy and procedure titled "Guidelines For Close Supervision," dated last revised "June 2019" was reviewed. It stipulated:
* "Purpose: To provide safe, consistent, effective care to patients that require increased surveillance and intervention."
* "Close supervision is an intervention that may be implemented in the presence of other interventions, such as restraints or seclusion. Close supervision does not replace other interventions."
* "For those patients who have a primary admitting diagnosis related to behavioral health conditions and/or are exhibiting behavioral health symptoms, close supervision may be appropriate to maintain safety for the patient and the workplace environment."
* "Close supervision may be ordered by the Charge Nurse or Emergency Department RN...The physician may also order close supervision...The nurse will notify the physician of the order and discuss rationale for close supervision with the physician...The charge nurse will reassess the need for close supervision each shift. The charge nurse has the authority to change the level of supervision based on patient status...Changes in level of supervision are to be documented."

3. Review of the ED record of Patient 14 reflected the following sequence of events:

* The patient presented to the ED by ambulance on 07/28/2019 at 1018 with an Arrival Complaint of "Migraine."
* On 07/28/2019 at 1024 the RN notes reflected "Pt quadriplegic...caregiver did not show up today [He/she] has no way to perform ADLs (sic) Also has a migraine."
* On 07/28/2019 at 1035 the RN flowsheet reflected "Temp...98.2 [degrees] F...Pulse 83...BP 120/70...Resp 20..."
* On 07/28/2019 at 1036 the RN flowsheet reflected "Pain Assessment...Pain Intensity 8."
* On 07/28/2019 at 1131 the RN notes reflected "Shouting at RN - refuses zyprexa...PA aware and encourages zyprexa Pt refuses and is verbally hostile to staff..."
* On 07/28/2019 at 1222 the RN notes reflected "Went into room as pt was screaming uncontrollably. Pt upset because [his/her] hood fell off [his/her] head. Attempt to redirect pt. Pt continued to scream and was inconsolable and uncooperative...not redirectable."
* On 07/28/2019 at 1250 the RN notes reflected "Angry affect and yelling at staff."

* RN CM progress notes dated 07/28/2018 at 1245 reflected:
- "1050: RN CM consulted to assist with helping patient return to [his/her] home. Placed a call to friends/caregivers...Left voicemail requesting return call."
- "1125: Spoke with [name], Kaiser Regional Telephonic Medicine Center...Discussed patient's case which was presented to Kaiser Case Management...RN CM at Kaiser Sunnyside ED is assigned to patient's case and will call this RN CM as plan evolves. Hopeful for transfer to Kaiser, however, patient has right to refuse."
- "1200: Call from...RN CM at Kaiser...who requested that Emanuel provider...presents (sic) patient's case to Kaiser MD. [RN CM at Kaiser] has entered referral to Kaiser PCP, Social Work, and, and Complex Care RN."
- "1220: Spoke with...PA providing care at Emanuel, patient has refused transfer to Kaiser. There is no medical reason for patient to admit to Emanuel. Patient has abundant resources and has proven to be capable of making [his/her] own arrangements for caregiver assistance. AMR stretcher transport arranged for 'ready now' transport back to Meyers Court Apartments. ED Care Coordination for Kaiser Sunnyside [phone number] if needed."

* On 07/28/2019 at 1404 the RN notes reflected "Continues to refuse zyprexa...Screaming and chanting 'I need my regular medication!' PA aware, no order changes. Pt not able to calm down or reason."
* On 07/28/2019 at 1424 the RN notes reflected "Many attempts to engage with patient...escalates and continues [his/her] 'mantras' at a higher volume...loudly talking over the speaker Requested pt to please lower voice as [he/she] is disturbing other patients...continue loud volume repeat mantras. This is unfortunate [because] it thwarts any possibility of helping [him/her]...refusing any information or assistance by constant interrupting and overtalking."

The RN notes on 07/28/2019 between 1454 and 1615 reflected the ED staff took the patient outside the ED to the ambulance bay and left the patient there for more than an hour as follows:
* On 07/28/2019 at 1454 the RN notes reflected the patient could not stop screaming and was moved outside to the ambulance bay.
* The next RN notes on 07/28/2019 at 1507 reflected "...reassess in ambulance bay. Hood repositioned...Provided with 400 ml of water..."
* The next RN notes on 07/28/2019 at 1520 reflected "Pt re-evaluated. Provided with 200 cc's water and personal fan. Hood repositioned...Screaming continues. No sign of injury."
* The next RN notes on 07/28/2019 at 1529 reflected "Wheels locked; Bed in lowest position; Identification Band on; Nonskid footwear; Overbed table within reach; Patient in view of nursing station; Siderails up."
* The next RN notes on 07/28/2019 at 1542 reflected "...provided with 200 ccs water via straw. Tolerated well. No sign of injury."
* The next RN notes on 07/28/2019 at 1554 reflected "...provided with 200 ccs of water. Hood repositioned..."
* The next RN notes on 07/28/2019 at 1600 reflected "Continues to yell and be angry while awaiting ambulance ride home. Continues to refuse meds..."
* The next RN notes on 07/28/2019 at 1604 reflected "Pt provided with 200 ccs of ice water while primary RN giving report to medics. Tolerated well."

* The "Care Plan" was not completed and reflected "...ADL Assessment [blank space]...Plan of Care Notes...No notes of this type exist for this encounter...Treatment Plan...No notes of this type exist for this encounter...Patient Care Conference...No notes of this type exist for this encounter."

* PA notes signed by the PA dated 07/28/2019 at 1608 reflected:
- "Neurological: Positive for headaches..."
- "Physical Exam: There were no vitals taken for this visit..."
- "Neurological: [He/she] is alert and oriented to person, place, and time...Psychiatric: Judgment and thought content normal...speech is rapid and/or pressured. Thought content is not delusional. Cognition and memory are normal...Laying on the bed with a black hood over [his/her] eyes. Hyperverbal...becomes fairly oppositional rapidly..."
- "ED Course...history of quadriplegia, borderline personality disorder with narcissistic and antisocial traits...Fibromyalgia, chronic headaches, PRESENTS TO THE ED because [his/her] caregiver did not show up at [his/her] home today and [he/she] is complaining of a headache. Patient was seen 2 days ago in a Kaiser facility for same complaint of no caregiver. [He/she] was discharged home...10:33...Patient appears with a black hood over [his/her] face but otherwise no acute distress, hyperverbal...Chronic headache....patient will be treated with Zyprexa...social situations with difficulty maintaining caregivers due to personality disorder issues...Discussed with social work who will discuss with case manager to work on getting the patient back in [his/her] facility...declined Zyprexa. If [he/she] changes [his/her] mind, we are happy to treat [his/her] headache with Zyprexa...social work is looking into disposition...12:25 per case manager, if patient is to be admitted [he/she] is to be admitted to Kaiser. I spoke with the patient and patient declines to be admitted to Kaiser. Given this, [he/she] will be discharged back to [his/her] residence. Patient is informed that I am happy to talk to Kaiser but [he/she] is not interested in this option...continues to chant loud mantras (that [he/she] does not have a caregiver) but [he/she] will not listen to any reasoned discourse on this matter."
- "Diagnosis and Disposition...No one available at home to care for patient."
There was no PA documentation that reflected the PA was aware of or intervened secondary to the ED staff taking the patient outside and leaving him/her outside because he/she could not stop screaming.

* On 07/28/2019 at 1613 the RN notes reflected "Departure Condition: Stable Mobility at Departure: Stretcher...Pt left w/No Teaching...Refused Learning. No evidence of Learning...Departure Mode...Per ambulance."

The record reflected the hospital failed to ensure hospital staff assessed, monitored and supervised the patient in accordance with hospital policies and procedures secondary to taking the patient outside on a gurney, where staff left the patient alone for periods of time unsupervised and unmonitored with no ability to seek assistance if needed, including for potential emergencies. Examples included:
- On 07/28/2019 at 1035 vital signs were documented. There were no further vitals signs documented, including at any time while the patient was outside, or prior to discharge.
- On 07/28/2019 at 1036 the RN notes reflected "Pain Assessment...Pain Intensity 8." There was no further pain assessment by the RN secondary to the patient's arrival complaint of migraine, headache, and subsequent yelling and screaming.
- On 07/28/2019 at 1250 the RN flowsheet reflected the patient was a quadriplegic with "some movement of upper extremities." There was no further assessment by the RN related to the patient's physical abilities with respect to the patient being put outside alone with no call system or other way to contact staff.
- On 07/28/2019 at 1454 the RN notes reflected the patient could not stop screaming and was moved outside to the ambulance bay. There was no documentation that reflected the RN assessed the reason the patient could not stop screaming.
- On 07/28/2019 at 1613 the RN notes reflected "Departure Condition: Stable Mobility at Departure: Stretcher..." There was no further assessment of the patient's condition at the time of discharge, including no vital signs or other assessment secondary to his/her screaming and being put outside in summer weather conditions.
- There was documentation of a care plan.
The medical record was reviewed with the EDD and ED ANM on 08/07/2019 at 1040. These findings were confirmed with the ED ANM during an interview at the time of the medical record review on 08/07/2019 at 1040.

The record reflected the hospital failed to implement its discharge planning policies and procedures and discharged the patient home with "No one available at home to care for patient." The documentation lacked an assessment of the needs, resources and personal preferences of the patient as required by hospital policies and procedures. Examples included:
- The RN CM notes reflected "consulted to assist with helping patient return to [his/her] home. Placed a call to friends/caregivers...Left voicemail requesting return call." There was no further information or follow up related to the call made to "friends/caregivers."
- The RN CM notes reflected the patient had abundant resources. There was no documentation of what the "abundant resources" were with respect his/her quadriplegia, lack of caregiver and inability to provide ADLs.
- The RN CM notes reflected the patient was determined proven capable of making his/her own arrangements for caregiver assistance. However, there was no documentation that reflected when the patient was assessed and determined capable and if he/she was currently capable of making those arrangements, including with respect to his/her current uncontrollable and inconsolable screaming.
- The RN CM notes reflected "patient has refused transfer to Kaiser." There was no documentation that reflected the reason the patient refused to be transferred or that the patient was informed of the potential implications of refusing transfer versus being discharged home with no one available to care for the patient. The documentation lacked a clear discharge planning assessment, and subsequent attempts to discuss the results with the patient, including what services were available at "Kaiser."

4. Video without audio of Patient 14 was reviewed with multiple staff including the EDD and MSS on 08/07/2019. The staff present during the video review confirmed the following:
* At 1450, the ED RN took the patient who was on a gurney from the direction of the patient's room, and exited the ED doors near the nurse's station, into an outside ambulance bay.
* Immediately after exiting the ED, the ED RN moved the patient to the left of the ED doors and out of camera view. Staff present during the video review stated the ED RN moved the patient to a sidewalk area within the ambulance bay that was not visible from inside the ED or the nurse station video monitor.
* At 1451 the ED RN did not remain with the patient after taking him/her outside as the ED RN was observed entering the ED through the ED doors.
* At 1529, the ED RN moved the patient to an area in the ambulance bay located in front of the ED doors. The patient was not visible from the nurse's station or the video monitor between 1450 and 1529, a period of 39 minutes. This was confirmed with the EDD.
* After moving the patient in front of the ED doors, he/she was positioned on the sidewalk in the ambulance bay adjacent to the parking spaces. There were no raised curbs or wheel stops observed between the parking spaces and the sidewalk to prevent ambulances or other vehicles from backing onto the sidewalk where the patient was positioned. The video reflected an ambulance was backed into a parking space and partially onto the sidewalk near the patient.
* The patient was facing away from the ED doors and nurse station and his/her face was not fully visible. The patient's facial color and expressions were not discernable. This was confirmed with the EDD at the time of the video review.
* The patient had a dark colored garment on his/her head and a sheet and/or blanket over his/her body, including his/her arms, legs, and feet. The blanket or sheet appeared to be tucked under the right side of the patient's body. Unidentifiable bulky items were observed piled awkwardly over the top of the sheet or blanket between the gurney and gurney rail and along the left side of the patient's arm, torso, and lower extremity. A sheet and other bedding items were partially dislodged from the upper portion of the mattress, and appeared wrinkled and bunched up beneath the patient's head and shoulders. The patient's head and shoulders moved in a repetitive rhythmic motion. No other movement of the patient's body was observed for the duration of the video review.
* ED staff approached the patient and appeared to engage him/her four times between 1529 and 1609. Each encounter lasted less than 40 seconds.
* No hospital staff repositioned the patient, moved the linens or clothing on the patient's body, checked the patient's positioning or skin beneath the linens/clothing for moisture or excessive heat secondary to the outside summer temperature, or moved the bulky items that were positioned awkwardly alongside the patient.
* No call system or other mechanism to notify staff if needed for assistance, including for emergencies, was observed.
* At 1609, EMS individuals moved the patient from the gurney onto an ambulance gurney and into an ambulance.

5. During an interview with the ED RN on 08/07/2019 at 1545, the following information was provided related to Patient 14:
* The ED RN stated he/she was assigned to care for the patient on 07/28/2019 while the patient's regularly assigned RN was on a meal break.
* The ED RN stated the PA had written discharge orders for the patient, and the patient was waiting for a ride home.
* The ED RN stated the patient was in his/her room and he/she recalled "hearing [the patient] yelling from the nurse station."
* The ED RN stated he/she went to the patient's room and the patient continued to scream.
* Regarding the patient's physical abilities, the ED RN stated the patient appeared completely dependent on nurses to provide his/her care. The ED RN stated "I saw [his/her] right arm move...I didn't see [his/her] legs move at all." The ED RN stated the patient had a call light on his/her chest but he/she didn't know if the patient had the ability to use it.
* The ED RN was asked to describe the patient's cognitive abilities and he/she stated "It's difficult to ascertain in a patient who continually shrieks." The ED RN provided no further information related to the patient's cognitive abilities.
* The ED RN stated "at some point" the patient's screaming increased significantly and he/she decided to put the patient outside in the ambulance bay because he/she "was screaming to the point of disrupting the entire ED." The ED RN stated he/she was not sure why the patient was screaming. He/she stated the patient had PTSD and a "psychiatric component and a quasi-behavioral component" that may have contributed to the screaming.
* The ED RN stated he/she told the patient he/she was going to take him/her outside and the patient continued to scream. The ED RN stated he/she then took the patient, who was on a gurney, out the ED doors, to the outside ambulance bay.
* The ED RN stated the temperature outside was "in the low 80's." He/she thought the patient had a sheet and blanket over him/her and was wearing a gown and a black silk-like hood on his/her head and part of his/her face.
* The ED RN stated after taking the patient outside, he/she came back inside the ED and had discussions with the PA and "several nurses" including the CN, and they "agreed collectively" to leave the patient outside.
* The ED RN stated the patient continued to scream while outside until he/she was discharged.
* The ED RN was asked how he/she normally managed patient's with disruptive behaviors. He/she stated "Everything starts with an assessment." The ED RN stated he/she would normally try "talk down methods," offering meds, offering a blanket, listening, and consider moving the patient to the psychiatric area in the ED. However, the ED RN confirmed the record contained no documentation that reflected he/she assessed the patient secondary to the patient's significantly increased and continued screaming. The ED RN stated he/she offered the patient Zyprexa medication but the patient refused. He/she confirmed the record contained no documentation of any other interventions attempted to address the patient's behaviors.
* The ED RN confirmed the record contained no care plan to address the patient's screaming.
* The ED RN confirmed the record contained no documentation that he/she assessed the patient and determined the patient, was safe to be outside alone with no way to contact staff.
* The ED RN stated there was no call system in the ambulance bay or any other way for the patient to notify staff for help if needed, including for an emergency. The ED RN stated the only way the patient could get staff assistance was to scream.
* The ED RN was asked if he/she completed an incident report secondary to the situation of putting the patient outside alone and he/she stated "I should have filed a [incident report] but I did not."

6. During an interview with the ED CN on 08/07/2019 at approximately 1200, he/she provided the following information related to Patient 14's 07/28/2019 ED visit:
* The ED CN stated he/she remembered the patient and acknowledged he/she knew the ED RN took the patient outside and left him/her in the ambulance bay. He/she stated "I saw [him/her] being wheeled out by [ED RN]."
* The ED CN stated the ED RN took the patient outside because the patient was yelling. He/she stated "I recall [his/her] non stop yelling out."
* The ED CN stated he/she could see the patient on a video monitor at the nurse's station and through the window of the ED doors leading to the ambulance bay. However, he/she acknowledged he/she could not see the patient and did not monitor the patient either by video or through the window during the entire time the patient was outside.
* The ED CN stated the only way the patient could get help while outside was by yelling. However, he/she stated the video monitor did not have audio and he/she could not hear the patient it he/she screamed for help.
* The ED CN confirmed the patient was quadriplegic and there was no call system or other way the patient could get staff assistance while outside, including if he/she needed assistance for an emergency.

7. During tour of the ED on 08/07/2019 beginning at 1325 with multiple hospital staff including ACC, EDD, and ED ANM, the following observations were made and confirmed with staff present:
* The ED exit doors leading to the outside ambulance bay were approximately 27 feet from the ED CN desk area at the nurse station. The upper half of the doors were glass. The lower half of the doors were solid and could not be seen through. The ED ambulance bay had a covered sidewalk next to the building with ambulance parking spaces directly next to the sidewalk.
* Staff present during the tour stated the ED doors were locked from the outside and required a key pad entry or badge swipe to enter the ED.
* Staff present during the tour stated an ED staff initially took the patient out the ED doors to an area in the ambulance bay to the left of the doors that was not visible through the doors from the nurse's station. Staff stated that sometime thereafter, an ED staff took the patient to a second area in the ambulance bay that was approximately 23 feet from the outside of the ED doors. From the nurse's station the patient was visible only from the left side of the nurse station and was not visible from the area where the ED CN normally sat.
* No call system or medical supplies were observed in or near the ambulance bay where the staff stated the patient was left.

8. An interview was conducted with the DTED on 08/07/2019 at 1300 at 1650 related to Patient 14's ED visit. The DTED provided the following information:
* The DTED stated that instead of putting the patient outside, he/she expected ED staff to contact the AOC to de-escalate the patient and "to help problem solve" the situation, or "would have liked to see" an RN stay in the patient's room with the patient until the patient was discharged. However, he/she stated "This wasn't done."
* The DTED confirmed there was no documentation in the medical record that reflected the PA was aware that ED staff took the patient outside, or that the PA assessed the situation and intervened.

9. Review of incident log documentation reflected no evidence of an incident report and investigation related to patient 14's ED visit on 07/28/2019.

10. During an interview with ACC on 08/06/2019 at 1450, an incident report and investigation related to the incident involving Patient 14 on 07/28/2019 was requested. The ACC stated "Risk was checking and they haven't found anything." During an interview with the CRM on 08/06/2019 at 1600, the CRM confirmed no investigation had been completed. The CRM stated he/she knew "nothing about that." No incident report or investigation was provided.

The hospital failed to ensure hospital staff intervened and ensured Patient 14 was appropriately supervised, monitored and maintained in a safe environment, and failed to ensure the staff assessed the patient including his/her uncontrollable and increasing behaviors, pain, physical abilities, vital signs and discharge planning needs and provided appropriate interventions. This failure resulted in potential or actual harm to Patient 14 as it led to the patient, who was quadriplegic, being left alone outside in July summer temperatures, unsupervised and unmonitored for periods of time with no way to seek staff if needed, including if he/she experienced an emergency; and then discharged home without conducting an appropriate discharge planning assessment in accordance with hospital policies when there was no one at home to care for the patient.

Based on observation, interview, review of recorded video footage, review of medical record documentation for a quadriplegic patient (Patient 14), review of event documentation for 7 of 9 patients who received hospital services (Patients 1, 2, 3, 4, 5, 14, and 15), review of grievance documentation for patients selected from the grievance log, and review of policies and procedures, it was determined that the hospital failed to enforce policies and procedures to ensure that all components of an effective abuse prevention program were evident, including clear and complete investigations of abuse or neglect, as defined by CMS, to ensure those incidents and events did not recur.
* Hospital staff failed to ensure patients were provided care in a safe environment. Patient 14, a quadriplegic patient, was left alone outside, unmonitored and unsupervised for periods of time with no way to contact staff if needed, including for emergencies and then discharged home where there was nobody to care for the patient; and an investigation and follow up actions were not conducted to ensure these events did not recur.
* The hospital failed to conduct thorough and timely investigations to allegations of abuse and neglect including those with potential or actual harm related to patient behaviors, elopement, medication errors, skin care, and ostomy/incontinence management; and failed to develop follow up actions to ensure they did not recur.

The CMS Interpretive Guideline for this requirement at CFR 482.13(c)(3) reflects "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Further, the CMS Interpretive Guideline reflects that components necessary for effective abuse protection include, but are not limited to:
o Prevent.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

Findings include:

1. The policy and procedure titled "Patient, Visitor, and Employee Incident Reporting," dated last revised "07/17," was reviewed. It stipulated:
* "Objectives...To provide a mechanism for reporting and documenting incidents inconsistent with the routine operations of the facility or care of a patient...To support the review of incidents for risk management, patient safety and improvement opportunities..."
* "Adverse event - An untoward, undesirable, and usually unanticipated event caused by patient care, treatment or services. An adverse event may not be caused by or related to an error."
* "Incident - Any event which may involve...actual injury or potential injury to an individual...The definition of the term incident may but does not always reflect an error, breach in the standard of care or any system or process or adverse event."
* "Any Legacy staff member or member of the Medical Staff...Submits a PSA, as soon as possible, preferably before the end of the shift...If you need immediate help with a patient or visitor event or the event requires action right away, do not wait. The PSA may not be seen right away, or what you think needs to happen may not be evident to others. Talk to the person in charge of your unit, the physician, the nursing supervisor the (sic) risk manager."
* "The Manager of the responsible unit...Receives an email notice when a PSA is submitted...Will assure review of the issue reported and will initiate the collection of additional relevant information, from anyone or any source who may have pertinent information...The Manager will investigate and document the investigation and actions taken to resolve the event....The Manager may take a variety of actions including reporting the issue up the chain of command...Based on the investigation the Manager will change the report status from NEW to OPEN, within 72 hours of the incident and...The Manager will assure the event is resolved and the status changes to CLOSED within 2 weeks."
* "...Statistics and other information derived from the reports may be used to identify trends and implement patient safety, risk reduction and quality improvement programs."

2. Policies and procedures provided in response to a request for policies and procedures related to management of patient behaviors included:

a. The policy and procedure titled "Code Gray: Emergency Safety/Security Assistance," dated last revised "10/18," was reviewed. It stipulated:
* "Staff will initiate a Code Gray for any safety/security emergency involving violent or aggressive behavior, including the application of restraints."
* "When a safety/security emergency develops, staff will call [number] to request a Code Gray response by the Safety/Security Department...Upon arrival, Safety/Security will meet with medical/clinical staff, as the situation allows, to develop a plan of action. In all clinical situations, medical staff will assume the role of 'Code Leader'."
* "The Nursing Supervisor, other staff, and/or local law enforcement may be requested by Safety/Security as needed."
* "Responding staff will be designated as a Code Gray Team and will perform such duties as may be directed by the Code Leader."
* "In the event that de-escalation techniques are not effective in managing aggressive patient behavior, and the emergency requires a patient restraint, the patient's nurse or the Nursing Supervisor will assess indicators of a medical crisis, authorize the restraint and relay all relevant medical, social, and psychiatric information to the team unless this delay poses a significant safety risk to the patient and/or staff."
* "The Safety/Security Officer(s) on the scene will work with medical/clinical staff and the Code Leader to give specific team assignments to safely and expediently secure the patient. The Code Leader will assign the following tasks to team members...Assign staff to designated body parts: two legs, two arms, head, one or two trunk...Assign other tasks...Assess the need for backup staff and dismiss extra staff...Assure use of personal protection equipment...Give direction for each step of process, clearly and specifically to staff, (may tell patient what is occurring and use that to direct staff)...Give the signal 'take parts' to staff, assuring that all parts are secured simultaneously...Check restraints to make sure they are safe and secure before staff releases hold...Give the order to 'release' when appropriate...Lead debriefing session...it is the responsibility of the patient's nurse and/or provider to select the appropriate restraint device...Upon mitigation of the emergency, the Code Leader will be responsible for conducting the debriefing with all staff involved...Safety and Security will be responsible for documenting the incident..."

b. The policy and procedure titled "Use of Force," dated last revised "07/19" was reviewed it stipulated:
* "All staff should be aware that patients are there for treatment not punishment. Accordingly, it is essential that they understand the importance of de-escalation interventions in any situation. Absent of imminent threat that requires immediate use of force, MOAB, verbal de-escalation, and other interventions must be utilized in such situations before force is applied."
* "This policy applies to Legacy Health Safety/Security Officers in the performance of their job duties while involved in a law enforcement action, such as making a private person's arrest or if it is necessary to use self-defense techniques to protect themselves or others from injury or death. All other situations requiring the use of force to control a patient, such as assisting medical/clinical staff with the application of restraints, will be performed under the supervision of a medical or clinical staff member."
* "Security Officers shall use only the amount of force that reasonably appears necessary given the facts and circumstances perceived by the Officer at the time of the event ..."

3. Regarding Patient 1:

a. An incident document for an incident involving Patient 1 was reviewed. A "Current Summary" with event date and time 04/07/2019 at 0701 was reviewed. The incident was categorized as "Abuse or Assault Allegation." The "Severity Level (Reported)" reflected "...Harm - Temporary - Minor Treatment." The "Brief Factual Description" reflected "On 4/7...[patient] from room 12 or 13...I stood there watching. [He/she] did throw a wadded up blanket at me during [his/her] sprint. [This] appeared to throw off [his/her] trajectory which caused [him/her] to run into the Plexiglas gown dispenser...It shattered into tons of pieces...the tech was also chasing this pt...did a running leap tackling the pt. [The] pt fell to the floor...various other ER staff (all [male/female]) and I think one security guard tried to subdue the pt. I could see the pt was bleeding a bit through a preexisting bandage to [his/her] left forearm...pt began to attempt to wiggle out of the [hold]...[tech] again took the pt to the ground. I thought pt hit [his/her] head on the ground, but per [tech] that did not happen. When [tech] was asked later why [he/she] was so invested on stopping the pt, [his/her] response was something along the lines of 'because no one has escaped yet on my watch. don't (sic) want to hurt my record'. All in all, it was overly aggressive...unnecessary to be so physical. the pt easily could of had [his/her] head thrown through the glass door. it (sic) the concern is truly about the well being of the pt, then that was not reflected in the take down." The "Attachments" reflected "No Attachment." The "Follow-Up Actions" reflected "This will be the main file. This [report] is not related to the earlier incident [report]...04-19-2019...Manager Review...This incident has been investigated by the ED MGMT, security, HR and Risk. [Report] can now be closed." The "File State" reflected "Closed." An investigation summary document provided reflected interviews with staff were conducted and the conclusion was "Not Substantiated" and "It was determined that [tech] acted in an unsafe manner but did not intentionally harm the patient. [He/she] was acting on assumptions, shared by coworkers, that patients should be prevented from eloping using whatever measures seem appropriate." The only documentation of follow up actions were "Planned wrap up...Collaboration to establish performance expectations for nursing staff related to elopement attempts." The "Discussion/resolution date" was 08/02/2019.

The documentation lacked a thorough and timely investigation. For example:
- There was no documentation that reflected if staff involved in the incident used appropriate interventions to manage the patient's behaviors and elopement attempt in accordance with hospital policies and procedures.
- There was no documentation that reflected whether an assessment of the patient's arm injury was conducted and treatment provided if needed.
- There was no documentation that reflected whether the patient's head was injured secondary to the reported "I thought pt hit [his/her] head."
- The resolution date was 08/02/2019, four months after the incident.
- The "Planned wrap up" reflected "...Collaboration to establish performance expectations for nursing staff related to elopement attempts," but did not indicate when this would occur, what the performance expectations entailed, and did not indicate whether ED tech staff would be included in the planned wrap up.

Additional incident documentation for the same incident involving Patient 1 on 04/07/2019 at 0701 was reviewed and included an investigation summary and interview documents. Those were unclear and also lacked a thorough and timely investigation of the incident and follow up actions. For example, investigation interview documents related to the incident unclearly reflected the incident occurred on 04/07/2019 at 0035.

There was no further follow up or corrective actions identified for Patient 1 and any other patients who may experience similar incidents.

b. An incident document for another incident involving Patient 1 was reviewed. A "Current Summary" with event date and time 04/07/2019 at 0035 was reviewed.
* The incident was categorized as "Abuse or Assault Allegation."
* The "Brief Factual Description" reflected "While reviewing video footage, I saw a patient restraint occur where one emergency department staff member climbed on top of the gurney and straddled the patient, appearing to use [his/her] body weight to help control the patient and hold [him/her] down on the gurney...This action appears unnecessary and unsafe to both the patient and the staff member who ended up standing on the gurney at one point. I believe the staff member is an ED Tech...It does not appear the patient's level of resistance required this action...The incident is also captured on...camera..."
- "Contributing Factors (Reported)" reflected "Action by Patient/Resident," "Organization - Procedures Not Followed," and "Task...Training Issue." The "Follow-Up Actions" reflected "04-09-2019...Manager Review...Details...Is this an allegation or a deficiency in training on behalf of the ED Tech? Is [sic) this is an allegation can you arrange interviews with the security officers that were present and we can start there?..04-10-2019...EDT shown in video climbing onto gurney was [name]...04-11/2019...Abuse investigation underway...Investigation complete. All notes have been submitted to Risk for final report." Interview documents with incident date and time 04/07/2019 at 0035 were provided and reviewed.

The documentation lacked a thorough and complete investigation including but not limited to:
- No identification of what the "Procedures Not Followed" were.
- No information related to what "Training Issue" was determined and if it was addressed or not addressed.
- No documentation of whether the allegation of abuse was substantiated or not substantiated.
- No clear definitive outcome and further follow up or corrective actions identified for Patient 1 and any other patients who may experience similar incidents.

4. Regarding Patient 2:

a. An incident document for an incident involving Patient 2 was reviewed. A "Current Summary" with event date and time 04/10/2019 at 0606 was reviewed. The incident was categorized as "Abuse or Assault Allegation." The "Brief Factual Description" reflected "[Patient] was being told by ED Tech...that [he/she] was being discharged... [Patient] violently grabbed the paperwork from [ED Tech]. [Patient] stood from the bed and made a motion to walk out of the room. [ED Tech] then shoved [patient] away from [him/her] towards the sink. [Patient] came back towards the door, then towards [ED Tech], pointing [his/her] finger at [him/her]. As this occurred, [ED Tech] turned [patient] around, grabbed [him/her] and put [him/her] in a sort of bear hug hold and threw [him/her] over [his/her] shoulder to the ground. After some fighting on the ground, they stood up together and [ED Tech] held [patient] out the door and into the hallway...[patient] was then escorted off property." The "Follow-Up Actions" reflected "Investigation underway, ED leadership collaborating with Risk Management and Security to follow up...[Tech] was interviewed by HR, Risk and ED MGMT." The "File State" reflected "Closed." Investigation summary documentation provided with the incident document unclearly reflected the incident occurred at 0630. The investigation summary documentation reflected interviews with staff were conducted and the conclusion was "Not Substantiated" and "[Tech] was not found to have used excessive force and the allegation of physical abuse was not substantiated." The only follow up actions were "Planned wrap up...Coaching for staff to wait until appropriate support available and not get boxed into room - Keeping exit available...at next opportunity." The "Discussion/resolution date" was blank.

Two other incident documents provided for the same incident involving Patient 2 on 04/10/2019 at 0606 were provided and reviewed. Those incidents unclearly reflected the incident occurred on 04/10/2019 at 0630.

The documentation lacked a thorough and timely investigation and follow-up actions. For example:
- The documentation reflected "[Tech] was not found to have used excessive force." However, there was no documentation that reflected whether applicable policies and procedures related to managing patient behaviors were appropriately carried out. The documentation additionally reflected "Planned wrap up...Coaching for staff to wait until appropriate support available and not get boxed into room - Keeping exit available." There was no documentation that reflected whether the identified "Coaching for staff" to be done "at next opportunity" was carried out. There was no further follow up or corrective actions for the incident involving Patient 2 and any other patients who may experience similar incidents.

5. Regarding Patient 3:

a. An incident document for an incident involving Patient 3 was reviewed. A "Current Summary" with event date 05/12/2019 at 0650 was reviewed. The incident was categorized as "elopement." The "Severity Level (Reported)" reflected "Safety Environment." The "Brief Factual Description" reflected "pt given oxycodone at 0625...About 0650...was sitting at nurses station near pt room. this RN noticed pt needed an EKG...[tech] entered room at 0653 and came immediately out reporting pt not in room...looked for pt in lobby...restrooms...outside...not found...has IV in upper right shoulder area" This RN made a report about elopement." The "Follow-Up Actions" reflected only "Patient not a hold. Left before treatment was completed without telling staff of [his/her] intention to leave. PPD was called since pt still had IV in place...Attachments: No Attachment." The "File State" reflected "Closed."

The documentation lacked a thorough investigation. For example:
- There was no documentation that reflected whether applicable policies and procedures related to patient elopement were implemented.
- There was no documentation that reflected whether the patient had been evaluated and determined to be at risk for elopement prior to the incident.
- There was no documentation that reflected when staff last saw the patient.
- There was no documentation of the patient's condition prior to elopement with respect to recent narcotic medication administration and need for an EKG.
- There was no documentation that reflected whether video footage of the incident was available and reviewed.
There was no further investigation or corrective actions for the incident involving Patient 3 or any other patients who may experience similar elopement incidents. During an interview with the EDD on 08/08/2019 at 1100, he/she confirmed there was no further investigation documentation.

6. Regarding Patient 4:

a. An incident document for an incident involving Patient 4 was reviewed. The "Current Summary" with event date and time 05/12/2019 at 1840 was reviewed. The incident was categorized as "Specific Event Type Other (please specify)" and "Other Specific Event Type Patient assaulted ER staff." The "Severity Level (Reported)" reflected "...Harm - Temporary - Minor Treatment." The "Incident Details" reflected "ER Patient [Patient 4] kicked Legacy Emanuel ER RN [name] and bit Legacy Emanuel Security Officer [name]. Event occurred while walking patient to the restroom for an ambulation trial. The patient became spontaneously volatile and aggressive and lashed out...and kicked...then clenched fists and attempted to punch and scratch...Security arrived and the patient continued to try to kick, punch, scratch and bite security. The patient then successfully bit [hospital staff name]. Portland PD called. Both [hospital staff name] and [hospital staff name] checked into ER. The "Contributing Factors (Reported) reflected "Action by Patient/Resident," and "Willful Misconduct." The "Immediate Actions" reflected "Other" and "Treatment Provided." The "Follow-Up Actions" reflected "Requesting video footage to assist RN who is pressing charges." The "Feedback to Reporter" reflected "...I have requested video footage and have asked that the patient be banned from the facility except for emergencies since [he/she] has a history of assaulting staff." The "File State" reflected "Closed."

Another incident document for the same incident involving Patient 4 on 05/12/2019 was provided and reviewed. The documentation was categorized as "Employee Work Incident." The "Incident Details" reflected "On 5/12/2019 at 1836...RN...was helping [patient] walk to the restroom...[patient] began to kick RN...I was watching from the hallway and sprinted down...opened the restroom door and began to pull [patient] from the restroom. While we were removing [patient] I had control of [his/her] arms, [he/she] lurched forward and bit me on the hand. I let go of [patient] and [he/she] fell to the floor (sic) I then went back on top to restrain [his/her] hands and head. Security Officers...were there at this time and helped us hold [patient] to the ground...Security Officer [name] restrained the arms and Security Officer [name] restrained the legs...[RN] was on scene and said that we would place [patient] in restraints and place [him/her] on a gurney...After the event both myself and RN...checked into the ED to be evaluated...No other injuries or complaints were raised after the event. The patient was transferred to ED [room number]." The "Employee Event - Manager Review" section reflected "Actions Taken by Manager Policy/procedure reviewed." The "File State" reflected "Closed."

The documentation lacked a thorough investigation and follow up actions. For example:
- The documentation reflected "Actions Taken by Manager Policy/procedure reviewed...It's hard to avoid sudden violence of patients. Video shows an ED staff member taking this patient to the restroom before [he/she] attacked [him/her] and security officers running to assist...the incident occurred in a small restroom area and security had limited space to work. It is very difficult to avoid being bit in that circumstance. Will be evaluating PPE to see if there are gloves that will allow security officers to apply restraints and perform other tasks while helping to avoid painful bites by combative patients." However, the documentation did not include if applicable policies and procedures related to management of patient behaviors, application of physical restraints, or other applicable policies related to care and management of patient behaviors were carried out.
- The documentation reflected "...Harm - Temporary - Minor Treatment" and "No other injuries or complaints were raised after the event." However, it was unclear if that pertained to the patient or the employee. It was unclear if the patient was harmed as a result of the incident.
There was no further investigation or corrective actions for the incident involving Patient 4 or any other patients who may experience similar incidents.

7. Regarding Patient 5:

a. An incident document for an incident involving Patient 5 was reviewed. The "Current Summary" with event date and time 05/28/2019 at 1342 was reviewed. The incident was categorized as "Employee Work Incident" and "Other Specific Event Type violence in workplace by patient against clinical staff." The "Severity Level (Reported)" reflected "Harm - Temporary - No Treatment." The "Brief Factual Description" reflected "This RN not involved in pt's care; pt found to be standing at end of stretcher w/ unsteady gait/stance; pt apparently had OD'd prior to arrival; pt yelling about needing a 'triage nurse.' [Patient] not redirectable and appeared at risk of falling and injuring self; [patient] assisted back into stretcher; [patient] began to kick, swing clenched fists in air; [patient] then spit directly in this writer's face; no injury occurred; documenting this strictly for violence in workplace." The "Parties Involved/Notified/Witnesses" section reflected the name of an individual and indicated the individual's role in the incident was "Witness." The "Attachments" section reflected "No Attachment." The "Follow-Up Actions" reflected "Review...05-28-2019...Manager Review...05-29-2019...Director Review." The "File State" reflected "Closed."

The documentation lacked a thorough investigation and follow up actions. For example:
- There was no documentation that reflected if applicable policies and procedures related to patient behaviors and/or other applicable policies related to patients were implemented.
- The documentation reflected "[patient] began to kick, swing clenched fists...no injury occurred; documenting this strictly for violence in workplace." It was unclear if no injury occurred to the RN involved in the incident or the patient. It was unclear if the patient was injured as a result of the incident.
- The documentation reflected the name of a witness but did not include any information about what the "Witness" witnessed.
There was no further investigation or corrective actions for the incident involving Patient 5 or any other patients who may experience similar incidents.

b. An incident document for another incident involving Patient 5 was reviewed. The "Current Summary" with event date and time 05/28/2019 at 1730 was reviewed. The incident was categorized as "Employee Work Incident," "Type of Concern or Incident Violence or Threats" and "Type of Concern or Incident Subtype Violence with Physical Injury." The "Incident Details" section reflected "Pt was getting out of bed and I was attempting to redirect the pt back to bed when the pt began screaming for [his/her] clothes then charged me. Pt ripped the monitor off the wall then struck me with closed fist to R side of my face and scratched me on the left side of the neck. After disengaging from the pt the pt picked up an IV pump and threw it at me, then picked up a stool and threw that at me. While I was attempting to clear the equipment from the doorway the pt spat on me. I was then able to get the door closed and pt began to strike and kick the door. At this point security arrived and pt was placed in restraints." The "Follow-Up Actions" reflected "Date 05-29-2019...Review...Follow-up By [name]...Followup (sic) Time 10:40...Director Review...Followup Time 11:23." The "Details" sections were blank. The "Attachments" sections reflected "No Attachment." The "Employee Event - Manager Review" section reflected "I followed up with employee today in person. [He/she] did not want to check in as [his/her] scratch was minimal. I offered assistance and resources as well. What do you think could have been done to prevent this incident? Patient volatile and escalated quickly. Hard to predict FYI s (sic) have been added to the chart. PPD was called and came and took a report. Patient was not arrested due to being sedated after the event...Manager Review of Report Complete?..Yes." The "File State" reflected "Closed."

The documentation lacked a thorough investigation and follow up actions. For example:
The documentation did not include if applicable policies and procedures related to management of patient behaviors, application of physical restraints, and/or other policies, if applicable were carried out.
The documentation reflected "Violence with Physical Injury" and "[Patient]...struck me with closed fist...began to strike and kick the door...pt was placed in restraints." It was unclear if the patient or the employee was injured as a result of the incident. There was no documentation that reflected if the patient was assessed for injuries as a result of the incident.
The documentation reflected "to prevent this incident...Patient volatile and escalated quickly. Hard to predict...FYI s (sic) have been added to the chart." It was unclear what was meant by "[FYIs] have been added to the chart."
There was no further investigation or corrective actions for the incident involving Patient 5 or any other patients who may experience similar incidents. During an interview with the CNO on 08/08/2019 at 1100, he/she confirmed there was no further investigation documentation.

8. Regarding Patient 14:

a. Refer to the findings identified under Tag A144 related to the hospital's failure to conduct an investigation and follow up actions for Patient 14, a quadriplegic patient who was taken outside by hospital staff and left alone unsupervised and unmonitored for periods of time, with no way to notify staff if needed, including for emergencies; and then discharged home with no one at home to care for the him/her.

b. An incident document for another incident involving Patient 14 was reviewed. The document was categorized as "Specific Event Type Drug Timing," "Drug Timing Duration," and "Severity Level (Reported)...Harm - Temporary - No Treatment." The "Current Summary" with "Event Date" 07/07/2019 reflected "Baclofen was re-ordered from home med list...with end time after 15 doses (continued from outpatient prescription). Order was verified by pharmacy with end time. Baclofen fell off the MAR as 'completed.' Patient went without Baclofen for 4 days before complaining to RN that they have not been receiving the medication. RN contacted pharmacy and error was caught..." The "Follow-Up Actions" reflected "07/16/2019...this is an error on my part. is (sic) there a way to see this easily when ordering on med rec? we (sic) are encouraged to resume home meds...07/17/2019...Adding IS, unsure who is the process owner that set's (sic) an auto-expire for outpatient medications...07/18/2019...Patient had four outside medication orders found in Care Everywhere (baclofen, dronabinol, dantrolene, and Strattera) pulled into [his/her] PTA medication list on admission...Each of these outside prescription orders had an end date...Each of these end dates carried forward into the inpatient admission orders unbeknownst to our staff...Suggest re-entering these meds onto the PTA med list as a patient-reported med, so providers know these were active meds prior to admission." The documentation reflected "Severity Level...No Harm-Reached Patient-No increased monitoring."

An incident document for the same incident involving Patient 14 was reviewed. The document was categorized as "Specific Event Type Drug," "Drug Omitted," and "Severity Level (Reported)...Harm - Temporary - No Treatment." The "Current Summary" unclearly reflected the "Event Date" was 07/16/2019. The documentation reflected "Patient had Baclofen ordered on admission to match [his/her] OP script. The order was entered into epic as a continued script, causing it to drop off and discontinue without notice on 7/12. Patient did not receive Baclofen TID x 3 days. [He/she] reported increased pain due to this error, and impaired trust in our care." The "Follow-Up Actions" reflected "07/16/2019...have addressed this on another Icare. would (sic) like help to see this better when we admit patients...07/17/2019...Appreciate any input from pharmacy. Have added IS to this report as well; unsure who is the process owner that determines the duration of an outpatient script that's continued when individual is admitted as an inpatient...07/17/2019...I have asked [three names] for further review and troubleshooting...07/20/2019...follow up from pharmacy...stop dates were generated as part of outpatient prescription when crossed over to inpatient (working as designed). Added [name]...to see if there are known items to communicate with OP providers that may be helpful for IP staff to understand...Attachments...No Attachment...End of Form."

The documentation lacked a clear and complete investigation and follow up actions. For example:
- The documentation reflected "Patient went without Baclofen for 4 days before complaining to RN..." and "Patient did not receive Baclofen TID x 3 days." It was unclear what dates, how many days, and how many doses of medication the patient missed.
- The documentation r

Based on observation, interview, review of recorded video footage, review of medical record documentation for a quadriplegic patient (Patient 14), review of event documentation for 7 of 9 patients who received hospital services (Patients 1, 2, 3, 4, 5, 14, and 15), review of grievance documentation for 5 of 5 patients selected from the grievance log (Patients 6, 8, 9, 12 and 14), and review of policies and procedures, it was determined that the QAPI program was not effective to ensure the provision of safe and appropriate care to patients in the hospital that complied with the Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.

Based on interview, review of documentation in the medical record of 1 of 1 ED patient who was quadriplegic and received nursing services (Patient 14), and review of policies and procedures and other documents it was determined that the hospital failed to ensure the RN supervised and evaluated the patient to ensure the provision of safe and appropriate care in accordance with hospital policies and procedures including:
* Patient supervision and monitoring in a safe physical environment;
* Vital signs;
* Physical functioning;
* Pain assessments and monitoring;
* Patient behaviors; and
* Discharge planning.

Findings include:

1. Refer to the findings cited at Tag 144, CFR 482.13(c)(2) Patient's Rights - Standard: Care in a Safe Setting. Those findings reflects the hospital's failure to ensure the RN evaluated and supervised Patient 14 to ensure the provision of safe and appropriate care in a safe environment.