HospitalInspections.org

Based on review of medical record, document review and interview, the facility did not provide each Medicare beneficiary (or his/her representative) who is an inpatient, with the standardized notice, " An Important Message from Medicare " (IM), as required. This was evident in 3 of 3 applicable medical records reviewed (#8, #9 & #10).

Findings include:
Review of medical record for patient # 8, an 80 year old patient and a Medicare Beneficiary, was admitted to the facility on 6/11/2016 and she was discharged on 7/12/2016. A copy of the IM form was not found in the patient ' s medical record.

Review of medical record for patient #9, on the unit, on 7/21/2016, the patient 65 year old was admitted on 7/19/2016. A copy of the IM within 2 days of admission was not found in the record.

A similar finding was identified in the medical record for patient # 10, a Medicare Beneficiary, which lacked a copy of an IM form in the record.

During the tour of the unit on 7/21/2016, Staff D was interviewed. The staff stated that on admission, a patient is given a handbook titled "Patient Family Orientation Information " . The staff stated that patient rights and responsibilities are listed in this handbook. This staff member was asked when is an IM form given to Medicare Beneficiary patients but this staff member was not familiar with this document.

Staff A was interviewed on 7/21/2016. This staff member stated that the facility does not provide patient/patient representative with IM forms.

The facility's policy and procedure (Section #: CL-413) titled, " Patient/Family Complaint and Grievances, " revised on March 31, 2016 was reviewed. This policy indicated that "a patient is provided notification on admission of his or her rights as a Medicare " An Important Message from Medicare " ". The facility is not following this policy.

Based on interview, review of Complaint log, and Patient Complaint Process, it was determined that the facility did not provide each patient /patient representative with written notice of its decision regarding the resolution of his/her grievances. This was found in one of one grievance records reviewed.

Findings include:

Staff A was interviewed on 7/18/2016. This staff stated that the facility did not have any grievances.
The facility ' s Complaint Log covering the period from 5/15/15 to 6/8/16 was reviewed on 7/19/2016. It was noted that a grievance that the facility received on 5/30/2016 was classified as a complaint.

It was documented on the log that the complainant filed a complaint with the facility on 5/30/2016 alleging that another patient touched her arm and the complainant did not feel safe. It was documented on the complaint log that the complaint was referred to Risk Management. The Risk Manager met with the patient and the issue was resolved. The patient did not want to lodge further complaint. The complaint log indicated that the case was closed on 6/1/2016. The patient was not provided with a written response describing the steps taken to resolve this grievance.

The facility's policy and procedure (Section #: CL-413), titled " Patient/Family Complaint and Grievances, " revised on March 31, 2016 was reviewed. This policy defines a grievance as: " A grievance is a formal request, oral or written, from a patient or representative to consider a complaint determination. "
The Center for Medicare and Medicaid Services (CMS) defines " a "patient grievance" as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient ' s representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. "

The hospital's policy did not meet the regulatory requirement for the definition of a grievance. This grievance was classified as a complaint but met the regulatory definition of a grievance, and therefore the complaint should have generated a written response.

Based on observation the facility failed to provide a physical environment that conforms to the provision of care in a safe setting.

The findings are:

1) During a tour of the facility on July 19, 2016 at approximately 11:00 am, ligature hazards were observed on the fourth floor inpatient unit including:

a) Cabinets in the activities room have protruding handles that would allow a ligature to pass through them. A patient was observed alone in the room at this time.

b) In patient restrooms (excluding those in patient rooms 4623 and 4624) sink faucet handles, shower faucet handles, and toilet plumbing pipes are of a type that would allow a ligature to be tied to them.

2) During a tour of the facility on the same date and time as above, a wide screen television was observed to be located unsecured on a table top in the patient activities room. Unsecured items of this type may be used as a weapon by an agitated patient.

3) During a tour of the facility on July 18, 2016 at approximately 11:45 am, outlets in the inpatient fourth floor unit were observed to be lacking tamper resistant features required by FGI 2.5-8.3.6.1.

4) During a tour of the Audubon outpatient site on July 19, 2016 at approximately 1:20 pm, the registration counter was observed to be lacking an ADA accessible counter in accordance with Americans with Disabilities Act Guidelines.

Failure to provide the necessary safety features in inpatient psychiatric facilities may negatively impact the safety of patients and staff.

These findings were verified by the Deputy Director of Administration, Plant Superintendent, and the Facilities Planner.

Based on document review and interview, the hospital does not have a full time employee who serves as the director of the food and dietetic services.

Findings include:
During interview with the food service director Staff C on July 18, 2016 at approximately 11:45 AM, she indicated that she works 60 % of the time and is at the hospital three days of the week.
Review of personnel file for Staff C on July 21, 2016, confirmed that she is a part time worker who works three (3) days per week and eight hours a day.
Therefore the hospital does not have a full time Food Service Director who is responsible for the daily management of the dietary services as required.

Based on interview and document review, it could not be verified that the hospital ' s utilization review (UR) plan in place meets all regulatory requirements.

Findings include:

The facility ' s Utilization Review (UR) Plan and UR committee minutes, for the year 2016, were requested from the facility ' s Regulatory Staff, on 7/18/2016 at approximately 10:30 AM. A copy of the Inpatient Utilization Review Plan revised on 2016 and Outpatient Utilization Review Plan for 2016 were submitted. However, Members of the UR committee and the UR minutes were not provided.
The staff members (A & E) were interviewed on 7/21/2016. They stated that this is a small facility and the Clinical Leadership and Quality Council committee members are also the members of the UR committee. These staff members were unable to provide the following information: The members of the UR committee, the dates the UR committee met, documentation of meeting attendance, and the agenda and copies of the UR meeting committee minutes.