HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital's Governing Body failed to:
- Ensure that the Chief Operating Officer (COO) effectively managed the hospital in order to meet applicable regulatory requirements. (A-0057)
- Provide the Patient's Bill of Rights when patients were admitted to the hospital. (A-0117)
- Contact the legal guardian (a person appointed by a judge to take care of and manage the property and rights of a person who is considered incapable of administering his or her own affairs) of a patient to obtain consent for treatment, and to advise them of the Patient's Bill of Rights. (A-0117)
- Ensure that all patients received their Patient's Rights notification that contained a phone number and address for lodging a grievance with the State Agency (SA). (A-0118)
- Ensure patients were informed of their rights to formulate an Advanced Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) when admitted to the hospital. (A-0132)
- Ensure the patient's code status (refers to whether or not a patient wants medical intervention if their heart or breathing stops) was visible in the medical record. (A-0132)
- Provide a safe setting for the care of patients with suicidal ideations (SI, thoughts of causing one's own death) on the Behavioral Health Unit (BHU) by ensuring that all ligature (anything which could be used for the purpose of hanging or strangulation) risks were removed. (A-0144)
- Immediately report and conduct a thorough abuse investigation for an allegation of sexual assault on the BHU. (A-0145)

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effect of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.12 Condition of Participation: Governing Body.

The hospital census was six.

Based on interview, record review and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital including accountability for the effective oversight of staff to comply with the requirements under 42 CFR 482.12 Condition of Participation (COP): Governing Body, and 482.13 COP: Patient's Rights. These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's document titled, "Board of Director Meeting Minutes," dated 03/16/21, showed that the Governing Body appointed one CEO who is responsible for managing the entire hospital and keeping the Board apprised of all necessary information.

The CEO failed to ensure compliance with the COP of Governing Body as evidenced by the ineffective management of the hospital that resulted in the failure to meet applicable regulatory requirements. (A-0057)

The CEO failed to ensure compliance with the COP of Patient's Rights as evidenced by failure to:
- Provide the Patient's Bill of Rights when patients were admitted to the hospital. (A-0117)
- Contact the legal guardian (a person appointed by a judge to take care of and manage the property and rights of a person who is considered incapable of administering his or her own affairs) of a patient to obtain consent for treatment, and to advise them of the Patient's Bill of Rights. (A-0117)
- Ensure that all patients received their Patient's Rights notification that contained a phone number and address for lodging a grievance with the State Agency (SA). (A-0118)
- Ensure patients were informed of their rights to formulate an Advanced Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) when admitted to the hospital. (A-0132)
- Ensure the patient's code status (refers to whether or not a patient wants medical intervention if their heart or breathing stops) was visible in the medical record. (A-0132)
- Provide a safe setting for the care of patients with suicidal ideations (SI, thoughts of causing one's own death) on the Behavioral Health Unit (BHU) by ensuring that all ligature (anything which could be used for the purpose of hanging or strangulation) risks were removed. (A-0144)
- Immediately report and conduct a thorough abuse investigation for an allegation of sexual assault on the BHU. (A-0145)

During an interview on 04/08/21 at 12:28 PM, Staff L, CEO, stated that she was responsible for the entire hospital and responsible for the oversight of the Governing Body and Patient's Rights.

Based on observation, interview, record review and policy review, the hospital failed to ensure a safe environment when the hospital failed to:
- Provide the Patient's Bill of Rights when patients were admitted to the hospital. (A-0117)
- Contact the legal guardian (a person appointed by a judge to take care of and manage the property and rights of a person who is considered incapable of administering his or her own affairs) of a patient to obtain consent for treatment, and to advise them of the Patient's Bill of Rights. (A-0117)
- Ensure that all patients received their Patient's Rights notification that contained a phone number and address for lodging a grievance with the State Agency (SA). (A-0118)
- Ensure patients were informed of their rights to formulate an Advanced Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) when admitted to the hospital. (A-0132)
- Ensure the patient's code status (refers to whether or not a patient wants medical intervention if their heart or breathing stops) was visible in the medical record. (A-0132)
- Provide a safe setting for the care of patients with suicidal ideations (SI, thoughts of causing one's own death) on the Behavioral Health Unit (BHU) by ensuring that all ligature (anything which could be used for the purpose of hanging or strangulation) risks were removed. (A-0144)
- Immediately report and conduct a thorough abuse investigation for an allegation of sexual assault on the BHU. (A-0145)

These failures had the potential to place all patients admitted to the hospital at risk for their health and safety. The cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

The hospital census was six.

Based on observation, interview, record review and policy review, the hospital failed to provide the Patient's Bill of Rights to four current patients (#1, #4, #5 and #6), and seven discharged patients (#15, #21, #24, #25, #26, #28 and #29) of 30 patient records reviewed. The hospital also failed to contact the legal guardian (a person appointed by a judge to take care of and manage the property and rights of a person who is considered incapable of administering his or her own affairs) to provide Patient's Rights information and obtain consent for treatment for one current patient (#4) of six current patients reviewed. These failures had the potential to prevent all patients and/or their guardians from understanding their rights as patients. The hospital census was six.

Findings included:

1. Review of the hospital's policy titled, "Patient Care Policy - Patient's Rights," dated 06/08/16, showed that:
- All patients should be made aware of their rights.
- A copy of the Patient's Rights should be posted in each unit.
- A signed copy of the Patient's Rights should be located in each patient's chart.
- Upon admission, the patient would be asked to review and sign their Patient's Rights.
- The Registered Nurse (RN) would document on the form if the patient refused to sign it.

Review of the hospital's policy titled, "Administrative - Emergency Guardianship Procedure for an Incapacitated Patient," revised 04/2018, showed that all decisions regarding patient care are to be directed to and approved by the guardian. These decisions would include consent for treatment, visitation, and any transfer of care.

Review of four current patients (#1, #4, #5 and #6) and seven discharged patients (#15, #21, #24, #25, #26, #28 and #29) of 30 patient records reviewed, showed that no Patient's Rights and Responsibilities were provided or explained to the patients or the patients' representatives.

Observation on the on 04/05/21 at 4:00 PM, showed no posted Patient's Rights signage within the patient care area of the Medical Unit.

During an interview on 04/05/21 at 4:00 PM, Patient #5, stated that there was no Patient's Rights discussion and he was not given any information related to Patient's Rights.

During an interview on 04/05/21, at 4:20 PM, Patient #6, stated that there was no Patient's Rights discussion and he was not given any information related to Patient's Rights.

During an interview on 04/05/21, at 4:10 PM, Staff E, Quality Director, stated that the Patient's Rights signage used to be posted on the unit; however, the previous hospital ownership had taken them all down and the current hospital ownership was rebranding them with their logo.

During an interview on 04/05/21 at 4:15 PM, Staff F, RN, Inpatient Services Director, stated that she thought registration staff discussed all Patient's Rights information during admission in the Emergency Department (ED).

During an interview on 04/05/21 at 4:30 PM, Staff G, Licensed Practical Nurse (LPN), stated that there used to be big packets of Patient's Rights information that was discussed with the patient and given to them to keep, but since the change of hospital ownership, those packets were gone.

During an interview on 04/05/21 at 4:40 PM, Staff I, RN, stated that nursing staff used to give the patients big packets of Patient's Rights information, but she thought registration staff gave them to the patient now.

2. Review of Patient #4's medical record on 04/05/21 at 4:10 PM, showed that the Consent for Treatment document and the Patient's Rights Acknowledgement page had no date, time, signature, or acknowledgement that Patient #4's legal guardian had ever been contacted in order for consent to be obtained or for the patient's rights to be explained.

During an interview on 04/05/21 at 4:10 PM, Staff B, RN, stated that:
- As part of the admission process, signatures, date, and time should be entered onto the Patient's Rights Acknowledgement and the Consent for Treatment forms.
- If the patient had a legal guardian, they should be contacted, and the same information documented on the forms.
- Patient #4's Consent for Treatment and Patient's Rights Acknowledgement forms were not completed.

During an interview on 04/08/21 at 10:40 AM, Staff Z, Interim Chief Nursing Officer (CNO), stated that she would expect the admitting nurse to contact a patient's legal guardian to obtain consent for treatment, review the Patient's Bill of Rights, and document these in the medical record.

During an interview on 04/08/21 at 12:30 PM, Staff L, Chief Executive Officer (CEO), stated that she would expect every patient to receive a copy of the Patient's Bill of Rights, and that nursing staff would contact a patient's legal guardian to obtain consent for treatment, review the patient's rights, and document these in the medical record, along with the date and time.

The hospital failed to ensure that patients were informed of their rights when they failed to communicate their rights verbally, or through alternative means such as posted signage or written materials, and when they failed to contact the legal guardian to review the patient's rights and obtain consent for treatment.



39147

Based on observation, interview and record review, the hospital failed to ensure that two current patients (#5 and #6) of five current patients received or reviewed their Patient's Rights notification that contained a phone number and address for lodging a grievance with the State Agency (SA). This failure had the potential to affect all patients by preventing them from knowing their rights as patients. The hospital census was six.

Findings included:

1. Review of the hospital's policy titled, "Patient's Rights," dated 06/08/2016, showed that a patient had a right to know the mechanism for initiation, review and resolution of complaints. This included contacting the department supervisor or the administrator on call and/or contacting the Missouri Patient Protection and Advocacy Agency at the Missouri Department of Health.

Review of the hospital's document titled, "Patient's Rights and Responsibilities," contained no phone number or address for the patient to lodge a grievance with the SA.

Observation on 04/05/21 at 4:00 PM, showed no posted Patient's Rights signage within the patient care area of the Medical Unit.

During an interview on 04/05/21, at 4:00 PM, Patient #5, stated that the admission process did not contain a Patient's Rights notification with a phone number or address to lodge a grievance with the SA.

During an interview on 04/05/21, at 4:20 PM, Patient #6, stated that the admission process did not contain a Patient's Rights notification with a phone number or address to lodge a grievance with the SA.

During an interview on 04/05/21 at 4:30 PM, Staff G, Licensed Practical Nurse (LPN), stated that there used to be big packets of Patient's Rights information that was discussed with patients and given to them to keep, but since the change of hospital ownership, those packets were gone.

During an interview on 04/05/21, at 4:10 PM, Staff E, Quality Director, stated that the Patient's Rights signage, that included the phone number and address for the SA, used to be posted on the unit; however, the previous hospital ownership had taken them all down and the current hospital ownership was rebranding them with their logo.

During an interview on 04/05/21 at 4:15 PM, Staff F, RN, Inpatient Services Director, stated that she thought registration staff discussed all Patient's Rights information during admission in the Emergency Department (ED).

During an interview on 04/08/21 at 12:30 PM, Staff L, Chief Executive Officer (CEO), stated that she would expect every patient to receive a copy of the Patient's Bill of Rights, included would be how to contact the appropriate person at the hospital and the state.

The hospital failed to ensure that patients were informed of the right to file a grievance with the SA, when Patient's Rights information was not provided to patients verbally, or through alternative means, such as posted signage or written materials. Additionally, the Patient's Rights information the hospital had available to provide to patients, did not include the phone number or address of the SA, should the patient want to file a grievance.

Based on interview, record review and policy review, the hospital failed to ensure patients were informed of their rights to formulate an Advanced Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) for two current patients (#5 and #6) and six discharged patients (#15, #21, #24, #25, #26 and #29) of 18 patient records reviewed and there was no code status (refers to the whether or not a patient wants medical intervention if their heart or breathing stops) recorded for six current patients (#1, #2, #3, #4, #5 and #6) and eight discharged patients (#11, #13, #15, #21, #24, #25, #26 and #29) of 30 patient records reviewed. The hospital census was six.

Findings included:

1. Review of the hospital's policy titled, "Advanced Directives," dated 03/10/13, showed that each patient would be shown respect for their expression of his or her desire about initiating, continuing or ceasing certain forms of medical or surgical treatment.

Review of the hospital's policy titled, "Code Blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing)," reviewed 06/2020, showed that the Code Blue Policy would assure that each patient's wishes and rights concerning resuscitation were fulfilled and would provide appropriate direction to staff in the event their heart or breathing were to stop.

Review of the hospital's policy titled, "Patient's Rights," dated 06/08/16, showed that the Advanced Directive Policy guaranteed the right to designate a representative decision maker who would exercise all patient rights and responsibilities on the patient's behalf in the event the patient was incapable of understanding or could not communicate their wishes.

Review of the hospital's document, "Patient's Rights and Responsibilities," showed that each patient would have the right to an AD that stated their wishes and values for health care decisions when they could not speak for themselves.

Review of two current patients (#5 and #6) and six discharged patients (#15, #21, #24, #25, #26 and #29) of 18 patient records reviewed showed that the patients had not formulated an AD. There was no evidence that the patients and/or their legal guardians (a person who has been court-appointed to care for another person, and make decisions on their behalf) were provided with information related to formulating an AD upon admission.

During an interview on 04/05/21 at 4:00 PM, Patient #5 stated that there was no AD discussion and he was not given any information related to AD. He was not sure what that was.

During an interview on 04/05/21 at 4:20 PM, Patient #6 stated that there was no AD discussion and he was not given any information related to AD.

During an interview on 04/05/21 at 4:30 PM, Staff G, Licensed Practical Nurse (LPN), stated that there used to be big packets of Patient's Rights information that included the AD information that was discussed with patients and given to them to keep, but since the change of hospital ownership, those packets were gone.

During an interview on 04/05/21 at 4:40 PM, Staff I, Registered Nurse (RN), stated that nursing staff used to give the patients big packets of information, which included AD information, but she thought registration staff gave it to patients now.

During an interview on 04/05/21 at 4:15 PM, Staff F, RN, Inpatient Services Director, stated that she thought registration staff discussed AD information during admission.
During an interview on 04/06/21 at 9:30 AM, Staff C, RN, Charge Nurse, stated that the new Electronic Medical Record (EMR) system did not hold patient information. The code status was not held in the EMR and not visible. She either called the previous hospitals where patients had come from or she asked the patients what their code status was and then wrote it on paper report forms used for each patient.

During an interview on 04/06/21 at 10:00 AM, Staff F, RN, Inpatient Services Director, stated that when they switched to the new EMR system, it took a while for it to start up. She stated they still had a difficult time programming the EMR with important patient information.

During an interview on 04/08/21 at 10:40 AM, Staff Z, Interim Chief Nursing Officer (CNO), stated that she would expect patients to be informed on ADs and they would be available in their medical records. She would expect the code statuses to be visible in the patients' medical records.

The hospital failed to ensure that patients were informed of their rights to formulate an AD and failed to ensure the patients' code statuses were visible in the medical record.

Based on observation, interview, record review and policy review, the hospital failed to recognize and remove ligature (anything which could be used for the purpose of hanging or strangulation) risks located on the Behavioral Health Unit (BHU) for one current patient (#3) of one current patient reviewed that was admitted with suicidal ideations (SI, thoughts of causing one's own death). This failure had the potential to affect each patient admitted to the BHU with SI. The BHU census was four.

Findings included:

1. Review of the hospital's policy titled, "Patient Care - Suicide Preventions for Patients in Inpatient Psychiatric Units," dated 12/04/19, showed that patients considered to be at high risk of suicide would be placed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) within line of sight (LOS, continuous visual contact with the patient), and that patient rooms and bathrooms should be ligature resistant.

Review of the hospital's policy titled, "Patient Care Policy - Observation Levels," dated 06/08/16, showed that:
- The hospital utilizes three levels of observation for behavioral health patients.
- Level one is a minimal level of observation, and requires every 15-minute observations for safety of the patient.
- Level two is a moderate level of observation, and the patient is to remain in LOS of an assigned employee at all times.
- Level three is the maximum level of observation, which consists of one patient to one staff member, where they remain within arm's length at all times.

Review of Patient #3's medical record showed that in March 2021, he had been admitted to an Intensive Care Unit (ICU, a unit where critically ill patients are cared for) on a ventilator (a machine that supports breathing) at another hospital, after he had overdosed. Once he had been medically stabilized, he was transferred to this hospital for psychiatric treatment, and placed on LOS precautions due to his recent suicide attempt.
Observation on 04/05/21 at 4:20 PM, showed that Patient #3 was left unattended, sitting in the dayroom, while Staff D, Patient Care Technician (PCT), left the area and followed another patient down the hall. Staff B, Registered Nurse (RN), along with Staff C, Charge Nurse (CN), remained in the nurse's station.

During an interview on 04/05/21 at 4:20 PM, Staff D, PCT, stated that when a patient was on LOS precautions, a specific staff member would be assigned to visualize the patient at all times. They could not watch two patients at the same time if they were in separate areas of the unit.

2. Review of the hospital's policy titled, "Patient Care Policy - Room Check and Search for all Inpatient Areas and Emergency Department (ED)," dated 06/08/16, showed that safety would be maintained by observing and removing contraband and potentially dangerous items from the patient care environment for all patients deemed SI or HI, and for all patients on the BHU. Any item with a cord should be removed.

Observation on 04/05/21 at 3:50 PM, showed that all 20 patient beds on the BHU each had one black electrical cord and two white bed alarm cords attached to them.

Observation on 04/06/21 at 11:00 AM, showed that the black electrical cords from the beds that plugged into the wall outlets measured 19 inches in length and were easily unplugged. The two white bed alarm cords were attached together, but easily pulled apart. The end of the white bed alarm cord that attached to the bed measured 27 inches in length, and the second white bed alarm cord end that attached to the wall measured 16 inches in length.

During an interview on 04/05/21 at 3:50 PM, Staff B, RN, stated that the cords on the beds were allowed on the BHU.

During an interview on 04/08/21 at 10:40 AM, Staff Z, Interim Chief Nursing Officer (CNO), stated that she was not aware of any ligature risks present on the BHU, but she would expect that they would be removed, especially if there were patients with SI on the unit.

During an interview on 04/08/21 at 12:30 PM, Staff L, Chief Executive Officer (CEO), stated that she would expect the BHU to be free of all hazards, including ligature risks.



39089

Based on interview, record review and policy review, the hospital failed to immediately and properly conduct an investigation regarding an allegation of sexual assault for one discharged patient (#12) of 30 current and discharged patients reviewed. This failed practice had the potential to expose all patients in the hospital to continued abuse or neglect. The hospital census was six.

Findings included:

1. Review of the hospital's policy titled, "Administrative - Abuse and Neglect Policy for Hospitalized Patients," revised 09/26/17, showed that:
- Upon identification of a case of suspected abuse/neglect a report should be made to the appropriate regulatory agency/hotline.
- Information to be included in the report would be the name of the patient, the nature and extent of the patient's condition, the nature of the abuse/neglect, the name of the alleged perpetrator, and the name of the person making the report.
- The department director, social work, and performance management should be contacted when a report is made, or the on call administrator, after 4:30 PM on weekdays, and Saturday or Sunday.
- The investigation should include the nature of the allegation, the identity of the victim, their physical and mental status, and any possible witnesses.
- Written and signed statements should be obtained from the individual bringing the allegation, the alleged victim, any witnesses to the allegation, and the individual being accused of the abuse/neglect.
- If the investigation indicates abuse/neglect occurred, or the findings were inconclusive, the Performance Management/Risk Manager will report the allegation to the Division of Aging Abuse/Neglect Hotline.

Review of the hospital's policy titled, "Administrative - Reported Event Review, Investigation, and Closure," revised 10/01/14, showed that:
- Managerial staff should ensure thorough follow up and investigation of an incident, prior to the closure of all events reported.
- Any event that has the potential to be reported to a regulatory agency should be escalated up the management chain of command, such as violent assault, or sexual assault/rape.
- A preliminary investigation should be completed to determine the facts of the event.
- Interviews with patients, family members, and other staff members should be obtained.
- All information obtained regarding the event (i.e. emails, forms, statements, etc.) should be forwarded to the Risk Manager.

Although requested, the hospital failed to provide an event report, witness statements, or a time line of the alleged event related to Patient #12.

Review of Patient #12's medical record showed that she had been admitted to the Behavioral Health Unit (BHU) on 12/10/20, for increased depression (extreme sadness that doesn't go away), self-neglect, and verbalization of SI. Her history included depression, bipolar (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), and she had been a victim of sexual abuse as a teenager.

During an interview on 04/08/21 at 4:25 PM, Staff V, Registered Nurse (RN), stated that:
- She had been approximately 15 feet away from Patient #14 when she observed him walk out of the main hall into Patient #12's room.
- She had followed him into the room within 10 seconds, and observed him standing at the foot of the bed, not touching anything.
- She heard Patient #14 ask Patient #12, "Why are you sleeping in my bed?"
- Patient #14 was easily re-directed out of the room.
- Patient #12 had been sound asleep, and had barely acknowledged that they were in her room.
- The morning following this incident, Patient #12 asked her if Patient #14 had walked into her room or not, and thought it was humorous that he had wandered into the wrong room.
- She did not complete an incident report, and had thought nothing of the incident until she was contacted a couple days later by Staff B, RN (Manager of the BHU at the time of the incident).
- Staff B, RN, told her that she had reviewed video surveillance of the hall, and had observed her immediately follow Patient #14.

During an interview on 04/07/21 at 4:40 PM, Staff C, RN, Charge Nurse (CN), stated that:
- She was informed by Staff V, RN, during report that Patient #12 had accused Patient #14 of sexually assaulting her when he entered her room and grabbed her breast during the night.
- She did not complete an event report about the incident.
- She thought that Staff B, RN (BHU Manager at the time of incident), had reviewed the video surveillance and determined that there had not been enough time for the incident to have occurred.
- She was not aware of any statements being obtained, there may have been a few phone calls, but not a formal investigation.

During an interview on 04/05/21 at 3:45 PM, Staff B, RN, stated that:
- There had been an allegation of inappropriate physical contact between two patients within the last few months, but she did not have any specific information related to the incident.
- Any incident would be documented on an event or incident report, then investigated.
- There were video cameras on the BHU, which could be used to review any incidents that were identified, and that security had the capability to download video surveillance to a compact disc.

Staff B, RN, failed to inform the survey team that she had been the Manager of the BHU at the time the sexual assault allegation had been made by Patient #12, and that she had been the administrator that had reviewed the video footage, but did not preserve a copy.

During an interview on 04/06/21 at 10:45 AM, Staff K, Facilities Manager, stated that:
- He was over the Security Department.
- There were a total of 14 cameras located on the BHU, which allowed video monitoring of all common areas on the unit.
- He had not received any requests for a copy of video surveillance over the last few months, and he did not maintain a log of any requests that were made.

During an interview on 04/06/21 at 9:45 AM, Staff A, Risk Manager (RM), stated that:
- When the hospital transitioned from the previous owner on 03/15/21, she had lost all content related to event reports, including email documentation related to all previous investigations.
- The hospital did not have an electronic event reporting process in place at the time of the survey, and that she had told staff to send an email to her for any incidents that occurred.
- The incident that involved Patient #12 had not been worked up as a sexual assault allegation, and had not been reported to the appropriate regulatory agency.
- No written statements were obtained and she did not review any video surveillance related to the allegation.
- She was told by Staff B, RN (BHU Manager at the time of incident), that the incident had lasted only a few seconds, and it could not have occurred.

During an interview on 04/08/21 at 10:40 AM, Staff Z, Interim Chief Nursing Officer (CNO), stated that she would expect all allegations to be documented in an event report, and to be properly investigated.

During an interview on 04/08/21 at 12:30 PM, Staff L, Chief Executive Officer (CEO), stated that she would expect all allegations of sexual abuse/assault to be immediately investigated and documented in an event report.

The hospital's failure to identify and to immediately complete a thorough investigation of a sexual assault allegation placed all current and future patients of the hospital at risk of harm.