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35054

Based on observation, interview, and record review, the hospital:

(1) failed to adhere to the time frames specified in its policies for review of grievances and response to patients or patient representatives who filed a grievance (refer to A122);

(2) failed to provide results of the grievance process and the completion date of the investigation to individuals who filed a grievance (refer to A123); and

(3) failed to provide care in a safe setting by not ensuring staff were trained and currently certified on cardiopulmonary resuscitation (CPR) (refer to A144).

The failed practice denied basic rights to patients or patient representatives who filed grievances, while the failed practice regarding CPR training jeopardized the health and safety of patients.

The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation for Patient Rights.

Based on interview and document review, the hospital failed to ensure that the facility is in compliance with the Condition of Participation for Quality Assessment & Performance Improvement (QAPI). The hospital failed to maintain an effective ongoing, hospital-wide, data-driven QAPI program and conduct performance improvement projects (refer to A297). This deficient practice has the likelihood to diminish the quality of care and therefore the well-being of patients.


The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation for Quality Assessment and Performance Improvement.

Based on record review and staff interviews, the hospital failed to ensure that a qualified individual was appointed and is serving as the Director of Nursing (refer to A 386).

The cumulative effect of these systemic practices resulted in the hospital nursing services' inability to ensure that the needs of patients are met.

Based on record review and interview, the hospital failed to adhere to the time frames specified in its policies for review of grievances and response to patients or patient representatives who filed a grievance.


The findings are:


A. On 07/08/16, at 12:40 pm, during interview, the complainant stated that Patient #1 had a fall on 05/14/16. The complainant stated she called on 05/16/16 and filed a grievance with the Compliance Officer about Patient #1 falling and not receiving medical care after the fall. The complainant added that the Compliance Officer told her that she would be looking into this fall. The complainant stated that she called again on 05/23/16 and was told by the Compliance Officer that the hospital was conducting an "ongoing investigation" of the complaint, but that was the last response she received from the Compliance Officer or anyone else from the facility about the grievance.


B. Record review of the document which the Complaints Officer submitted as the complaint/grievance log was entitled "List of Falls," and consisted of undated handwritten entries on the notepad of a hotel chain indicating the names of four patients and the dates they fell between 04/01/16 and 06/30/16.


C. On 07/12/16, at 1:30 pm, during interview, the Compliance Officer explained that the facility had received only one complaint from 04/01/16 to 06/30/16, and that the complaint concerned one of the patients (Patient #1) whose name appeared on the "List of Falls."


D. Record review of the hospital's response to grievances filed for the past three months revealed no notification had been communicated to anyone that had filed a grievance.


E. Record review of the hospital's policy "Patient Rights, Responsibilities, and Grievance Procedure dated 10/21/14" revealed the following:

"Article III Patient Grievance Procedure - Section 1: The patient or authorized guardian may present his/her alleged grievance to any Rehab Center employee verbally, in writing, email, fax or telephone. Section 6: If the grievance cannot be resolved within seven (7) days, the patient or patient's respresentative ... will be notified within a reasonable period of time of the resolution."


F. On 07/12/16, at 1:30 pm, during interview, the Compliance Officer stated that she handles grievances as they are reported. She stated that when the family of Patient #1 reported concerns, she addressed them on the spot. The Compliance Officer confirmed that she did not comply with the hospital's grievance process and that she did not follow up with the family of Patient #1. The Compliance Officer stated that she only tracks grievances that are reported to the state.

Based on record review and interview the hospital failed to provide results of the grievance process and the completion date of the investigation to individuals who filed a grievance. The findings are:

A. On 07/08/16 at 12:40 pm during interview, the complainant stated that Patient #1 had a fall on 05/14/16. The complainant stated she called on 05/16/16 and filed a grievance with the Compliance Officer about Patient #1 falling and not receiving medical care after the fall. The complainant added that the Compliance Officer told her that she would be looking into this fall. The complainant stated that she called again on 05/23/16 and was told by the Compliance Officer that the hospital was conducting an "ongoing investigation" of the complaint, but that was the last response she received from the Compliance Officer or anyone else from the facility about the grievance.

B. Record review of the document which the Complaints Officer submitted as the complaint/grievance log was entitled "List of Falls," and consisted of undated handwritten entries on the notepad of a hotel chain indicating the names of four patients and the dates they fell between 04/01/16 and 06/30/16.

C. On 07/12/16 at 1:30 pm during interview, the Compliance Officer explained that the facility had received only one complaint from 04/01/16 to 06/30/16, and that the complaint concerned one of the patients (Patient #1) whose name appeared on the "List of Falls."

D. Record review of the hospital's response to grievances filed for the past three months revealed no notification had been communicated to anyone that had filed a grievance.

E. Record review of the hospital's policy"Patient Rights, Responsibilities, and Grievance Procedure dated 10/21/14" revealed the following:
"Article III Patient Grievance Procedure - Section 1: The patient or authorized guardian may present his/her alleged grievance to any Rehab Center employee verbally, in writing, email, fax or telephone. Section 6: If the grievance cannot be resolved within seven (7) days, the patient or patient's representative ... will be notified within a reasonable period of time of the resolution."

F. On 07/12/16 at 1:30 pm during interview, the Compliance Officer stated that she handles grievances as they are reported. She stated that when the family of Patient #1 reported concerns, she addressed them on the spot. The Compliance Officer confirmed that she did not comply with the hospital's grievance process and that she did not follow up with the family of Patient #1. The Compliance Officer stated that she only tracks grievances that are reported to the state.

35054

Based on interviews and record review, the hospital failed to provide care in a safe setting by not ensuring staff were current certification and trained on cardiopulmonary resuscitation (CPR). This deficient practice could result in incorrect technique and thus failure of the staff to aid a patient who may require CPR to survive a life-threatening emergency medical condition. The findings are:


A. On 07/13/16, at 9:00 am, record review revealed that the CPR training certificates of Staff #8, #9, #10, #11 and #12 had expired.


B. On 07/13/16, at 10:50 am an interview was conducted with the Department of Health Chief Nursing Officer (DOH CNO), who stated that he is not the Director of Nursing for the hospital, but has provided "support" to the hospital. He stated that he understands that training is lacking and that CPR certification expired for some RN's and personnel that he referred to as "Techs." When asked whose responsibility it is to ensure clinical staff members are current on required training, the DOH CNO stated he understands staff development is the responsibility of Human Resources (HR). The DOH CNO stated that the Staff Development position is currently vacant and this is why staff members have not been updated on training. The DOH CNO stated he believes that the Compliance Officer is a CPR instructor and that the Compliance Officer is in the process of having staff caught up on training.


C. On 07/14/16, at 10:45 am, the Compliance Officer and the Human Resources (HR) Director were interviewed. The Compliance Director attributed the lack of staff training to the vacant Staff Development position, as did the DOH CNO. The HR Director stated that frontline supervisors are responsible for monitoring staff training. When the HR Director was asked who would be responsible for monitoring employee files and training in the absence of the Staff Development personnel, she replied that this would fall on Compliance and HR.

Based on record review and interview, the hospital failed to ensure that the Quality Assessment & Performance Improvement (QAPI) program conducted performance improvement projects. This deficient practice has the likelihood to diminish the quality of care and therefore the well-being of patients. The findings are:


A. Record review of Performance Improvement Committee Meeting dated 04/19/16 revealed the following:

1. "Facility education/requirements - PI [performance improvement] project on hold. DON [Director of Nursing] - vacant, Staff Development vacant - no report.

2. Fall assessment and prevention - DON - vacant - On hold."


B. On 07/14/16, at 10:45 am, during interview, the Compliance Officer confirmed that performance improvement projects are not currently going forward due to the vacant positions of Director of Nursing and Staff Development Coordinator.

Based on interviews, the hospital failed to hire and appoint a qualified individual as the Director of Nursing (DON). The deficient practice could result in lack of staff supervision as well as lack of oversight of patient care to the extent of failure to deliver care to patients. The findings are:


A. On 07/12/16, at 8:30 am, during interview at the entrance conference, the Administrator stated that the acting DON for the facility was the Department Of Health Chief Nursing Officer (DOH CNO). The Administrator asserted that the CNO "has been here three times in the last few months." The Administrator stated the facility has not had a full time DON on site since April 2, 2016. The Administrator added that the shift supervisors on the floor are performing DON responsibilities and consulting with the DOH CNO.


B. On 07/13/16, at 10:50 am, during interview, the DOH CNO was asked if he was the acting DON for the facility. The DOH CNO stated, "I am not putting my name on anything as acting DON and I am not acting DON." The DOH CNO stated, "I am here for support only."


C. On 07/13/16, at 2:50 pm, during interview, the Compliance Officer stated she is doing the staffing schedule. The Compliance Officer stated she checks to see what staff members are requesting time off and lets the Administrator know if the facility can accommodate the requested time off. The Compliance Officer stated that the Administrator then approves the schedules.