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Based on record review and interviews, the hospital failed to ensure effective implementation of the grievance process for prompt resolution of patient grievances as evidenced by: 1) failing to identify, investigate and document a patient representative's concerns for 1 of 1 (#3) sampled patients reviewed for grievances out of a total sample of 5 (#1-#5), and;
2) failing to provide a written response to the patient/patient representative in accordance with the hospital's grievance policy for 1 of 1 (#3) sampled patients reviewed for grievances out of a total sample of 5 (#1-#5).

Review of the hospital's policy titled PC-816: Grievances, revealed in part the following: Upon receiving a verbal complaint, a complaint report form (see attached form) will be completed by the employee receiving the complaint. Administration or administrative on-call personnel will be notified immediately upon receipt of a complaint....Within 72 hours of receipt of grievance, Lead Investigator will respond in writing to complainant indicating the name of the contact persons(s) who will assist patient and family in the resolution of problems....The Lead Investigator will provide the following written communication to the complainant within 7 days: description of complaint, steps taken to resolve complaint, and date of completion/resolution.

1) Failing to identify, investigate and document a patient representative's concerns:

Review of the Grievance Log for the hospital's offsite inpatient campus revealed no documented evidence of any grievances for the year 2015.

Review of the Grievance Log for the hospital's PHP clinic revealed a grievance was filed on 11/17/15 for Patient #3. Review of the grievance investigation revealed the patient eloped from the PHP program on 11/17/15.

In an interview on 12/22/15 at 11:29 a.m., S12AD/CM (Activity Director/Case Manager) confirmed she remembered Patient #3. S12AD/CM confirmed the patient's daughter contacted her by telephone on the afternoon the patient eloped from the PHP. S12AD/CM stated the patient's daughter was upset and wanted to know why the patient was referred to the PHP. S12AD/CM stated the patient's daughter also expressed concern about finding pills in the patient's pocket. S12AD/CM stated she did not document the family member's concerns. S12AD/CM stated she did talk to S4PD (Program Director) and informed her of the family's concerns and that the patient's daughter was upset.

In an interview on 12/22/15 at 1:00 p.m. S4PD confirmed S12AD/CM had communicated the family's concerns regarding the patient's discharge to the PHP and also finding patient with pills. S4PD confirmed the family called the hospital on Tuesday (11/17/15) after the elopement incident. She confirmed the family's concerns were not documented as a complaint or grievance and they should have been. S12AD/CM confirmed the hospital's grievance policy had not been followed.



2) failing to provide a written response to the patient/patient representative in accordance with the hospital's grievance policy:

Review of the Grievance Log for the hospital's PHP clinic revealed a grievance was filed on 11/17/15 for Patient #3. The Log revealed written communication was provided to the complainant on 11/30/15, 13 days after the grievance was filed with the hospital. Review of the grievance investigation revealed the patient eloped from the PHP program on 11/17/15. The grievance investigation and written response to the complainant were regarding events that occurred in the PHP and were documented by S6PD (Program Director) at the PHP.

In an interview on 12/22/15 at 11:29 a.m., S12AD/CM (Activity Director/Case Manager) confirmed she remembered Patient #3. S12AD/CM confirmed the patient's daughter contacted her by telephone on the afternoon the patient eloped from the PHP. S12AD/CM stated the patient's daughter was upset and wanted to know why the patient was referred to the PHP. S12AD/CM stated the patient's daughter also expressed concern about finding pills in the patient's pocket. S12AD/CM stated she did not document the family member's concerns. S12AD/CM stated she did talk to S4PD (Program Director) and informed her of the family's concerns and that the patient's daughter was upset.

In an interview on 12/22/15 at 1:00 p.m. S4PD confirmed S12AD/CM had communicated the family's concerns regarding the patient's discharge to the PHP and also finding patient with pills. S4PD confirmed the family called the hospital on Tuesday (11/17/15) after the elopement incident. She confirmed the family's concerns were not documented as a complaint or grievance and they should have been. S4PD confirmed the hospital's grievance policy had not been followed and no written response was sent to the complainant. S4PD confirmed the written response to the complaint regarding the grievance made to the PHP was not sent to the complainant within 7 days as directed in the hospital's policy.

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Based on observation, record review and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1.) failing to ensure patients in the hospital's PHP were screened for admission to ensure the patient was appropriate for that level of care, and failing to provide supervision to prevent elopement for 1 (#3) of 3 (#1, #2, #3) sampled patients referred to the the PHP, and;

2.) failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services by failing to ensure the patients' environment was free of ligature risks and safety hazards.

Findings:

1.) failing to ensure patients in the hospital's PHP were screened for admission to ensure the patient was appropriate for that level of care, and failing to provide supervision to prevent elopement:

Review of the IOP/PHP policy titled, OP-200: Admission Policy revealed in part the following: It is the policy of [the IOP/PHP] to process admissions to the Program in an orderly and efficient manner. Further review of the policy revealed all inquiries to the program were to be directed to the Program Director and/or designated clinical staff. The policy revealed the staff were to obtain the necessary information for pre-screening and complete an admission inquiry form. The policy revealed the physician on-call was to be contacted to clarify the final disposition of the case. The policy revealed once insurance coverage was verified the date and time of admission was to be scheduled.

Review of the referral documents provided to the PHP by the inpatient hospital for Patient #3 revealed only copies of the inpatient record and a form titled, "Liaison Screening Tool." The faxed inpatient record had a faxed date and time of 11/13/15 at 11:54 a.m. The Liaison Screening Tool was dated 11/13/15 and revealed only the name of the referring facility, the patient's name, address, phone number and social security number, and one emergency contact. There was no other information documented on the form. Review of the form revealed sections titled Last Psychiatric Admission and Presenting Symptoms, (both sections left blank). Further review of the form revealed the discharge date of 11/16/15 and start dated of 11/17/15 was hand written at the top of the form.

Review of the Review of the Grievance Log from the IOP/PHP revealed the following:
Patient: Patient #3 (patient was not yet admitted to the program)
Date/Time of occurrence: 11/17/15 at approximately 10:15 a.m.
Review of the occurrence report revealed the patient arrived by program transportation at 9:15 a.m., and attended the first group which ended at 10:00 a.m. During the load up time around 12:55 p.m. the patient's driver reported the patient could not be located.
Further review of the occurrence report revealed the Action Taken was as follows: Staff immediately began searching the facility in an effort to locate Patient #3; however, he was not in or outside of the facility. Each driver was contacted to ensure that the client had not gotten on the wrong van/bus. The Client ' s family and the Program Administrator were contacted immediately and informed of the incident. Several staff got into their vehicles to go looking for the client. Shortly after leaving the facility, the patient's POA contacted the facility and informed them that the patient had been found safely and was being transported home by the Sheriff's office.
Review of the occurrence report Findings, revealed the following: Upon review of Patient #3's referral to PHP it was found that his primary diagnosis is Dementia. His records from the Inpatient indicate that Patient #3 was admitted due to increased confusion and "wandering the streets." He was noted to be an elopement precaution during his stay on the inpatient unit. Due to the voluntary nature of PHP treatment, Patient #3's cognitive functioning excludes him from meeting criteria for this level of care. Patient #3 is in need of an environment that is more restrictive with a higher level of supervision to maintain his safety and wellbeing.

In an interview on 12/21/15 at 4:20 p.m. S6PD at PHP stated the referral for Patient #3 was received late on Friday afternoon and it was from "our" facility. S6PD confirmed the patient's referral was not reviewed on Friday. S6PD stated she was the person designated to review the referrals. S6PD stated she was not there on Monday and no one reviewed the referral that day. S6PD confirmed the patient was picked up on Tuesday by the program driver. Stated if she had been there on Monday and saw that the patient had been an elopement risk, she would have paid more attention to the appropriateness for him. She stated the patient had multiple red flags. S6PD stated she would have put 1:1 supervision of the patient until he could be evaluated. S6PD confirmed they do have patients with Dementia, but stated elopement risks are dangerous. She stated a patient who is an elopement risk is not appropriate for IOP/PHP. "Just his history alone was a flag." S6PD stated the patient was not admitted to their program and stated the patient was there as a visitor. S6PD stated patients are not admitted to the program until they are evaluated by a physician. She stated the physician did the evaluations on Wednesday and Friday only. S6PD stated around 12:55 p.m. during load up time the staff could not find Patient #3. She confirmed the patient's driver reported she could not locate the patient. S6PD stated the patient was found in the middle of a really bad area.

In an interview on 12/22/15 8:25 a.m. S6PD confirmed the driver was the first person at the clinic to notice that Patient #3 was missing. She stated she was loading her van (around 12:55 p.m.) and asked where the patient was. S6PD stated she then asked the counselors and the only one who had seen him in her group was S7CM. She stated they searched clinic and when they could not find him she called S1Adm. She stated staff got in cars and went looking for him. She stated the patient's wife called the inpatient unit and reported the patient had been found. When asked if the intake and prescreening was done for this patient as directed in the PHP policy, S6PD stated, "That is where the ball was dropped on this end." She stated the referral came late on Friday and they knew the patient was not going home until Monday. She stated the process was that the referral goes to S14LPN. She stated she does not know if S14LPN looked at the referral on Friday either. S6PD stated, "It just didn't get done."

In an interview on 12/22/15 at 9:21 a.m., S8MHT/Driver for the IOP/PHP confirmed she had transported Patient #3 on 11/17/15 to the clinic and stated she realized he was not on the van after she had left the clinic for the transport of clients back to their homes. She stated she called back to clinic and asked if he was put on someone else ' s van. Stated they called other vans and he was not on there. Stated she got a call that he was not other vans and could she go by patient ' s house to see if he was there. She stated before she could do that she received a call that the patient was found. Stated she does not look at sheet before she leaves the clinic to make sure she has everyone. Stated she just looks in the review mirror to make sure everyone is on van. Stated she realized someone was missing when she was leaving out. S8MHT/Driver was asked if there was a process for making sure all patients are on van. She stated drivers do things differently and she asked patients " Is everybody here? " She stated she did not know patient had a history of wandering and elopement. She stated she saw the patient outside during the break after the first group. She stated normally the therapist does a check in to make sure clients are accounted for.

In an interview on 12/22/15 at 10:30 a.m. S6PD stated she re-educated the staff on supervision after this incident. She stated she had a supervision schedule for all MHTs to monitor patients during breaks. S6PD stated the hospital had been working on a policy for supervision in clinics prior to this incident but the policy has not been implemented yet.




2.) failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services by failing to ensure the patients' environment was free of ligature risks and safety hazards:

An observation was conducted on 12/21/15 at 11:00 a.m. the psychiatric unit. The following areas are considered ligature risks and/or safety hazards:

The beds in all 14 patient rooms (16 beds) were observed to have 1/4 side rails on both sides of the upper end of the bed (Head of the bed) and 3 cranks located at the foot of the beds, which elevated and lower the beds and the head and foot of the beds. Also there were ligature risks associated with the metal frame of the beds.

In all the patients' bathrooms (14) there were exposed plumbing on the toilets, which were a ligature risk.

In patient Rooms 201, 205, and 207 the hard plastic front casing of the air condition units had been broken, leaving sharp edges, which posed a safety hazard.

Review of the hospital policy for Bedrails, Policy PC-1019 revealed in part the following: Purpose-Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who are identified at Risk for Fall thus the use of bedrails may be indicated. The purpose of this policy is to establish guidelines for the safe use of bedrails.

Potential Risks/Benefits of Bed Rail Use... Risks: Strangling, suffocating bodily injury or death when patients or part of their body are caught between rails and between the bed rails and mattress. More serious injuries from falls when patients climb over the rails. Skin bruising, cuts, and scrapes. Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.
Procedures: Use of bedrails
Lower one or more sections of the bed rail, such as the foot rail.
Use proper size mattress.
Reduce the gaps between the mattress and side rails.

Review of the hospital policy for Bedrails, Policy PC-1019 revealed the policy does not address the patients with suicidal ideations/risks and the potential ligature risks of the bedrails.

An interview was conducted with S3ADON on 12/22/15 at 9:00 a.m. She confirmed the bed frames, bed cranks, siderails, exposed toilet plumbing and the sharp edges on 3 broken air conditioner front casings pose ligature risks and/or safety hazards to the patients.

Based on record review and staff interview, the hospital failed to ensure a written policy was developed and implemented to ensure the visitation rights of patients. Findings:

Review of the policy and procedure manual provided by S4PD as the hospital's current policies revealed no documented evidence of a policy for visitation by patient's family.

In an interview on 12/22/15 at 11:15 a.m. S10RN confirmed she remembered Patient #3 and confirmed she was present when the patient was admitted to the hospital. S10RN confirmed the patient arrived at 6:30 p.m., during visiting hours. When asked when family members were allowed to visit the patient, she stated patient's family can visit when they are admitted if the family brought the patient or if the family followed he patient from the Emergency Room. S10RN stated when Patient #3 arrived the family buzzed in at the rear entrance and asked to visit the patient. S10RN stated she heard S11LPN tell the family to come back the next day when it was visiting hours. S10RN stated she would not have done that. She stated she allows family to visit and stated every nurse is different on how they handle visitation. S10RN stated she was not aware of the hospital's policy for visitation. S10RN stated she would at least go and talk to the family and not just turn them away.

In an interview on 12/22/15 at 1:00 p.m. S4PD stated when a patient is admitted, the staff are to ask the family to come around to administration and the staff should come to administration and explain the telephone and visitation times to the family. She stated visitation times are Monday-Friday from 6-7 p.m. S4PD stated she was not aware the staff had told the family through the intercom to return the next day at visiting hours. S4PD stated the family should have been instructed to come around to the visitor entrance and the nurse should have come out of the unit and talked to them. S4PD confirmed the hospital did not have a written policy, but they had a Family Information Sheet that included rules of visitation and times for visitation and phone calls. S4PD provided the Family Information Sheet for review which included rules and times for visitation. The form also indicated the family must have the patient's ID number for visitation and information.

Based on record review and staff interview, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by failing to notify the physician and document an incident report in accordance with hospital policy when the patient was found to have unknown pills for 1 (#3) of 5 sampled patients (#1-#5). Findings:

Review of the hospital policy titled, PC-1004: Incident-Occurrence Reporting revealed Employees will report all incidents, whether if be a patient, visitor, or employee. An injury or property damage need not occur to generate a report. By reporting "near-misses" future occurrences can be eliminated....Complete an "Occurrence Report" for any patient or visitor incident.

Review of the incident reports for the last 3 months revealed no documented evidence of an incident report related to Patient #3.

In an interview on 12/21/15 at 3:30 p.m., S5RN was asked if she was aware of any incidents with Patient #3 that occurred on 11/13/15. S5RN stated the patient's daughter that came to visit talked to the LPN about finding the patient with pills. S5RN stated the LPN said the pill was not wet and he had likely cheeked the pill. S5RN stated S11LPN said she saw the pill, apparently the patient put them in his mouth but did not swallow them. S5RN stated she was in shift report at the time the daughter visited, around 6:45 p.m. S5RN stated they do not check the patient's mouth unless they suspect they are cheeking. S5RN stated S11LPN could not say it was the patient's pill. When asked if an incident report was done or the physician was notified, she stated S4PD questioned her about it on Monday or Tuesday after the patient was discharged. S5RN stated the S11LPN nor the daughter reported the incident to her when it happened. S4RN confirmed she did not report the pill incident to the physician because she did not know about it.

In an interview on 12/21/15 at 3:45 p.m. with S11LPN was asked about the pill incident with Patient #3. S11LPN stated the MHT came in nurse ' s station in the middle of shift change and handed her a dry pill. S11LPN stated she could not identify the pill. S11LPN stated the MHT reported Patient #3 pulled it out of his pocket. S11LPN stated she threw it away, and there was no way to go into the Omni cell to identify it. S11LPN stated she went and looked at the patient, and he seemed fine. S11LPN stated she passed it on to the oncoming shift to watch for cheeking. She confirmed she did not document the incident on an incident report. When asked if she reported the incident to the RN in charge, she stated she assumed the RN heard of the incident as they were all in report. S11LPN confirmed the family was not there when she looked at the patient, as it was the end of visitation. S11LPN stated she checked his mouth and pocket and he did not have any more pills. S11LPN confirmed she did not report the incident to the physician. She stated she always makes sure pills are in the mouth. S11LPN stated she tries to sit and watch the patient swallow. S11LPN stated after this incident she checked patient ' s mouth. Stated she did not think he pulled it from his mouth because the pill was dry. She stated he may have found the pill. S11LPN stated she did not know where he got the pill from or even if it was his pill.

In an interview on 12/21/15 at 4:00 p.m., S4PD stated she found out about the pill incident with Patient #3 from S12AD/CM a day or so later. S4PD stated the patient's POA called S12AD/CM and told her the patient was digging in his pocket and came out with pill fragments and the MHT went and told the nurse. S4PD stated she asked S5RN and she was not aware of the incident. S4PD confirmed the staff did not pass it on appropriately to the RN Charge Nurse or the Physician. She confirmed the staff should have documented the incident on incident-occurrence report. S4PD also confirmed the hospital did not have a policy that indicated the nursing staff were to check the patient's mouth to ensure medications were swallowed, but that was the expectation for all patients during medication administration.

Based on record review and staff interview, the hospital failed to ensure the patient's discharge plan to a Partial Hospitalization Program (PHP) was reassessed for factors affecting the continuing care needs of the patient as evidenced by the patient continued to demonstrate elopement behavior on the day of discharge and the discharge plan was not reassessed for 1 (#3) of 5 sampled patients (#1-#5). Findings:

Review of the hospital policy titled, PC-301: Discharge Planning revealed the Social Worker would evaluate potential discharge problems and make recommendations for discharge planning in the psychosocial assessment within 72 hours of admission. The policy also revealed discharge planning will be ongoing throughout the patient's stay with any changes in discharge plans being documented in the medical records. The case manager, along with the treatment team, will facilitate discharge planning for each patient.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 78 year old male admitted under a PEC with a history of advanced Dementia, brought in by family secondary to increased confusion, wandering around in the streets. The PEC indicated the patient was dangerous to self, unwilling/unable to seek voluntary admission, and was gravely disabled.
Review of the Psychiatric Evaluation dated 11/05/15 revealed a diagnosis of Alzheimer's Dementia with Behavior Psychosis. The discharge criteria was as follows: No longer a danger to self or others, Remission of behavior disturbance, medication stabilization, no longer in need of detox, development of appropriate and/or adequate support system.

Review of the Psychosocial Assessment dated 11/05/15 revealed the preliminary discharge plan was to return to home and follow up with primary care physician, neurologist, psychiatrist and home health. Review of the Treatment Team Plan Review dated 11/10/15 revealed the discharge plan was to follow up with primary care physician, home and follow up with Psychiatrist.

Review of the Psychiatric Progress Note dated 11/12/15 revealed, "Refer to PHP."

Review of the Multidisciplinary Note dated 11/13/15, documented by S12AD/CM revealed the POA for Patient #3 was informed of the plan for patient attending a day program. The note revealed the patient's POA expressed concern due to having a caregiver watching patient. The note revealed once program was explained, POA was agreeable.

Review of the 15 Minute Checks 12 Hour Shift Patient Observation Record for 11/15/15 and 11/16/15 revealed multiple entries of "wandering" during the day and night shifts.

Review of the Multidisciplinary Notes and Group Progress Notes revealed the following:
11/13/15 at 7:10 p.m. - Up in day room, wandering around. He appears more anxious and confused that last night. He is wandering around unit more than yesterday as well. Under Elopement Precautions, as he still goes to the outside door...
11/14/15 - Nursing Group at 10:30 a.m. and 10:38 p.m. revealed patient was confused, offered minimal interaction and had a very difficult time organizing his thoughts. The patient's mood was noted as "Helpless and Constricted." The Multidisciplinary Note revealed the patient was anxious, forgetful and unaware he was in the hospital. The note revealed he was walking up and down the hallway with a peer.
11/15/15 - Nursing Group at 9:52 a.m. and 9:56 p.m. revealed the patient was confused, forgetful and had difficulty expressing self. The 9:56 p.m. group also revealed the patient was ambulating hallway, was incoherent, confused and needed redirection. Review of the Multidisciplinary Note at 8:10 p.m. revealed the patient was confused and needed redirection often. The note revealed the patient bonded with a female peer and followed her around. "Very confused and helpless."
11/16/15 at 8:00 a.m. the Multidisciplinary Note documented by S10RN revealed the following: Patient #3 wandering around unit following another patient around. He is on elopement precautions, tries to get out of the door anytime it is opened. Confused, pleasant....
Further review of the Multidisciplinary Notes revealed the patient was discharged to home on 11/16/15 at 9:00 a.m. with instructions to follow up with PHP. Patient was transported home by the hospital's van and driver.

There was no documented evidence the patient's elopement behavior on 11/16/15 was reported to the physician, social worker, or case manager. There was no documented evidence the plan to refer the patient to the PHP was re-assessed after the patient continued to demonstrate confusion and elopement behavior.

Review of the Grievance Log revealed Patient #3 eloped from the PHP on 11/17/15. Review of the grievance investigation and findings revealed the following: Upon review of Patient #3's referral to PHP it was found that his primary diagnosis is dementia. His records from Inpatient indicate that Patient #3 was admitted due to increased confusion and "wandering the streets". He was noted to be an elopement precaution during his stay on the inpatient unit. Due to the voluntary nature of PHP treatment, Patient #3's cognitive functioning excludes him from meeting criteria for this level of care. Patient #3 is in need of an environment that is more restrictive with a higher level of supervision to maintain his safety and wellbeing.

In an interview on 12/22/1511:15 a.m. S10RN confirmed she was the charge nurse when Patient #3 was discharged. S10RN stated she knew PHP was the plan for discharge. She stated after he was in the hospital a few days he did not try to open doors. Stated every day she would have to tell him he was not going home today. After reviewing patient's record she confirmed she had documented the patient was trying to get out anytime the door was opened. She confirmed the patient's behavior was not reported to the physician or social worker.

In an interview on 12/22/15 at 11:29 a.m. S12AD/CM confirmed Patient #3 was to follow up with PHP. S12AD/CM stated she contacted the family and sent the final referral to the PHP. S12AD/CM stated she told S15PA at the PHP that patient had wanted to get outdoors and was very confused when he was first admitted, but was participating better now. S12AD/CM stated she was informed at treatment team that he was no longer an elopement risk. Stated he was attending groups. After review of the nurse's notes dated 11/16/15 indicating patient was trying to get out of doors, she confirmed she was not aware.
She stated they had seen improvement in the patient's behavior and it was discussed in treatment team meeting. She stated, "We thought we would try him with outpatient."

In an interview on 12/22/15 at 12:05 p.m., S13SS Director confirmed she was responsible for discharge planning and she had conducted the psychosocial evaluation of Patient #3. When asked how was it determined a PHP was appropriate for Patient #3, she stated as treatment went on, his cognitive status was improving. She stated based on her groups and reports from the nursing groups, the patient was participating. After reviewing the nursing documentation on 11/16/15, she confirmed the nurse had documented the patient was wandering and attempting to exit doors. S13SS Director stated she spoke with the day nurse's regarding elopement. Stated her understanding of PHP was there was more supervision and she did not expect the patient to leave. S13SS Director confirmed she was aware the PHP was not locked. She confirmed she was not aware of the PHP admission process. She stated they (hospital) send discharge paperwork to the PHP, and if the PHP has any questions, they call the hospital.

In an interview on 12/22/15 at 1:00 p.m. S4PD confirmed the discharge plan should have been re-evaluated after patient continued to have elopement behavior. She confirmed they needed to tighten up their evaluation of returning patients to their previous environment especially when elopement was involved. She confirmed if door opened, Patient #3 would try to slip out.