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Based on observation, interview, and record review, the facility failed to investigate a reported grievance of injury and failed to protect and promote the rights of 1 (P-3) patient out of 10 records reviewed, resulting in injury and the potential for harm for all patients served by the facility. Findings include:

See tags:
A0123 - Notice of Grievance Decision
A0144 - Care in a Safe Setting
A0145 - Free from Abuse/Harassment

Based on interview and record review, the facility failed to ensure that a grievance alleging abuse and injury was addressed, investigated, and followed up accurately and timely per facility policy for 1 (P-3) of 3 patients reviewed for complaints, resulting in denying a patient of their right to a complete grievance process. Findings include:

On 1/28/25 at 0855, an interview was conducted with the father/guardian of P-3. The guardian stated he called the facility in mid-December to request medical records and informed the COO (Staff B) that P-3's arm was found to be fractured on 11/18/24, the same day as discharge from the facility. The guardian stated that the orthopedic surgeon informed him the fracture appeared to be 3 to 4 weeks old.

The guardian stated he received a letter regarding a complaint investigation that was conducted 10/24/24 regarding allegations of abuse on P-3 and the termination of a BHA (behavioral health associate). He stated that he received a medical records release form but no further correspondence from the facility regarding an investigation into the arm fracture.

On 1/27/25 at 1315, the complaint and grievance logs were reviewed, and an interview was conducted with the Patient Advocate/Recipients Rights Officer (Staff E). There was no evidence a grievance was entered for P-3 during the month of December.

On 1/28/25 at 1253 an interview with conducted with Staff B. Staff B confirmed that P-3's guardian had left him a message on 12/16/24 and that is when the facility learned about the fracture. Staff B stated he conferred with the Director of Quality & Risk Management (Staff D) to discuss the case. Staff D acknowledged that there was no formal investigation conducted or that the process to send the grievance letter was followed, stating, "I should have alerted the ORR (Recipient Rights Officer) to open a second investigation."

Policy #RI 1.2, Patient Complaint and Grievance Process (date revised April 2023). "A written response will be provided within 7 business days to the patient who is the subject of the grievance."

Based on interview and record review, the facility failed to provide patient centered and dignified care in a safe setting for 1 (P-3) of 1 patient reviewed with a developmental disability, resulting in the likelihood of poor patient outcomes. Findings include:

P-3 is a 43-year-old male with a diagnosis of autism spectrum disorder with moderate cognitive impairment and bipolar disorder, current episode mixed, severe, without psychotic features. During an interview on 1/28/25 at 0835, with the home supervisor (Staff Q) of the Adult Foster Care where P-3 resides, Staff Q was queried on his communication skills. Staff Q stated that P-3 struggles with communication. If you ask him a this-or-that question, he will always reply with the second option and he does not always answer yes/no questions appropriately.

Nursing notes indicated P-3 was frequently isolative to self and does not socialize with peers. He would regularly refuse group participation.

Record review indicates P-3 was placed in seclusion on 10/22/24 for aggression toward staff and peers; was placed in seclusion, received chemical restraints, and placed in physical restraints on 10/23/24 for extreme agitation and aggression; and received a chemical restraint on 11/5/24 for aggression toward staff.

Record review indicates a behavioral plan, addressing strategies for comfort and communication barriers was put in place for P-3 on 11/5/24, 15 days after admission. No further instances of seclusion/restraint were noted after implementation of the plan.

An interview was conducted with the behaviorist (Staff H) on 1/28/25 at 1115. Staff H stated an order for a consultation was triggered after the third instance for seclusion/restraint with P-3. Staff H was queried on P-3's communication barriers and acknowledged the patient would struggle with communication, stating that he would look to the person speaking for cues on how they may want him to respond. Staff H stated there is a PECS (picture exchange communication system) board on the unit. When queried if P-3 would have the skills to use it, Staff H responded no.

Based on interview and record review, the facility failed to protect 1 (P-3) of 10 patients reviewed from excessive use of force by staff, resulting in the potential for physical and psychological abuse to all patients served by the facility. Findings include:

On 1/27/25 at 1315, the complaint and grievance logs were reviewed, and an interview was conducted with the Patient Advocate/Recipients Rights Officer (Staff E). Staff E produced a complaint folder regarding P-3 which indicated, on the evening of 10/23/24, P-3 was aggressive with staff and was placed in the seclusion room. The team on the DD (developmental delayed) unit requested assistance, which the facility refers to as a "PBX call" for de-escalation. A behavioral health associate (BHA) from the 4S crisis unit (Staff N) responded to assist. Two BHAs from the DD unit (Staff O and Staff P) witnessed Staff N being forceful and hitting P-3 and not utilizing proper CPI (crisis prevention institute) training techniques. Staff O and Staff P notified their nurse manager (Staff J), and a complaint investigation was initiated by Recipient Rights. Staff N was suspended pending investigation and was terminated on 10/28/24 for gross misconduct. Staff N did not appeal the findings.

Staff O and Staff P were interviewed on 1/28/25 to discuss the complaint and their observations of this situation.

Record review indicates that on 10/27/24, the nurse noted, "pt (patient) left arm edematous, bruising, painful, and tender to touch. Generalized bruising noted throughout. Small open area noted to nose. No drainage noted." The nurse entered an order for a medical consult and notified the physician.

Record review indicates a medical consultation on 10/28/24 for "left arm swelling and bruising." P-3 was evaluated by nurse practitioner (Staff G). The recommendations and plan stated, "left arm bruising/swelling - full range of motion intact in wrist/pam/shoulder. [sic] Palm size firm hematoma inside center of left arm. Good radial pulse. Patient to stop taking Motrin. Continue to monitor."

Record review indicates that on 11/17/24 at 2206, the nurse noted, "Patient was found in room on midnight shift around 2030. Upon assessment patient found to have a large bruise on left anterior bicep." An order for medical consult was placed on 11/18/24 at 0700.
On 11/18/24, a medical consultation was performed by Staff G for left arm bruising and pain. The recommendations and plan indicated, "Left arm pain - bruising on anterior left arm. Patient to continue use of Acetaminophen 500mg by mouth every 6 hours prn for pain. Continue to monitor."

During a phone interview on 1/28/25 at 1015, Staff G stated that P-3 was a poor historian and had to rely on nursing report. She states she conducted a thorough physical examination and P-3 had good range of motion. She states she would have anticipated feeling crepitus (crackling or grating caused by the bones rubbing against each other) if there was a fracture present and states the physical findings determined the patient did not require an x-ray.

During a phone interview on 1/28/25 at 1020, Staff G's supervising physician (Staff F). Staff F stated the NP (nurse practitioner) is supposed to let him know about injury cases and didn't tell him. He stated this population can't always verbalize what they are feeling, so doing the x-ray would have been appropriate.

P-3's guardian stated the adult foster care home transported P-3 to the emergency room on 11/18/24 (same day as discharge from the facility) during an interview on 1/28/25 at 0855. He stated P-3 was diagnosed with a left arm fracture and was informed by the orthopedic surgeon that the fracture appeared to be 3 to 4 weeks old. He underwent elbow surgery on 11/25/24.

Based on interview and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care of 1 (P-3) of 10 patients reviewed, resulting in poor hygiene and the potential for adverse outcomes. Findings include:

P-3 is a 43-year-old male with a diagnosis of autism spectrum disorder with moderate cognitive impairment and bipolar disorder, current episode mixed, severe, without psychotic features. Record review indicates patient appearance as "poor hygiene or disheveled" throughout hospital stay. Medical consultation report indicated medical diagnosis as "very low level of personal hygiene."

Record review revealed an order dated 11/8/24 at 1340, "Nursing staff to check patient's brief every two hours and to help him with daily ADL's (activities of daily living) every shift" and another order dated 11/11/24 at 1232, "Patient is to receive a staff assisted shower daily. Patient cannot perform own ADL's."

Reviewed all ADL documentation which indicated shower/bath as either "independent" or "unable/refused" throughout his stay except for on 11/11/24 where a "partial assist" was documented and on 11/12/24 and 11/13/24 where "total assist" was documented.

During an interview on 1/28/25 at 1107, the Chief Nursing Officer (Staff D) stated the facility does not have a policy for ADL's. Staff D acknowledged that staff failed to follow orders regarding a staff assisted shower daily.

Based on record review, the facility failed to establish an individualized plan of care for 1 (P-3) of 10 patients reviewed, resulting in negative outcomes for the patient. Findings include:

P-3 is a 43-year-old male with a diagnosis of autism spectrum disorder with moderate cognitive impairment and bipolar disorder, current episode mixed, severe, without psychotic features. Record review indicates his plan of care began on 10/22/24 which indicated one problem, Anger/Aggression. On 10/28/24, six problems were added to the care plan, impaired skin integrity related to bruising, swelling, and skin tear; altered sleep pattern related to insomnia; depressed mood with psychosis; altered tissue perfusion related to hypertension; altered nutrition related to gastritis; and risk for altered psychological wellbeing related to acute withdrawals to alcohol.

The plan of care failed to address special needs related to autism/cognitive impairment or communication. Additionally, the care plan listed alcohol withdrawals as a problem on the plan of care when the psychiatric evaluation on 10/22/24 at 0830 states P-3 denies alcohol and drug use and "never" has a drink containing alcohol.