HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Governing Body was met by failing to ensure:

1. Patient rights were promoted and protected (Refer to A115); and,

2. Patients were kept safe when an allegation of abuse was made, the alleged perpetrator (Certified Nursing Assistant 1) was allowed to continue patient care and the facility policy and procedure was not followed, to include notification of the facility Social Worker and the local police department for one patient (Patient 1). (Refer to A145).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutorily mandated compliance with the Federal regulations for the Condition of Participation: Governing Body, to ensure all patients were apprised of their rights and afforded quality healthcare in a safe setting.

Based on observation, interview and record review, the facility failed to ensure:

1. Patients admitted to the Bariatric Outpatient Clinic were provided information regarding patient's rights and responsibilities, and when applicable provided with the document, "An Important Message from Medicare." (Refer to A117);

2. The "Conditions of Admission, Advanced Directive Determination, Patient Information Access Codes and the Patient Information Pamphlets," which include the patients' rights and responsibilities, were given to the patients or the patients' responsible parties for eight patients (Patients 4, 5, 11, 23, 24, 27, 28 and 29). (Refer to A117);

3. The Conditions of Admission consent was obtained from the patient's responsible party (Patient 27) in a timely manner. (Refer to A117);

4. Conditions of Admission, Patient Information Pamphlets, and Advance Directive consents were obtained from the patients responsible party for two patients (Patients 6 and 7) admitted to the Neonatal Intensive Care Unit (NICU). (Refer to A117);

5. The Conditions of Admission, Patient Information Pamphlets, and Advance Directive consents were obtained from the patient's responsible party in a timely manner for one patient (Patient 10). (Refer to A117);

6. The grievance process was effective by failing to review grievances and failing to maintain accurate grievance logs. (Refer to A119, A122 and A123);

7. A written notice of the facility's decision to the patient's grievance was provided for one patient (Patient 20). (Refer to A123);

8. Patient 30's primary health care decision maker (PDM), according to the patient's Durable Power of Attorney for Health Care (DPOHC), was contacted in order to consent/or not consent, to a surgical procedure on behalf of Patient 30. (Refer to A132);

9. Patients were kept safe when an allegation of abuse was made, the alleged perpetrator (Certified Nursing Assistant 1) was allowed to continue patient care and the facility policy and procedure was not followed, to include notification of the facility Social Worker and the local police department for one patient (Patient 1). (Refer to A145); and

10. The less restrictive and alternative methods to physical wrist restraints were explored prior to their use for one patient (Patient 14). (Refer to A164).

The cumulative effect of these systemic problems resulted in failure to ensure patients were cared for in a safe manner, and their rights were protected and promoted at all times.

Based on observation, interview, and record review, the facility failed to ensure:

1. Patients admitted to the Bariatric Outpatient Clinic were provided information regarding patient's rights and responsibilities, and when applicable provided with the document, "An Important Message from Medicare;"

2. The "Conditions of Admission, Advanced Directive Determination, Patient Information Access Codes and the Patient Information Pamphlets," which include the patients' rights and responsibilities, were given to the patients or the patients' responsible parties for eight patients (Patients 4, 5, 11, 23, 24, 27, 28 and 29);

3. The Conditions of Admission consent was obtained from the patient's responsible party (Patient 27) in a timely manner;

4. Conditions of Admission, Patient Information Pamphlets, and Advance Directive consents were obtained from the patients responsible party for two patients (Patients 6 and 7) admitted to the Neonatal Intensive Care Unit (NICU); and

5. The Conditions of Admission, Patient Information Pamphlets, and Advance Directive consents were obtained from the patient's responsible party in a timely manner for one patient (Patient 10).

These failures resulted in a delay and/or omission of the patients or their responsible parties receiving information regarding the patient's rights.

Findings:

1. An observation of the Bariatric Clinic was conducted on February 8, 2016, at 2:30 p.m. A concurrent interview was conducted with the Supervising Receptionist (SR) at the clinic. The SR stated she oversees the admission process for all patients presenting to the clinic.

The SR further stated when a patient was admitted to the clinic they were given the "Conditions Of Admission" document to sign along with a document labeled, "Patient Information Pamphlets."

The "Patient Information Pamphlets" indicated in both English and Spanish, "I read and understand English/Spanish and I have received the following informational pamphlets in English/Spanish: Patients Rights and Responsibilities, Quit Smoking for Good, Speak Up, (Facility) Notice of Privacy Practices, State of California Organ & Tissue Donor, Safety Precautions for Avoiding Falls, and Patient has been advised the (Facility) is a no smoking hospital."

An interview was conducted with the SR on February 9, 2016, at 9:15 a.m. The SR stated she did not routinely give the pamphlets listed on the document, "Patient Information Pamphlets," unless the patient specifically requested them. When asked if she gave out the "Patient Rights and Responsibilities" document to every patient upon admission, the SR stated she did not. The SR further stated the "Patient Information Pamphlets" document which she was having the clinic patients sign was dated 2010. The SR further stated was not aware that a revised document dated 2015, was now distributed to all patients upon admission.

When the SR was asked if she gave the, "Important Message from Medicare document," to the applicable patients, she stated she did not.

A review of the facility policy, "Patient Rights (Reviewed 1/2007)," was conducted. The policy indicated, "All personnel are properly oriented and instructed in observing the patient rights policies...Each patient, his family and/or responsible party is fully informed of the patient's rights and responsibilities prior to or at the time of admission and during the hospital stay as evidenced in written statements in the brochure that is handed out to each patient at the time of admission."

2a. On February 8, 2016, the record for Patient 4 was reviewed. Patient 4, a minor child, was admitted to the facility on February 7, 2016, with diagnoses including asthma and pneumonia.

The "Conditions of Admission," "Advanced Directive Determination," and "Patient Information Access Code" were completed on February 7, 2016, and signed by Patient 4's responsible party with documentation of a witness as needed by a facility employee.

The "Admitting - Patient Information Pamphlets" dated February 7, 2016, did not indicate that Patient 4's responsible party had received the following information in either English or Spanish:
- Financial Assistance Information;
- Complaint or Concern Contact;
- Notice of Privacy Practice; and
- Right to Visitors Notification.

b. On February 8, 2016, the record for Patient 5 was reviewed. Patient 5, a minor child, was admitted to the facility on February 8, 2016, with diagnoses including fever and urinary tract infection.

There was no indication Patient 5 had insurance and "cash" rates for the emergency room visit were provided to Patient 5's responsible party.

The "Conditions of Admission," "Advanced Directive Determination," and "Patient Information Access Code" were completed on February 8, 2016, and signed by Patient 5's responsible party with documentation of a witness as needed by a facility employee.

The "Admitting - Patient Information Pamphlets" dated February 7, 2016, did not indicate that Patient 5's responsible party had received the following information in either English or Spanish:
- Financial Assistance Information;
- Complaint or Concern Contact;
- Notice of Privacy Practice; and
- Right to Visitors Notification.

During an interview with Admitting Clerk (AC) 1, on February 8, 2016, at 10:48 a.m., she reviewed the records and was unable to find documentation of Patient 4's or Patient 5's responsible parties receiving the patient information pamphlets. AC 1 stated the Admitting Clerk who had the patient's responsible party sign the admitting documents should indicate which pamphlets were given to the patient's responsible party.

c. A review of the admission documents for six patients, (Patients 11, 23, 24, 27, 28, and 29) was conducted.

A review of the "Patient Information" document included in the admission packet indicated in both Spanish and English, "I read and understand English and I have received the following information in English: Financial Assistance Information, Complaint or concern Contact, Notice of Privacy Practice, Right to Visitors Notification and Patient has been advised that (Facility) is a no smoking hospital."

Six out of six of the "Patient Information" documents for Patients 11, 23, 24, 27, 28, and 29, did not indicate that the patients or their responsible parties received the information reflected on the "Patient Information" document.

An interview was conducted with the Admitting Supervisor on February 8, 2016, at 3:10 p.m., who stated the "Patient Information" document should be completed to include the acknowledgement that the information documents were given to the patient or to the patient's responsible party.

3. A review of Patient 27's record was conducted. Patient 27 was admitted to the facility on February 5, 2016, with a diagnosis of pneumonia. The patient also had a history of profound intellectual disability and autism.

Patient 27 was nonverbal. Patient 27 resided in a home for intellectually disabled individuals.

Further record review indicated an individual profile of Patient 27, which contained emergency contact information was sent with the patient from his residence when he arrived at the facility.

A review of Patient 27's Conditions of Admission document dated February 5, 2016, at 11:24 a.m. indicated the patient was unable to sign the document. There was no documentation to show that efforts were made to contact the patient's responsible party to sign the Conditions of Admission document.

A review of the facility policy, "Conditions Of Admission (Last Revision: November 2015)," was conducted. The policy indicated, "The primary intent of the Conditions of Admissions form is to establish the contractual relationship between the hospital and the patient being admitted for services...In the event the patient due to their medical condition (is unable to sign) it is acceptable for their spouse, adult child or responsible party to sign."

An interview was conducted with the Admitting Supervisor on February 9, 2016, at 10:50 a.m., who stated the admitting office should be notified when there was a responsible party or emergency contact who could sign the Conditions of Admission document.


28294

4a. On February 8, 2016, the record for Patient 6 was reviewed. Patient 6 was admitted to the facility on February 5, 2016, with diagnoses including respiratory distress and prematurity.

There was no indication the "Conditions of Admission," "Advanced Directive Determination," and "Admitting - Patient Information Pamphlets" had been signed by and provided to Patient 6's responsible party.

b. On February 8, 2016, the record for Patient 7 was reviewed. Patient 7 was admitted to the facility on February 2, 2016, with diagnoses including respiratory distress and prematurity.

There was no indication the "Conditions of Admission," "Advanced Directive Determination," and "Admitting - Patient Information Pamphlets" had been signed by and provided to Patient 7's responsible party.

During an interview with the Admitting Supervisor (AS), on February 9, 2016, at 12:55 p.m., she reviewed the records for Patients 6 and 7, and was unable to find the admission documents. The AS stated the responsible party's for Patients 6 and 7 should have signed and received the "Conditions of Admission," "Advanced Directive Determination," and "Admitting - Patient Information Pamphlets."

The facility policy and procedure titled "Patient Rights" revised November 2007, revealed "... Each patient, his family and/or responsible party is fully informed of the patient's rights and responsibilities prior to or at time of admission and during the hospital stay as evidenced in written statements in the brochure that is handed out to each patient at the time of admission. ..."

The facility policy and procedure titled "Conditions of Admission" revised November 2015, revealed "... Signatures in the Conditions of Admission (COA) form are required prior to services being rendered. Upon signing the COA form, the patient has given his/her approval for receiving treatment and ensured the facility financial responsibility. ... Elements of the "Conditions of Admission" form: ... Patients Rights ..."

The facility policy and procedure titled "Admitting a Patient" revised May 2011, revealed "... The admitting clerk will explain the forms contained in the patient admission packet and have the patient sign the pamphlet check off form confirming receipt of pamphlets. ..."

5. On February 8, 2016, the record for Patient 10 was reviewed. Patient 10 was admitted to the facility on January 24, 2016, as a transfer from another acute care facility because of the need for a higher level of care, with the diagnosis of respiratory distress.

Patient 10's responsible party signed consents for the treatment of Patient 10 in the Neonatal Intensive Care Unit (NICU) on January 24, 2016.

Patient 10 was discharged from the facility on February 1, 2016.

The "Conditions of Admission," "Advanced Directive Determination," "Patient Information Access Code," and "Admitting - Patient Information Pamphlets" were signed by and provided to Patient 10's responsible party on February 1, 2016, at 2:45 p.m. (8 days after admission to the facility and the day Patient 10 was discharged from the facility).

During an interview with the Admitting Supervisor (AS), on February 10, 2016, at 12:25 p.m., she reviewed the record and was unable to find documentation of the admitting documents prior to February 1, 2016. The AS stated the "Conditions of Admission,"Advanced Directive Determination," "Patient Information Access Code," and "Admitting - Patient Information Pamphlets" should have been signed and given to Patient 10's responsible party at the time of Patient 10's admission to the facility on January 24, 2016.

The facility policy and procedure titled "Conditions of Admission" revised November 2015, revealed "... Signatures in the Conditions of Admission (COA) form are required prior to services being rendered. Upon signing the COA form, the patient has given his/her approval for receiving treatment and ensured the facility financial responsibility. ... Elements of the "Conditions of Admission" form: ... Patients Rights ..."

Based on interview and record review, the facility failed to ensure the grievance process was effective. This resulted in the failure to review grievances by the facility's Grievance Committee and the failure to maintain an accurate grievance log.

1. Patient 18's family member's grievance was not acknowledged for 14 days and one of the family member's grievances was not addressed; and,

Patient 20's grievance was not investigated and the patient did not receive a response to her grievance.

This had the potential to result in a delay in the investigation and response to patients' grievances.

Findings:

On February 8, 2016, the facility's grievance log was reviewed.

a. On February 9, 2016, at 10:10 a.m., the grievance file for Patient 18 was reviewed with the Director Quality and Risk Management (DQRM).

On May 20, 2015, Patient 18's family member "called in" a grievance to the facility in regards to Patient 18's hospitalization at the facility on May 2 through 5, 2015.

One of Patient 18's family member's concerns was in regards to the social worker providing her cell telephone number but the cell number did not have a voicemail set up.

Patient 18's family member was sent a letter dated June 3, 2015 (14 days after the facility had received the grievance), which indicated the facility had "a clearly delineated program of complaint/grievance investigation," the "process can take up to 30 days," and "upon the conclusion of the investigation, a letter will be sent to you."

Patient 18's family member was sent a letter dated June 16, 2015, which indicated the grievance process was completed on June 16, 2015, and as a result of the facility's investigation Patient 18's family member's grievance regarding care of the physician was sent to Peer Review Committee "so they may take corrective actions necessary."

There was no indication the grievance in regards to the ability to contact the social worker was addressed.

During a concurrent interview with the DQRM, he reviewed the grievance file and was unable to find documentation of an investigation of Patient 18's family member's grievance in regards to the social worker/social services. The DQRM stated the family member's grievance in regards to the social worker/social services should have been investigated as part of the grievance and a response provided to Patient 18's family member in the letter dated June 16, 2015.

b. The facility grievance log indicated Patient 20's grievance "Day 30 Final Notice" had been done on January 5, 2016.

On February 9, 2016, at 10:20 a.m., the grievance file for Patient 20 was reviewed with the Director Quality and Risk Management (DQRM).

On December 8, 2015, Patient 20 came to the facility Patient Relations Office to file a grievance in regards to her hospital stay on November 25 through 27, 2015, and the documentation indicated the patient "would like a response from the hospital about her complaint."

Patient 20 was sent a letter dated December 14, 2015, which indicated the following:
"We strive to provide appropriate medical care of the highest possible quality to our patients. To ensure this, a clearly delineated program of complaint/grievance investigation and resolution process is already in place. Your concerns will go through this process and will be discussed and investigated by the Radiology Director and the Nursing Director. This process can take up to 30 days. Upon the conclusion of the investigation, a letter will be sent to you."

There was no indication the facility's investigation had been completed.

There was no indication Patient 20 had received a letter after December 14, 2015, with the facility's conclusion of the investigation (63 days after Patient 20 had filed a grievance).

During a concurrent interview with the DQRM, he reviewed the grievance file and was unable to find documentation of an investigation of the patient's grievance, and a response letter being sent to Patient 20. The DQRM stated the investigation should have been completed and Patient 20 should have received a letter in response to her concerns.

On February 10, 2015, the facility Grievance Committee meeting minutes were reviewed. The Committee met on June 24, 2015, and reviewed the grievances for January, February, and March 2015.

There was no indication the Committee had met since June 24, 2015, and there was no indication the grievances received had been reviewed since March 2015 (10 months).

During an interview with the DQRM and the Chief Nursing Officer (CNO), on February 10, 2016, at 10:55 a.m., the DQRM stated the Grievance Committee had not met since June 24, 2015, and there had not been a review of the grievances since March 2015.

The facility policy and procedure titled "Patient Complaints, Grievances, and Problems" revised January 2012, revealed "...(Name of Facility) Board of Directors has, by approval of this policy, provided the formal authority for the establishment of this grievance process. ... The following functions have been delegated to the Grievance Committee: Responsibility for assuring the effective operation of the grievance process. Conducting a review of grievances and assuring the prompt resolution of those grievances. ... The Grievance Committee will meet quarterly or within seventy-two (72) hours of receipt of a grievance if needed. The Grievance Committee will assure that the grievance is investigated. ..."

Based on interview and record review, the facility failed to ensure acknowledgement of a grievance was completed within seven days of receipt for one patient (Patient 18). This had the potential to result in a delay in the investigation of the grievance.

Findings:

On February 8, 2016, the facility's grievance log was reviewed.

On February 9, 2016, at 10:10 a.m., the grievance file for Patient 18 was reviewed with the Director Quality and Risk Management (DQRM).

On May 20, 2015, Patient 18's family member "called in" a grievance to the facility in regards to Patient 18's hospitalization at the facility on May 2 through 5, 2015.

Patient 18's family member was sent a letter dated June 3, 2015 (14 days after the grievance had been filed with the facility), which indicated the facility had "a clearly delineated program of complaint/grievance investigation," the "process can take up to 30 days," and "upon the conclusion of the investigation, a letter will be sent to you."

Patient 18's family member was sent a letter dated June 16, 2015, which indicated the grievance process was completed on June 16, 2015, and as a result of the facility's investigation Patient 18's family member's grievance regarding care by the physician was sent to Peer Review Committee "so they may take corrective actions necessary."

During a concurrent interview with the DQRM, he reviewed the grievance file and stated the initial letter, in response to the grievance, should have been sent within seven (7) days of the facility receiving the grievance.

The facility policy and procedure titled "Patient Complaints, Grievances, and Problems" revised January 2012, revealed "... A letter, signed by Administration or designee, shall be given to the complainant within seven (7) business days following the investigation. Should the investigation require more time the response should address that the hospital is still working to resolve the complaint and that there will be follow up with another written response once the grievance is resolved. At no time shall resolution take longer than thirty (30) days. ..."

Based on interview and record review, the facility failed:

1. To ensure the written notice of its decision to the patient's/patient's responsible party grievance addressed one of the issues/concerns for one patient (Patient 18). This resulted in an incomplete response to the patient's/patient's responsible party grievance.

2. To ensure a written notice of its decision to the patient's grievance was provided for one patient (Patient 20). This resulted in Patient 20 not receiving a resolution of the grievance submitted.

Findings:

On February 8, 2016, the facility's grievance log was reviewed.

1. On February 9, 2016, at 10:10 a.m., the grievance file for Patient 18 was reviewed with the Director Quality and Risk Management (DQRM).

On May 20, 2015, Patient 18's family member "called in" a grievance to the facility in regards to Patient 18's hospitalization at the facility on May 2 through 5, 2015.

One of Patient 18's family member's concerns was in regards to the social worker providing her cell telephone number but the cell number did not have a voicemail set up.

Patient 18's family member was sent a letter dated June 3, 2015, which indicated the facility had "a clearly delineated program of complaint/grievance investigation," the "process can take up to 30 days," and "upon the conclusion of the investigation, a letter will be sent to you."

Patient 18's family member was sent a letter dated June 16, 2015, which indicated the grievance process was completed on June 16, 2015, and as a result of the facility's investigation Patient 18's family member's grievance regarding care by the physician was sent to Peer Review Committee "so they may take corrective actions necessary."

There was no indication the grievance in regards to the ability to contact the social worker was addressed.

During a concurrent interview with the DQRM, he reviewed the grievance file and was unable to find documentation of an investigation of Patient 18's family member's grievance in regards to the social worker/social services. The DQRM stated the family member's grievance in regards to the social worker/social services should have been investigated as part of the grievance and a response provided to Patient 18's family member in the letter dated June 16, 2015.

2. On February 9, 2016, at 10:20 a.m., the grievance file for Patient 20 was reviewed with the Director Quality and Risk Management (DQRM).

On December 8, 2015, Patient 20 came to the facility Patient Relations Office to file a grievance in regards to her hospital stay on November 25 through 27, 2015, and the documentation indicated the patient "would like a response from the hospital about her complaint."

Patient 20 was sent a letter dated December 14, 2015, which indicated the following:
"We strive to provide appropriate medical care of the highest possible quality to our patients. To ensure this, a clearly delineated program of complaint/grievance investigation and resolution process is already in place. Your concerns will go through this process and will be discussed and investigated by the Radiology Director and the Nursing Director. This process can take up to 30 days. Upon the conclusion of the investigation, a letter will be sent to you."

There was no indication the facility's investigation had been completed.

There was no indication Patient 20 had received a letter after December 14, 2015, with the facility's conclusion of the investigation (63 days after Patient 20 had filed a grievance).

During a concurrent interview with the DQRM, he reviewed the grievance file and was unable to find documentation of an investigation of the patient's grievance, and a response letter being sent to Patient 20. The DQRM stated the investigation should have been completed and Patient 20 should have received a letter in response to her concerns.

The facility policy and procedure titled "Patient Complaints, Grievances, and Problems" revised January 2012, revealed "... A letter, signed by Administration or designee, shall be given to the complainant within seven (7) business days following the investigation. Should the investigation require more time the response should address that the hospital is still working to resolve the complaint and that there will be follow up with another written response once the grievance is resolved. At no time shall resolution take longer than thirty (30) days. ..."

Based on observation, interview, and record review, the facility failed to ensure Patient 30's primary health care decision maker (PDM), according to the patient's Durable Power of Attorney for Health Care (DPOHC), was contacted in order to consent/or not consent, to a surgical procedure on behalf of Patient 30.

DPOHC-written instructions relating to the provision of health care when a patient is incapacitated and delegates health care decision making authority to another individual. The individual's responsibility is to make decisions to the same extent as the patient would have if able.

This failure resulted in Patient 30 having a percutaneous endoscopic gastrostomy (PEG tube) surgically placed which could potentially have contradicted the wishes of the PDM. (PEG tube- allows nutrition and/or medications to be put directly into the stomach via a surgically placed opening).

Findings:

A tour and observation of the facility's Intensive Care Unit (ICU), was conducted on February 9, 2016. Patient 30 was observed in Bed 5. The patient was sedated and had ventilator support (mechanical device providing respiratory support through a tube placed in the patient's airway). Patient 30 was nonresponsive and required total nursing care/assistance. The patient also had a PEG tube.

A review of Patient 30's record was conducted. Patient 30 was admitted to the facility on January 28, 2016, with a two day history of abdominal pain and distention. The patient was subsequently diagnosed with a bowel obstruction.

A review of Patient 30's DPOHC, which was located in her record, signed by the patient, and notarized on October 23, 1997, was conducted. The document reflected Patient 30 appointed a PDM. The document also reflected if the PDM was unable, unwilling, or ceases to act, Patient 30 had appointed a secondary decision maker.

A review of a palliative care assessment dated February 2, 2016, at 2:50 p.m. was conducted. The assessment indicated Patient 30 appointed the PDM because the PDM had been Patient 30's friend for over 30 years.

Upon further record review, the record reflected that the PDM had given telephone consent for two procedures. On January 30, 2016, at 1:35 p.m., the PDM gave consent for Patient 30 to have a Colonoscopy (visual examination of the colon with a scope).

On February 3, 2016, at 3:55 p.m., the PDM had given telephone consent for placement of a peripherally inserted central catheter ( a long, thin hollow tube placed into a vein, used to give medication or nutrition).

A review of a completed consent form dated February 4, 2016, at 11:05 a.m., for Patient 30 for PEG tube placement was conducted. The informed consent was obtained from the patient's secondary decision maker, not the patient's PDM.

Further record review failed to show that efforts to contact Patient 30's PDM were attempted. There was no documentation to indicate the patient's PDM was unable or unwilling to act on the patient's behalf.

An interview was conducted with the Admitting Supervisor on February 9, 2016, at 10:50 a.m. The Admitting Supervisor stated the PDM should have been contacted to obtain the consent for PEG tube placement.

A review of the facility policy, "Advance Directive (Last Revision: December 2015)," was conducted. The policy indicated the purpose of an Advance Directive was to establish a mechanism whereby an individual may declare in writing their health care wishes and desires in the event of incapacitation.

Patient 30 subsequently had a PEG tube placed on February 7, 2016, without consent from the PDM.

Based on interview and record review, the facility failed to ensure patients were kept safe when an allegation of abuse was made, the alleged perpetrator (Certified Nursing Assistant 1) was allowed to continue patient care and the facility policy and procedure was not followed, to include notification of the facility Social Worker and the local police department for one patient (Patient 1). This resulted in a delay in the investigation by the facility of the abuse allegation, and had the potential to result in harm to the patients cared for by Certified Nursing Assistant (CNA) 1.

Findings:

On January 13, and February 8, 2016, the record for Patient 1 was reviewed. Patient 1 was admitted to the facility on January 7, 2016, with the diagnosis of pneumonia.

The "NSG (Nursing) - Narrative" dated January 9, 2016, at 8:40 p.m., indicated Patient 1 was assigned a 2:1 (two patients to one CNA) sitter for safety and Patient 1's family member was at the bedside.

The "NSG - Narrative" dated January 10, 2016, indicated the following:
- At 3 a.m., Patient 1's family member was leaving the facility for the rest of the night and CNA 1 continued to be at Patient 1's bedside as ordered (Entry into record was done by Registered Nurse (RN) 1 on January 10, 2016, at 11:27 p.m. - after the patient had been discharged from the facility).
- At 5 a.m., Patient 1 was given a bed bath by CNA 1 and CNA 2, and the patient was noted to be noncompliant and agitated during the bath (Entry into record was done by RN 1 on January 10, 2016, at 11:20 p.m. - after the patient had been discharged from the facility).
- At 6 a.m., the RN assisted CNA 1 with a diaper change, and "pt (patient) was agitated pointing to CNA 1 while speaking to me in (a language other than English) and kicking CNA 1: reassured pt helping her get cleaned: no noted issues upon cleaning pt (Entry into record was done by RN 1 on January 10, 2016, at 11:20 p.m. - after the patient had been discharged from the facility)."
- At 6:20 a.m., Patient 1's family member was at the patient's bedside (Entry into record was done by RN 1 on January 10, 2016, at 11:30 p.m. - after the patient had been discharged from the facility).

During an interview with the Guest Services Representative (GSR), on January 13, 2016, at 11:57 a.m., she stated she was doing rounds on January 10, 2016, at 10 a.m., and RN 3 called the front desk requesting for someone from Patient Relations to see Patient 1. The GSR stated when she arrived at Patient 1's room on January 10, 2016, at 10:38 a.m., Patient 1's family member requested if they could speak outside of the room because Patient 1 had just fallen asleep. The GSR stated Patient 1's family member stated she had been called early in the morning by Patient 1 who stated she was being abused by the "sitter" who was twisting her fingers and picked her up and threw her on the bed. The GSR stated Patient 1's family member stated, Patient 1 was a little confused but she had never seen her this upset and Patient 1 kept telling her the same thing over and over again, she had been abused, mistreated last night and she needed to call the police. The GSR stated she informed RN 3 (the Charge Nurse) of Patient 1's family member's concerns, and RN 3 stated Patient 1 would not have CNA 1 as a sitter again. In addition, the GSR informed House Supervisor (HS) 1 of the patient's and family member's concerns.

There was no indication in the record of Patient 1's concerns/allegations.

There was no indication in the record of Social Services being notified of Patient 1's concerns or Patient 1 being evaluated by a Social Worker.

There was no indication in the record Patient 1's physician was notified of her concerns/allegations.

There was no indication the local police department was notified.

Patient 1 was discharged from the facility on January 10, 2016, at 6:40 p.m.

During an interview with the Patient Relations Supervisor (PRS), on January 13, 2016, at 9:40 a.m., he stated he had been made aware of Patient 1's complaint on January 11, 2016, in the morning; and Patient 1's family member had come to the facility on January 11, 2016, to file a grievance.

On January 13, 2016, CNA 1's time cards were reviewed and indicated she worked on January 9, 2016, at 6:48 p.m., until January 10, 2016, at 7:34 a.m.; January 10, 2016, at 6:51 p.m., until January 11, 2016, at 7:31 a.m.; and January 12, 2016, at 6:49 p.m., until January 13, 2016, at 7:24 a.m.

CNA 1 worked by providing direct patient care for two, twelve hour shifts, following the allegation of abuse made by Patient 1 and her family member.

During an interview with the Manager Medical/Surgical/Telemetry (MMST), on January 13, 2016, at 11:12 a.m., she stated CNA 1 had not been asked about Patient 1's allegations and CNA 1 should not have returned to work/patient care until the investigation of the allegations was completed.

During an interview with House Supervisor (HS) 1, on January 13, 2016, at 12:08 p.m., she stated the GSR told her on January 10, 2016, Patient 1's family member was concerned that Patient 1 was being physically abused during the night by CNA 1 by twisting her finger and throwing her on the bed. HS 1 stated Patient 1 wanted the police to be called. HS 1 stated she informed RN 3 that an incident report should be completed and CNA 1 should not care for Patient 1 again. HS 1 stated she did not notify the administrator on call; she did not remove CNA 1 from patient care (allowed to work two additional 12 hour night shifts); she did not call the local police department about the alleged incident; and she did not inform CNA 1 of the allegation. HS 1 stated she should have informed the administrator on call and CNA 1 should not have worked/done patient care until a facility investigation was completed.

During an interview with the Director Quality and Risk Management (DQRM), on January 13, 2016, at 12:25 p.m., he stated he was informed of Patient 1's grievance/allegation of abuse on January 12, 2016, in the morning when he returned to work (CNA 1 worked the 7 p.m. shift on January 12, 2016).

The facility policy and procedure titled "Abuse Reporting" revised July 2011, revealed "... Alleged in Hospital Abuse. Upon a patient making an allegation, Nursing Staff will take the following actions: Perform a Nursing Assessment using the RN Shift Reassessment form. Notify the Social Services Department for psychosocial assessment and possible referral for community resources. Notify the patient's attending physician of the allegation. Notify Patient Relations and complete an Incident Report. The (Name of City) Police Department will be notified of the allegation by Nursing, Patient Relations or Social Services as soon as possible. ..."

There was no indication in the facility's policy and procedure that the accused individual would be removed from patient care, was to leave the facility premises and was to be placed on administrative leave pending the results of the facility's investigation of the allegation of abuse.

Based on interview and record review, the facility failed to ensure less restrictive, alternative methods to physical wrist restraints were explored prior to their use for one patient (Patient 14). This failure had the potential to employ a more severe method to restrain a patient than may have been necessary.

Findings:

On February 9, 2016, the record for Patient 14 was reviewed. Patient 14 was admitted to the facility on January 19, 2016, with diagnoses of urinary tract infection and humerus (long bone of upper arm) fracture.

According to the document titled, "Restraint Flow Sheet..." dated January 23, 2016, the behavior of "Disrupting Therapies" was the reason for the need to restrain Patient 14. The restraint being used was a cloth encircling each wrist and then tied to the bed frame to limit mobility of both arms. No alternatives, to this type of restraint, were attempted according to the documentation for this date.

Another, undated, "Restraint Flow Sheet" did not have alternatives attempted documented. It also did not include the type of restraint used and the reason for using a restraint.

On February 9, 2016, at 1:10 p.m., the Director of Medical/Surgical (DMS) was interviewed regarding the "Restraint Flow Sheet." The DMS stated, the flow sheet should have alternatives to the use of restraints documented and it should be filled out completely.

On February 10, 2016, the facility policy titled, "Restraint and Seclusion" revised January 2015, was reviewed. The policy indicated, "...The use of restraint...occurs only after alternatives to such use have been considered and/or attempted as appropriate. Such alternatives may include, but are not necessarily limited to: Re-orientation; De-escalation; Limit setting; Increased observation and monitoring; Use of a sitter; Change in the patient's physical environment; and Review and modification of medication regimens..."