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Based on record review and interview, the Chief Executive Officer failed to ensure the effective implementation of a timely and comprehensive internal investigation into an allegation of staff to patient abuse which would include the immediate removal of an employee, who had allegedly abused a patient, from direct patient care pending results of the internal investigation for 1 of 1 patients in a total sample of 14 patients. Findings:
The Hospital's Abuse Policy was reviewed. The Abuse Policy documents "The patient has the right to be free from abuse (verbal, sexual, physical, mental), corporal punishment, neglect, involuntary seclusion, or harassment from staff, visitors, other patients, consultants, volunteers, family member or guardians, friends, or other individuals. The Abuse Policy further documents "Verbal abuse refers to any use of oral, written, gestured language that includes disparaging and derogatory terms to patient or families or heard by others."
Further review of the Hospital's Abuse Policy revealed that all alleged violations would be investigated through questioning of patient, family members, staff and co-workers involved and through observation. The patient would be protected from further potential abuse while the investigation was in progress by reassignment of the accused employee. The results of all investigations will be reported to the Administrator or his representative, and to the police, State surveying agency, and certification agency within five days of the incident. Documentation of the Abuse Policy reflected if an alleged violation by an employee had been verified, the employee would be terminated.

#S3, Radiology Aide was interviewed on 02/23/10 at 11:00 a.m. #S3, Radiology Aide revealed that on 08/21/09 she witnessed #S2, Radiology Tech when he became agitated because he could not properly position Patient #1 for X-ray. #S3, Radiology Aide stated that after #S2, Radiology Tech became frustrated, he spoke abusively in the presence of Patient #1. When asked, #S3, Radiology Aide reported that she was standing at the door of the X-ray room and clearly heard #S2, Radiology Tech speak in a loud tone of voice instructing the patient's sitter to "get his damn old ass out of my x-ray room now".

In further interview on 02/23/10 at 11:00 a.m., #S3, Radiology Aide stated that she assisted Patient #1 back to the ER and immediately reported to #S1, R.N., House Supervisor that #S2, Radiology Tech was physically rough and had instructed her (#S3) to "get his [Patient #1] damn old ass out of my X-ray room now " . #S3, Radiology Aide reported that this was not the first time that #S2, Radiology Tech had been abusive around patients and staff. #S3, Radiology Aide stated that #S2, Radiology Tech "yells and curses very frequently". #S3, Radiology Aide stated that #S2, Radiology Tech behavior had been reported to his supervisor in the past but nothing was done. #S3, Radiology Aide stated that on Monday morning (02/24/09), she reported the incident to #S4, R.N., Director of Nursing (DON) who took her statement over the telephone. When asked, #S3, Radiology Aide stated that no one asked her to give a written statement and if she had been asked, she would have wrote one because she was the person who immediately reported the abuse.

Interview with #S1, R.N., House Supervisor on 02/23/10 at 10:10 a.m. revealed that she provided patient care in the ER on 08/21/09 from 7 a.m. to 4 p.m. and worked in the capacity as House Supervisor on 08/21/09 form 4:00 p.m. until 7:00 p.m. #S1, R.N., House Supervisor reported that she recalled when Patient #1 returned from the Radiology Dept., #S3, Radiology Aide and the patient's sitter informed her (#S1) that #S2, Radiology Tech had treated and spoke to Patient #1 in a rough manner. #S1, R.N., House Supervisor stated that she immediately assessed Patient #1 after being informed of the incident. #S1, R.N., House Supervisor stated that Patient #1 did not have any obvious injuries but the patient verbalized that his right leg was hurting, and the patient was given medication for pain [Lortab 5ml].

Further interview on 02/23/10 at 10:10 a.m. #S1, R.N., House Supervisor stated that she did not request a written statement from anyone involved and did not interview #S2, Radiology Tech because she was not sure that she was in charge of #S2, Radiology Tech, he had his own department head that he reported to. #S1, House Supervisor reported that #S4, R.N., DON called every Saturday and Sunday evening to check on staffing. #S1, R.N., House Supervisor reported that she did not have any written documentation pertaining to the reported incident. When asked, #S1, R.N., House Supervisor indicated that she verbally reported the incident to #S4, R.N., (DON) near the end of the shift but was not sure of what day and time.
#S5, Ultrasound Tech was interviewed on 02/24/10 at 10:30 a.m. #S5, Ultrasound Tech revealed that she completed an Ultrasound on Patient #1 on 08/21/09 at approximately 2:00 p.m. #S5, Ultrasound Tech reported that after she had completed the Ultrasound, Patient #1 was scheduled for an x-ray of his right knee and leg to be done by #S2, Radiology Tech. #S5, Ultrasound Tech reported while [#S2] Radiology Tech was positioning Patient #1 she heard Patient #1 say, "stop you are hurting me" she then heard [#S2], Radiology Tech say, " get his damn old ass out of my x-ray room now." #S5, Ultrasound Tech stated that #S2, Radiology Tech had treated other patients abusively and this event was not uncommon. #S5, Ultrasound Tech stated that #S2, Radiology Tech had been reported to his supervisor (#S7, ) concerning his abusive behavior on multiple occasions however nothing was ever done. #S5, Ultrasound Tech stated that she had not been trained on what to do if abuse occurs and did not know if the Radiology Dept. had a policy on handling abuse if it occurred.
#S7, Radiology Dept. Head was interviewed on 02/23/10 at 9:40 a.m. #S7, Radiology Dept. Head reported that she had supervised #S2, Radiology Tech since the year 2000. #S7, Radiology Dept. Head stated that she had encountered several occurrences when #S2, Radiology Tech had been physically and/or verbally abusive. #S7, Radiology Dept. Head stated that she had never given #S2, Radiology Tech a written reprimand but had talked to him several times in reference about abusive actions toward staff and patients.
In further interview with #S7, Radiology Dept. Head on 02/23/10 at 9:40 a.m. #S7, Radiology Dept. Head indicated that she had not recalled being trained on what to do if abuse occurs. When asked, #S7, Radiology Dept. Head reported that she was responsible for investigating and documenting information of complaints within the Radiology Department but did not document anything in reference to the incident involving #S2, Radiology Tech and Patient #1. #S7, Radiology Dept. Head confirmed that #S2, Radiology Tech was not immediately reassigned while the investigation into the allegation of staff to patient abuse was being conducted. #S7, Radiology Dept. Head stated that she did not become aware of the incident concerning Patient #1 until Tuesday August 25, 2009 after she spoke to #S6, Administrator in reference to another matter.
#S2, Radiology Tech was interviewed on 02/23/10 at 10:30 a.m. #S2, Radiology Tech confirmed that he X-rayed Patient #1 on 08/21/09. #S2, Radiology Tech stated that he had difficulty positioning Patient #1. #S2, Radiology Tech stated that the x-rays were O.K. but he wanted to get a better view. #S2, Radiology Tech reported that he knew Patient #1 was hurting because Patient #1 informed him that he [#S2] was hurting him. #S2, Radiology Tech reported that he (#S2) attempted several times to reposition the patient after being informed by the patient that he was hurting the patient.

Review of the Hospital's In-service log on Abuse Policy & Procedure Training revealed that the hospital had provided training in November 2009. Further review of the In-service log on Abuse Policy & Procedure Training reflected that the hospital did not provide training on Abuse for the year 2008, 2007 and 2006.

Interview with #S4, R.N., DON on 02/24/10 at 11:00 a.m. confirmed that the hospital had not provided Abuse Policy & Procedure Training to the hospital staff for the years 2008, 2007 and 2006.

Interview with #S7, Radiology Dept. Head on 02/24/10 at 10:15 a.m. confirmed that #2; Herman Murphy's last documented annual performance was dated 09/25/05. #S7, Eva Williamson, Radiology Dept. Head could not explain why she had not completed an annual appraisal on #S2 Herman Murphy for the year 2006, 2007, 2008, and 2009.

#S6, Administrator, #S4, R.N., DON and #S9, Regulatory Compliance Officer were interviewed on 02/23/10 at 11:30 a.m. #S6, Administrator confirmed the hospital's Abuse policy was inadequate and revisions were needed. #S6, Administrator stated the Abuse policy did not have an adequate process for reporting abuse. #S6, Administrator stated every department had a different process for reporting complaints. #S6, Administrator stated he considered and investigated the incident as a grievance. #S6, Administrator stated, while he investigated the incident, he did not believe that the complaint/grievance was an allegation of abuse. However, the Administrator confirmed he was mislead because he followed the Grievance policy and not the hospital's Abuse policy. Further interview with the #S6, Administrator, #S4, DON and #S9, Hospital's Regulatory Compliance Officer, the Administrator confirmed the allegation was substantiated as verbal abuse and he had not followed the Hospital's Abuse Policy. The Administrator stated that #S2, Radiology Tech should have understood he had been reprimanded for verbal abuse. #S6, Administrator confirmed documentation in the investigation section of the Hospitals Grievance Form that he had authored an entry that read: "I [#S2] personnel folder, and found good to excellent evaluations and no write-up for any complaints that have been received in the past." Further interview with #S6, Administrator could not provide explanation why #S2's Personnel file did not contain an annual appraisal on #S2, for the year 2006, 2007, 2008, and 2009.

#S6, Administrator was interviewed on 02/24/10 at 11:20 a.m. #S6, Administrator reported that he did not have his own copy of the Hospital's Policy & Procedure Manual and was vaguely familiar with Federal Regulations for the Hospital's Conditions of Participation.
#S6, Administrator confirmed that #S2, Radiology Tech was not immediately reassigned while the investigation into the allegation of staff to patient abuse was being conducted.

Based on record review and interview the hospital failed to ensure a patient had the right to be free from all forms of abuse. The hospital failed to have mechanisms in place to ensure a patient was not physically or verbally abused. The hospital failed to identify events and occurrences that constituted abuse, failed to thoroughly conduct an objective investigation into an allegation of abuse, and failed to analyze an incident of abuse. The hospital also failed to protect a patient who returned for care and services after an allegation of abuse was made for 1 patient whose family alleged physical and verbal abuse in a total sample of 14 (#1). Findings:

Interview with Administrator #S6 on 2/22/10 at approximately 10:30 a.m., during the entrance conference, revealed the hospital had an incident that occurred in August, 2009 concerning (Patient #1). Administrator #S6 revealed the incident occurred in the X-Ray department and there was a complaint made by the patient's daughter concerning the treatment of patient #1. Administrator #S6 further stated he self reported the incident to the Department of Health and Hospitals (DHH) and sent the information concerning the incident to DHH - State Office. The Administrator stated that following his investigation he could not determine that physical and/or verbal abuse had occurred.
Review of the clinical record of (Patient #1) revealed he was a 94 y/o male who presented to the Hospital's Emergency Room (ER) on 08/21/09 at 1211 (12:11 p.m.) with a chief complaint of swelling to the right knee and ankle. Documentation reflected the patient had experienced a fall approximately one week prior to the ER visit. Further review of the record reflected the patient was alert and oriented to person, place, and time and had a past medical history of Congestive Heart Failure (CHF) and Hypertension (HTN).
Documentation of the ER physician's orders reflected an X-ray of the chest, right leg, right knee and Venous Ultrasound were ordered and completed on 08/21/09. Review of the Radiology department reports dated 8/21/09 reflected the ultrasound was dictated at 2:38 p.m. and the chest x-ray, right leg and right knee x-rays were dictated at 4:27 p.m. No abnormalities were found.

Interview with #S1, Registered Nurse (RN) House Supervisor on 02/23/10 at 10:10 a.m. revealed that she provided patient care in the ER on 08/21/09 from 7 a.m. to 4 p.m. and later worked in the capacity as House Supervisor on 08/21/09 until 7 p.m. RN, #S1, revealed
that she recalled when Patient #1 returned from the Radiology department to ER. She stated the patient was transferred by stretcher by #S3, Radiology Aide and by the patient's sitter. #S1, RN House Supervisor stated that Patient #1's sitter complained to her that #S2, X-Ray Tech was rough with Patient #1. #S1, RN House Supervisor stated she was also informed by #S3, Radiology Aide during that time that #S2, Radiology Tech had treated and spoke to (Patient #1) roughly.

Further interview with #S1, RN, House Supervisor at that time revealed she assessed Patient #1 and did not see any problems. She stated the patient was complaining of his right leg hurting and that the patient did require some pain medication (Lortab 5 mg) after X-Ray.

#S1, RN House Supervisor confirmed she did not report the incident to the DON or Administrator immediately. However, she stated she did report the incident to the DON prior to the end of her shift at some point. This interview revealed she work as House supervisor on Friday 8/21/09 from 4 p.m. - 7 p.m. and on Saturday (8/22/09) and Sunday (8/23/09) from 7:00 a.m. - 7:00 p.m. #S1, RN House Supervisor stated she did not remember the exact date or time she reported the incident but knew it was prior to the end of her shift sometime during the weekend. #S1, RN House Supervisor stated she did not get any written statements from anyone concerning the incident. #S1, RN House Supervisor revealed she considered the incident to be a complaint registered against #S2, X-Ray Tech.

Review of documentation on a form titled "Complaint Register" August, 2009 revealed an entry dated 8/22/09 which reflected #S1, RN, House Supervisor, reported that #S2, X-Ray Tech was "rude to [patient]" - "Grievance". An entry under the "action taken/by whom section" of the form reflected "phone call interview - discussed with [Administrator]". Further review of the "Complaint Register" form revealed a date of 8/23/09 which contained an entry under the section "Resolution Date" "to [Administrator] for resolution" and a notation that certified mail was sent on 9/15/09. There was no specific documentation which reflected what was sent nor to whom the certified mail was sent to.

Interview of #S3, Radiology Aide on 02/23/10 at 11:00 a.m. revealed that on 08/21/09 she witnessed #S2, Radiology Tech become agitated because he could not properly position Patient #1 for an x-ray of the knee. #S3, Radiology Aide stated that after #S2, X-Ray Tech became frustrated he spoke abusively in the presence of (Patient #1). #S3, Radiology Aide, reported that she was standing at the door of the X-ray room and clearly heard #S2, X-Ray Tech speak in a loud tone of voice instructing the patient's sitter to "get his damn old ass out of my x-ray room now ".

#S3, Radiology Aide on 02/23/10 at 11:00 a.m. stated that she assisted Patient #1's sitter back to the ER and immediately reported the incident to #S1, RN House Supervisor. #S3, Radiology Aide stated she told #S1, RN, House Supervisor exactly what was stated by #S2, Radiology Tech. #S3, Radiology Aide stated she informed #S1 RN House Supervisor that #S2, Radiology Tech was physically rough with the patient during the X-Ray and that #S2 Radiology Tech had instructed the patent's sitter to "get his damn old ass out of my x-ray room now".

During this interview, #S3, Radiology Aide stated that this was not the first time that
#S2, Radiology Tech had been rough to and/or with patients. #S3, Radiology Aide stated that #S2, Radiology Tech "yells and curses very frequently" and that those incidents were sometimes witnessed by patients. #S3, Radiology Aide stated that #S2, Radiology Tech had been reported to the Radiology Supervisor for his actions in the past but nothing had been done.

#S3, Radiology Aide, further stated during this interview, that she was not asked to write a statement concerning the incident. However, #S3 stated she called #S4 DON on Monday morning (8/24/09), and reported the incident to the DON and #S4, DON took her verbal statement over the telephone. #S3 stated she was never asked to write a statement and if she would have been asked, then she would have written a statement.

Interview with #S1, Ultrasound Tech on 2/24/10 at 10:30 a.m. revealed that she completed an ultrasound on Patient #1 on 8/21/09 at approximately 2:00 p.m., and Patient #1 was scheduled for an x-ray of his right knee and leg to be done by #S2, Radiology Tech after the ultrasound was completed. #S5, Ultrasound Tech stated she heard Patient #1 hollering and telling #S2, Radiology Tech to stop because it was hurting. #S5, Ultrasound Tech further stated she heard #S2 Radiology Tech say"get his damn old ass out of my x-ray room now". #S5 stated she was not asked anything about the incident, and she did not complete a written statement. #S5, Ultrasound Tech further stated that #S2 has been rude and rough with patients in the past, and that #S7 Radiology Department Head was aware but did not do anything about the incidents.

Interview with #S7, Radiology Dept Head on 2/23/10 at 9:40 a.m. revealed she is the Department Head for the Radiology Department. #S7, Radiology Dept. Head stated she had encountered occurrences when #S2, Radiology Tech was being physically and/or verbally abusive. She stated #S2, Radiology Tech becomes aggravated with patients when he is unable to obtain a good x-ray film. #S7, Radiology Dept Head stated she has talked to #S2 in the past about his behavior but had never given #S2 a verbal or written reprimand. #S7 stated she was responsible for investigating and documenting complaint information for complaints within the Radiology Department. However, #S7, Radiology Dept. Head stated that she was not aware of an incident concerning (Patient #1). She stated she became aware on Monday (8/24/09 or Tuesday (8/25/09) when she went to the Administrator's office to talk to the Administrator about something else. #S7, Radiology Dept. Head indicated she had not received annual inservice or training pertaining to abuse.

Interview of the DON #S4 and the Administrator #S6 on 2/24/10 at 11:00 a.m. revealed RN Supervisor #S1 called her on Friday (8/21/09) and that she returned #S1 the RN Supervisor's call on Saturday (8/22/09) to check on staffing. During this conversation, she learned Patient #1 was back in the ER.

Review of documentation on the ER log revealed Patient #1 returned to the ER on 08/22/09 at 11:06 a.m. with a complaint of lower back and lower extremity pain. Documentation reflected X-Rays were ordered of the patient's chest, pelvis, and lumbar spine which were obtained at 1:18 p.m. by Radiology Tech #S2. Upon return to the ER on 08/22/09, Patient #1 was given an Intramuscular (I.M.) injection of Toradol 30 milligrams (mg), and he was discharged to home at 5:00 p.m. on 08/22/09.

Review of a form titled "Improvement Opportunity" dated 8/24/09 at 8:55 a.m. revealed a summary by #S6, Administrator which reflected Patient #1's daughter, called to complain about services received by her father on 8/21/09. The form was noted to also contain a section titled "Investigation" which was completed by the Administrator #S6. An entry in this section reflected #S4, DON, had given information on an incident that happened over the weekend and that she was interviewing employees and obtaining statements from them. The Administrator documented after reviewing this information (from #S4,the DON) he spoke to #S7, Radiology Dept. Head and learned there had been incidents before where #S2, Radiology Tech had been rough with patients who were not able to comply with his requirements (to be still or for proper positioning) when he (#S2) was completing an x-ray. Documentation also reflected #S7 Radiology Dept. Head informed #S6, the Administrator that she did not believe #S2 Radiology Tech's actions were confined to the elderly but that parents of young children had complained as well. Neither the time or date were noted by #S6, the Administrator in this section. However, documentation under the action taken section of the form was initialed by #S6 Administrator and dated 8/31/09.

Review of the investigation completed by #S4, DON reflected she called to check on staffing Saturday, August 22, 2009 and Supervisor, #S1, RN House Supervisor informed her (DON #S4), that Patient #1's family and a sitter had problems in the x-ray department when the patient was x-rayed. This documentation reflected #S1 RN Supervisor informed the DON #S4 that Radiology Tech #S2 was "extremely rude and tried to straighten the patient's extremity out and the patient was hollering and did not want it done. #S2 Radiology Tech was noted to tell the sitter that unless he could straighten the extremity, he could not get the shot and that at one point tension was high because the Radiology Tech #S2 told the sitter to "take his damn old ass out of the x-ray room because he could not do the film". The DON #S4, was also informed #S3 Radiology Aide was a witness.

Further review of the investigation's documentation reflected she (DON #S4), instructed the House Supervisor RN #S1 to get the witness #S3 Radiology Aide, to write a statement but that RN Supervisor #S1 told the DON #S4, that #S3, stated she'd wait to see if they complained and if so then she (#S3 Radiology Aide) would call the DON #S4 on Monday 8/24/09. The DON #S4 documented #S3 the Radiology Aide contacted her on Monday and that #S3 Radiology Aide, informed her that patient #1 was 94 years old and was having foot and leg problems and that the patient had limited ability to straighten his leg.

The DON #S4 documented the RN Supervisor #S1 told her #S2 Radiology Tech attempted to reposition Patient #1's extremity in hopes of getting a film but that the patient was hollering and telling #S2 Radiology Tech to stop. The sitter was eventually told "to take his damn ole ass out of x-ray he couldn't do it". According to the DON #S4's investigation, RN #S1 informed her the patient's family was highly "upset".

There was no documentation provided for surveyor review which evidenced the hospital's "investigation" included the gathering of written statements from persons who witnessed the incident on 8/21/09.

Review of a Policy titled "Grievance Policy" reflected a grievance was defined as "formal, written, or verbal grievance that is filed by a patient, when a patient issue cannot be resolved promptly by staff present." The policy reflected a patient was notified in the hospital's "Patient Rights Statement" upon admission of the proper person with whom to file a grievance. Further review of the policy reflected a grievance committee was appointed by the "Board" (unspecified) to review grievances for resolution and that calls (complaints) should be taken by grievance committee members and reported on a complaint form. The grievance must be reviewed within five working days of the report with at least one episode of communication with the aggrieved party. The policy also reflected "all major grievances" (the term major grievances was not defined) with resolution would subsequently be reported to the Board of Commissioners (in April and October) and that all major grievances were to be monitored for issues which could result in safer practices through the Quality Improvement Committee.

This investigation determined the hospital did not have a written policy for the handling of "Complaints".

Review of the ER Department's "Patient's Rights" statement reflected each patient had the right to be treated with consideration, respect.... To be free from all forms of abuse and harassment and to receive care in a safe setting. The form reflected to express any concerns about the quality of care received to contact "Administration" at [extension #]. The policy did not reflect the name/title of the person to report to.

Review of the hospital's "Abuse Policy" reflected the hospital would not tolerate mistreatment, neglect, or abuse of patients. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Further review reflected that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source......would be reported to the Director of Nurses and CEO and all alleged violations would be investigated through questioning of patient, family members, staff and co-workers involved and through observation. The policy stated the patient would be protected from further potential abuse while the investigation was in progress by reassignment of the accused employee.

Further review of the policy reflected the results of all investigation would be reported to the Administrator or his representative, to the police, State surveying agency, and certification agency within five days of the incident. If an alleged violation by an employee was verified, the employee would be terminated. The hospital's Abuse procedure was noted as:

A. Prevention - To always have sufficient staff to take care of all patients' needs.

C. Training - Provided during orientation and annually on abuse, neglect, and related reporting requirements, including prevention, intervention and detection.

D. Investigation - In a timely and thorough manner, all allegations are investigated by the nursing supervisor with findings forwarded to "Administration".

E. Reporting/Responding - Any incidents or abuse/neglect is to be reported, analyzed and the appropriate corrective remedial, or disciplinary action taken in accordance with local, state, and federal laws.

Interview with #S6, Administrator on 2/24/10 at 11:20 a.m. revealed he was vaguely familiar with the Federal Regulations /Conditions of Participations for the hospital. The Administrator confirmed the hospital's Abuse policy was inadequate and revisions were needed. He stated the Abuse policy did not have a process for reporting abuse. Administrator #S6 stated every department had a different method for reporting. The Administrator stated he investigated the 8/21/09 incident as a grievance, not as patient abuse. The Administrator stated he did not feel that the complaint/grievance was an allegation of abuse. However, the Administrator later confirmed he was mislead because he was following the hospital's "Grievance Policy" rather than the hospital's "Abuse Policy." When conversing with the Administrator, DON and the hospital's Compliance Regulator, the Administrator confirmed the allegation was substantiated as verbal abuse.

At the time of exit on 2/24/10, Radiology Tech #S2 had been reprimanded but remained employed by the hospital.

Review of the hospital's in-service training log reflected annual training on Abuse was provided in November, 2009 using the hospital's current Abuse policy, after this incident occurred in August, 2009. Prior to the November, 2009, training on Abuse, annual training was last provided to hospital staff in 2005.

Interview with #S4 DON on 02/24/10 at 11:00 a.m. confirmed Abuse Policy & Procedure Training was not provided to hospital staff in 2006, 2007, or 2008.

Interview with the Administrator #S6, #S4 DON, and #S9 Regulatory Compliance Officer on 02/23/10 at 11:30 a.m. revealed the hospital's Abuse policy was inadequate and revisions were needed to reflect the process for reporting abuse.

Based on review of the hospital's QAPI (Quality Assurance Performance Improvement) data and interviews with staff, the hospital failed to measure, analyze, and track quality indicators and maintain an ongoing program for quality improvement by failing to ensure that each department addressed patient care problems; the cause of problems; documented corrective actions relating to patient care problems; and monitoring or follow up to determine the effectiveness of the corrective actions taken. Findings:

Review of the hospital's QAPI meeting minutes dated October 15, 2009 revealed no evidence to indicate that quality indicators relating to abuse and/or complaints were evaluated and monitored through the hospital's QAPI program.

#S8, QAPI Director was interviewed on 02/24/10 at 9:30 a.m. #S8, QAPI Director confirmed that the hospital failed to evaluate and monitor Patient Rights indicators concerning complaints and grievances. #S8, Quality Improvement Coordinator stated each department was responsible for reporting, investigating complaints that originated within each department and then reported that information to the QAPI Director. #S8, Quality Improvement Coordinator reported the Quality Improvement Committee met monthly and any incidents of abuse and/or complaints would only be reported to the committee at that time. When asked, #S8, Quality Improvement Coordinator stated the hospital QAPI Program did not utilize critical indicators for abuse and/or complaints. #S8, Quality Improvement Coordinator reported the hospital had not tracked and trended complaints through the Hospital's QAPI program. #S8, Quality Improvement Coordinator indicated that she did not know of a specific hospital policy that pertained to tracking & trending critical indicators.

Based on review of the hospital's QAPI (Quality Assurance Performance Improvement) data and interviews with staff, the hospital failed to monitor the effectiveness and safety of service and quality of care by failing to ensure that each department addressed patient care problems; the cause of problems; documented corrective actions relating to patient care problems; and monitoring or follow up to determine the effectiveness of the corrective actions taken. Findings:

The Hospital's Grievance Policy was reviewed and read: "A grievance is defined by the interpretive guidelines as a "formal, written, or verbal, grievance that is filed by a patient; when a patient issue cannot be resolved promptly by staff present. Any complaint is viewed as an opportunity to improve the quality of patent care and satisfaction "Documentation reflected 1). The grievance must be reviewed by five working days of the report unless the severity of the circumstances dictates more prompt resolution. 2. The written notice will include the steps to investigate the grievance, the result of the investigation, and the date of completion. In some cases, providing the required information may be done by calling the patient or meeting with the patent and his family. Any meeting or call will be documented and attached. The Hospital's Grievance Policy further documented "all major grievances with resolution are also monitored for issues that could result in safer practices through the Quality Improvement Committee."

Review of the hospital's QAPI meeting minutes dated October 15, 2009 revealed no evidence to indicate that quality indicators relating to Patient Rights were evaluated and monitored through the hospital's QAPI program. Documentation failed to provide evidence to indicate that the hospital had completed an ongoing QAPI Program by failing to measure, analyze, and track quality indicators including adverse patient events, (patient abuse) & other aspects of performance that assess processes of care, hospital service and operations.

#S8, QAPI Director was interviewed on 02/24/10 at 9:30 a.m. #S8, QAPI Director confirmed that the hospital failed to evaluate and monitor critical indicators concerning abuse and/or complaints. #S8, Quality Improvement Coordinator stated each department was responsible for reporting, investigating complaints that originated within each department and then reported that information to the QAPI Director. #S8, Quality Improvement Coordinator reported the Quality Improvement Committee met monthly and any incidents of abuse and/or complaints would be only reported to the committee at that time. #S8, Quality Improvement Coordinator reported the hospital had not tracked and trended abuse and/or complaints through the Hospital's QAPI program. When asked, #S8, Quality Improvement Coordinator stated the hospital QAPI Program did not utilize critical indicators for abuse and/or complaints. #S8, Quality Improvement Coordinator indicated that she did not know of a specific hospital policy that pertains to tracking & trending critical indicators.