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Based on policy review, document reviews, and interviews, the hospital failed to provide patient's rights in advance and discontinuation of care; lack of a prompt resolution of patient grievances, not informing patients in writing of the results of grievance investigations, not providing patients with the "Important Message from Medicare" standardized notice, not developing a policy on abuse prevention, failing to ensure the patient rights policy and the information presented to patients for the acute care setting and the Swing Bed program included all forms of abuse and not developing a policy that addressed not employing or otherwise engaging with individuals found guilty of abuse, neglect, and exploitation.

The cumulative effects of this deficient practice have the potential to affect the resolution of patient concerns and patient safety for the current 32 inpatients and any future patient admitted to the facility.

Findings Include:

1. The hospital failed to provide each Medicare beneficiary who was an inpatient with a standardized notice, "Important Message from Medicare", within two days of admission and within two days prior of discharge for two (Patient (P) 3, P9) of 13 medical records reviewed. (Refer to A0117)

2. Facility failed to promptly review and resolve patient grievances in accordance with the facility's policy for four (P8, P10, P12, P13) of five grievances reviewed. (Refer to A0119)

3. The facility failed to provide three (P8, P12, P13) of five grievances reviewed with a written notice of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. (Refer to A0123)

4. The facility failed to ensure a policy was developed that included a written procedure for investigation allegations of abuse and neglect, including methods to protect patient from abuse during the investigation of allegations. The hospital failed to ensure the patient rights policy and the information presented to patients for the acute care setting and the Swing Bed program included all forms of abuse from which patients were to be free for one (P10) five incident reports reviewed. The facility failed to develop a policy that addressed not employing or otherwise engaging with individuals found guilty of abuse, neglect, and exploitation. (Refer to A0145).

Based on policy review, record review, and interview, the hospital failed to provide each Medicare beneficiary who is an inpatient with the standardized notice, "An Important Message from Medicare (IMM)" within two days of admission and within two days prior to discharge for two (Patient (P) 3, P9) of 11 Medicare inpatients reviewed from a sample of 13 patients. This failure had the potential to affect any current and future Medicare patients admitted to the hospital.

Findings Include:

Review of the hospital's policy titled "Utilization Review Plan," revised 03/16/21, showed ". . . On admission, all Medicare inpatients should receive the IMM [Important Message] from Medicare. . . Admissions staff should issue the IMM from Medicare (Appendix A), a form provided by Medicare which cannot be altered. . . Have the patient sign, date, and time the notice. Give a copy to the patient/ representative and retain a copy for the medical record. . . Care Management Staff should deliver a follow-up IMM as far in advance of discharge as possible, but not more than two calendar days before discharge. A copy must be given to the patient and a copy must be in the chart. . ."

Review of the hospital's policy titled "Admission to Swing Bed," revised 02/02/21, indicated ". . . The Important Message from Medicare (IMM) will be given to the patient by case management or social worker, informing him/her of the change in level of care. This notice should be given to the patient two days prior to the discharge to swing bed.

Patient 3

Review of P3's electronic medical record (EMR), showed P3 was admitted on 10/12/21 at 4:10 PM and discharged on 10/13/21 at 3:00 PM (located under the "Admissions Routine" tab, "reprint admission form" tab, "face sheet" tab in the EMR). Review of the "EMR" tab, "Summary" tab, "Risk/Legal" tab, revealed that there was no documentation that "An Important Message from Medicare" form had been signed by P3 or P3's representative.

During an interview on 10/18/21 at 2:00 PM, Quality Improvement Auditor (QIA) confirmed P3's EMR did have a signed "Important Message from Medicare" documents.

Patient 9

Review of P9's EMR showed P9 was admitted on 10/10/21 at 4:00 AM and discharged on 10/15/21 at 11:42 AM (located under the "Admissions Routine" tab, "reprint admission form" tab, "face sheet" tab in the EMR). P9 was admitted to the Swing Bed Program on 10/15/21 at 12:00 PM. Review of the "EMR" tab, "Summary" tab, "Risk/Legal" tab, there was no documentation that "An Important Message from Medicare" form had been signed by P9 when P9 was discharged from the acute care bed and prior to admission to the swing bed.

During an interview on 10/20/21 at 8:50 AM, Social Worker (SW) stated that the care management department was responsible for having the IMM form completed at admission and discharge. SW stated a lot of times the admit form is done by Admissions on admit. SW stated when they are notified of a pending discharge, SW's department does the IMM at least two days prior to discharge. SW stated, "I do not know" why the IMM form was not done for P9. The SW confirmed that the SW didn't know they were to be done for the swing-bed patients.

Based on policy review, document review, and interviews, the facility failed to implement its grievance process by failing to effectively review, investigate, promptly resolve grievances, and document the investigation, in accordance with the hospital's policy for three patients (P) (P8, P12, P13) of five grievances reviewed on the grievance log dated 04/17/21 to 10/17/21, and one (P10) of five incident reports reviewed. These failures had the potential to affect the resolution of patient concerns for the current 32 inpatients, as well a future patients admitted to the hospital.


Findings Include:


Review of the hospital's policy titled, "Grievance Resolution / Patient Feedback / Complaint Resolution," effective 08/16/19, showed a grievance was defined as a "grievances may be presented verbally or in writing. Grievances may be made by the patient or the patient's representative. A grievance is an issue presented to any employee, regarding the patient's care; abuse or neglect; issue related to the hospital's compliance with the Center's for Medicare and Medicaid Services (CMS) ...when the issue raised cannot be resolved at the time of occurrence by staff present the issue is considered a grievance. The following are considered grievances for purposes of this policy: 1. Written complaint including those received by mail, e-mail or fax, from an inpatient, outpatient, released/discharged patient or their representative regarding the patient care provided, abuse or neglect ...2. Whenever the patient or the patient's representative requests their complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is considered a grievance ...4 Telephone calls from the patient or patient representative are considered grievances if they are regarding the patient's care, an allegation of abuse or neglect; or failure of the hospital to comply with one or more of the Conditions of Participation or other CMS requirements ...a. Per CMS' Conditions of Participation 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances ...c. When staff present are unable to resolve the complaint, the issue is communicated to tan authorized representative ...a Feedback Ticket is generated in the Event Reporting System (ERS) and the grievance process begins ...d. Grievances about situations that endanger the patient such as abuse, or neglect are investigated immediately. A Feedback Ticket is completed in the ERS to relay the information to Risk Management Department ...e. The patient or their representative filing a grievance that was not resolved by staff present receives an acknowledgement (written or verbal), within seven (7) working days of receipt of the grievance. Written responses to the appropriate parties are sent by the Risk Management Department. If necessary, the written acknowledgement of a grievance includes a time frame for a complete response, not to exceed 30 working days. If the investigation is not or will not be completed within 30 working days, the Risk Management Department or designee will inform the patient or patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days in accordance with the hospital's grievance policy. The hospital must attempt to resolve all grievances as soon as possible ...g. A letter is sent to patients and/or their representative at the conclusion of all grievance investigations. The letter is sent by the Risk Management Department or designee following the receipt of the investigative findings, conclusions, and actions from the involved department(s') leadership ...The response letter includes the name of the hospital's authorized representative, the steps taken on behalf of the patient to investigate the grievance, the results of the investigative process and date of completion.

Patient 8

Review of a grievance submitted by P8 on 05/03/21 showed P8 indicated, "staff is always rude and make her feel as she is not welcome. She states on her last visit the provider did her screening by asking questions outside the door by keeping it cracked and never came in the room. She reports she was told by her nurse she was getting 2 bags of intravenous (IV) fluids but only received one. She reports shortly after being told she would be getting a second IV bag a male nurse came in handed a clipboard to sign and said she could go home. Patient feels she was treated like she was a burden and communication were not consistent. Patient would like for her care to be reviewed for appropriateness on only using one IV bag when she'd been informed, she was getting two and she would like the appropriateness of an assessment being completed in the manner the physician completed hers."

Review of P8's grievance investigation performed by the facility and dated 06/10/21 at 8:56 AM, indicated "Patient was tolerating oral fluids, physician made decision to discharge. Due to other needs within the department at time of discharge, the patient's primary nurse was unable to discharge the patient, so another ER nurse discharged the patient and was unaware that the patient had been told she would receive 2 bags of fluid," The grievance indicated the immediate action taken for P8 "discussion with RN's about updating patient on plan of care." Review of the P8's grievance list of action/resolution dated 07/12/21 at 3:40 PM, indicated "Patient did not want to be contact via letter or phone regarding this incident."

During an interview with the Risk Manager (RM) on 10/18/21 at 2:28 PM, the RM confirmed the above documented details of the facility investigation and the action plan. The RM confirmed the facility failed to address the patient's concerns that staff were rude and made her feel not welcome, the provider performed the screening by asking questions outside the door and never came in the room, was told she was getting 2 bags of IV fluids but only received one, and that she was treated like a burden and communication was not consistent.

During an interview with the Director of Risk Management (DRM) on 10/19/21 at 10:55 AM, the DRM stated, "the frontline leader, ED Manager, investigated the grievance and completed and closed out the grievance on 06/10/21. The DRM confirmed P8 requested that her care be reviewed for appropriateness on only using one IV bag when she'd been informed she was getting two and she would like the appropriateness of an assessment being completed in the manner the physician completed hers. " The DRM confirmed there was no investigation into P8's concerns about staff always being rude and making her feel as she is not welcome, the provider performing the screening by asking questions outside the door and keeping it cracked and never came in the room and being treated like she was a burden and communication was not consistent. The DRM confirmed the action plan for the rude staff and making the patient feel not welcomed, was to update the patient's care plan. The DRM confirmed he did not have any evidence the physician and nurses were interviewed or spoken with about the alleged behavior." The DRM stated, "we are open to looking into our complaint/grievance process, and this particular patient did not want to be contacted."


Patient 12

Review of a grievance submitted by P12 and received by the facility on 05/03/21, showed a letter written to the facility by P12 indicating, "my oxygen level was 70 and my blood pressure was around 200/100. My chest and legs were filled with fluid, and they wanted to do a CAT (CT) scan on me a [sic] put me on an IV ...While doing the CT scan they got my left arm stuck in the machine, which tore out the IV they had placed in my arm previously. I also sustained a burn on my left arm from the CT scan ...My arm was in pain; I have a scar from my hand to my elbow and in the middle of it there is a little hole where the IV was placed. It hurts terribly and still does. I asked the Administrator if they could do anything for the burn and she told me they could do nothing for me. All the time my arm was causing me terrible pain ...I continued to have pain in my arm and I had an appointment with (a physician). He/she looked at my arm and told me that this is a serious matter and that I need to write a letter to the Director of Quality Management (DQM) because he/she needs to be informed on what happened. The (physician) told me that I may need to see a surgeon after a follow up with him/her. I was treated poorly during my time spent at (the facility)."

Review of P12's grievance investigation performed by the Radiology Department Leader (RDL) dated 06/09/21 indicated "Reviewed case with CT technician on this event. The CT technician on this event had filled out an event report regarding the IV infiltration and restarting of the IV. The CT technician followed the correct process with an IV infiltration. A new IV was started and test was completed without incident. The CT technician stated he/she was not aware of any incident where the patient had been injured by or in the CT unit. The immediate action taken indicated, "IV was removed and ice pack applied, ED nurse was contacted to restart IV. The risk mitigation poll and recommendation indicated, "CT tech performed check and followed correct steps prior to IV infiltration and post. Follow up with patient regarding IV infiltration that occurred as this is likely the cause of his/her arm pain and patient could be confusing this with an injury in the CT machine. The probability of this type of feedback recurring indicated, "remotely."

Review of P12's grievance investigation performed by the Nurse Manager Inpatient Services (NMIPS) dated 06/09/21 and located under the heading investigation summary indicated, "Per chart review, CT with contrast on 04/14/21 at 7:14 AM. Admit ...on 04/14/21 at 11:00 AM. Peripheral IV-line care intervention on 04/12/21 at 12:00 PM 20-gauge IV right chest - continue to monitor. Midline placed on 04/14/21 at 3:20 PM. Nurse unable to provide access with multiple peripheral intravenous line (PIV) that were placed infiltrated easily. Midline placed for more secure peripheral line. Registered Nurse (RN) who admitted the patient on 04/14/21 does remember the patient talking about her arm hurting and that the patient said the IV came with the CT." Under the heading immediate action taken indicated, "A midline was placed on 04/14/21 at 3:20 PM due to multiple attempts and prior IV infiltrating. Continued review of the investigation revealed no further investigation, risk mitigation, recommendations, or immediate action taken.

The DRM confirmed the facility failed to investigate P12's grievance concerns related to the low oxygen level of 70 (normal oxygen level 95% to 100%), a blood pressure around 200/100 (normal BP less than 120/80), left arm getting stuck in the CT machine, which tore out the IV, or the burn sustained to P12's left arm from the CT scan. The DRM confirmed there was no evidence documented showing the Administrator was questioned about P12 talking to the Administrator about whether there was anything that could be done for the burn or the RTL documenting in his/her investigation "patient could be confusing this with an injury in the CT machine."


Patient 13

Review of a grievance submitted by P13 and entered by the Risk Manager (RM) on 04/01/21 at 5:08 PM indicated, "Patient reports that primary RN who was tall, had blonde hair and a deep voice, was rude and failed to be compassionate with him. He reports that this same primary RN who cared for him a couple different times was yelling in the hallway about other staff members, complaining about the Supervisor and yelling about materials that "were laying around." Patient reports that this primary RN made inappropriate comments about why he was here and shared that with other staff members in the hallway. He reports that he could hear them laughing at him and they were peaking around the doorway to look at him."

Review of the P13's investigation by the RM dated 04/01/21 at 5:21 PM indicated, "I attempted to call this patient last week. No answer. Voicemail left. I called the patient 03/31/21 and left additional voicemail ...Today 04/01/21 patient showed up to the hospital and complained to the Chief Nursing Officer (CNO). Today 04/01/21, I spoke with the patient and discussed his complaint. He wishes to receive a letter once review is complete. Explained this process to him."

Review of P13's grievance investigation performed by the NMIPS and dated 04/09/21 at 4:35 PM, indicated P13's nurse and CT tech were spoken with, and both denied the RN made inappropriate comments about why he was there or shared that with other staff members in the hallway. Both denied any staff were laughing at him.

Review of the investigation performed by the RM dated 04/12/21 at 2:46 PM indicated the RM reviewed an email received from the Chief Nursing Officer (CNO) that indicated " ...a day or two after discharge, he came back to the hospital to make a complaint ...he was brought to visit with a supervisor ...He said they were going to follow-up with a call time the next day. He said no one has called him. He said he had a voice mail from a number stating to call the number if he wanted to make a complaint against a nurse ... NMIPS ....and RM reviewed the events. The NMIPS spoke to the patient and nurse on 03/22/21. NMIPS requested the RM to contact the patient. The RM called and left a voicemail on 03/23/21 ...and 03/31/21. Plan is for the RM to call the patient again, listen, explain that actions the RM will take of entering event report. NMIPS will add his/her investigation and RM will follow up with the patient.

Review of the RM notes showed the RM attempted to call patient again on 04/14/21 at 2:50 PM but got no answer and left a voicemail.

Review of P13's grievance investigation dated 04/14/21 at 5:28 PM indicated, "If the nurse was sharing/discussing his/her information with those outside of his/her care team there is a HIPAA violation, not a reportable breach. If the nurse was speaking with those appropriate with his care, the nurse should be using hushed tones or speak with the individuals in another private room as to avoid disclosing the patient's information to others. This incident is more indicative of a patient dignity issue. If the events are true, then the nurse should receive coaching regarding the HIPAA violation."

Review of the RM notes dated 06/0321 at 1:44 PM indicated the RM left P13 a message to call him.

Review of the DRM documentation dated 06/21/21 at 11:44 AM indicated " I spoke with the patient via phone on 06/14/21 at approximately 9:30 AM. We discussed his/her case. He kept coming back to his belief that "someone needs to talk to that associate." I advised that our investigation included communication with all involved and other who may have been witnesses.

Review of P13's grievance response letter sent by the RM and dated 04/12/21 indicated, "Our Risk Management and Compliance department completed a thorough investigation of your concerns." The letter did not indicate any further investigation was being performed despite documentation the facility was still investigating the grievance after the response letter was sent.

During an interview with the DRM on 10/19/21 at 10:55 AM, the DRM confirmed the P13's final response letter was sent on 04/12/21, prior to completion of the grievance investigation. The DRM also stated that there was documentation P13 had attempted to file a grievance before 04/01/21 as indicated in the documentation related to the CNO's email that the NIMPS spoke to the patient and nurse on 03/22/21 and the RM left a message with the patient on 03/23/31 and 03/31/21.

The DRM also confirmed there was ongoing grievance investigation documentation on 04/14/21, 06/03/21, and 06/21/21. The DRM confirmed there was no documentation of investigation related to P13's grievance concerns that the same primary RN who cared for him a couple different times, was yelling in the hallway about other staff members, complaining about the Supervisor and yelling about materials that were laying around.


Patient 10

Review of an incident report selected from the list of incident reports dated 04/17/21 to 10/17/21 indicated P 10 had a pelvic ultrasound for pelvic pain. Review of the description documented on the incident report of an occurrence on 05/06/21 and reported on 05/07/21 by the imaging department leader indicated "Patients [sic] daughter called concerned that her mother had a procedure done yesterday that she didn't consent to. ...Both state that patient gave verbal consent after the procedure was explained. Both stated that patient never asked for the procedure to be stopped at any time or expressed any concern. Both denied that patient complained about pain during the procedure. The student did say while walking the patient out she expressed if she would have known what the procedure was going to be she wouldn't had it done."

Review of the "Safety Event Classification" section of the incident report indicated the incident was categorized as "Treatment & [and] Therapies Communication Inadequate with Patient." The severity of the event was classified as "A - No Harm: Circumstance or unsafe condition that had the capacity to cause a safety event."

During a telephone interview on 10/19/21 at 10:47 AM, the DRM stated that he/she would concur that P10's incident report would rise to a grievance level. DRM stated that it was processed as a grievance. DRM stated, "would have preferred to see that this event would have been entered into our feedback system/complaint system, rather it was submitted into the safety event manager system [incident reporting system], and because it was submitted in the incident reporting system rather than the complaint system, it was not processed as a grievance." In this case, the RM closed this incident report, and this would have been an opportunity for RM to recognize the event as a grievance, and process the event accordingly as a grievance, and that did not occur from the information I have in front of me."

Based on policy review, document review, and interviews, the hospital failed to ensure the patient was provided written notice of the hospital's decision, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for three (Patient (P) 8, P12, P13) of five grievances reviewed for documentation of a resolution letter. This failure had the potential to affect the current 32 inpatients and any future patients admitted to the hospital.


Findings include:


Review of the hospital's policy titled, "Grievance Resolution / Patient Feedback / Complaint Resolution," effective 08/16/19, indicated "Grievances may be presented verbally or in writing. Grievances may be made by the patient or the patient's representative. A grievance is an issue presented to any employee, regarding the patient's care; abuse or neglect; issue related to the hospital's compliance with the Center's for Medicare and Medicaid Services (CMS) ...when the issue raised cannot be resolved at the time of occurrence by staff present the issue is considered a grievance ...e. The patient or their representative filing a grievance that was not resolved by staff present receives an acknowledgement (written or verbal), within seven (7) working days of receipt of the grievance. Written responses to the appropriate parties are sent by the Risk Management Department. If necessary, the written acknowledgement of a grievance includes a time frame for a complete response, not to exceed 30 working days. If the investigation is not or will not be completed within 30 working days, the Risk Management Department or designee will inform the patient or patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days in accordance with the hospital's grievance policy. The hospital must attempt to resolve all grievances as soon as possible ...g. A letter is sent to patients and/or their representative at the conclusion of all grievance investigations. The letter is sent by the Risk Management Department or designee following the receipt of the investigative findings, conclusions, and actions from the involved department(s') leadership ...The response letter includes the name of the hospital's authorized representative, the steps taken on behalf of the patient to investigate the grievance, the results of the investigative process and date of completion ...i. A grievance is considered resolved when the patient or patient's representative is satisfied with the actions taken on his or her behalf."


Patient 8

Review of a grievance submitted by P8 on 05/03/21 indicated, "staff is always rude and make her feel as she is not welcome. She states on her last visit the provider did her screening by asking questions outside the door by keeping it cracked and never came in the room. She reports she was told by her nurse she was getting two bags of IV [intravenous] fluids but only received one. She reports shortly after being told she would be getting a second IV bag a male nurse came in handed a clipboard to sign and said she could go home. Patient feels she was treated like she was a burden and communication was not consistent. Patient would like for her care to be reviewed for appropriateness on only using one IV bag when she'd been informed, she was getting two and she would like the appropriateness of an assessment being completed in the manner the physician completed hers."

During an interview on 10/18/21 at 2:28 PM, the Risk Manager (RM) confirmed the facility failed to send P8 a response letter that contained the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the grievance investigation as per policy.


Patient 12

Review of a grievance submitted by P12 and received by the facility on 05/03/21 showed a letter written to the facility by P12 indicating, "my oxygen level was 70 and my blood pressure was around 200/100. My chest and legs were filled with fluid, and they wanted to do a CT scan on me and put me on an IV ...While doing the CT scan they got my left arm stuck in the machine, which tore out the IV they had placed in my arm previously. I also sustained a burn on my left arm from the CT scan ...My arm was in pain. I have a scar from my hand to my elbow and in the middle of it there is a little hole where the IV was placed. It hurt terribly and still does. I asked the Administrator if they could do anything for the burn and she told me they could do nothing for me. All the time my arm was causing me terrible pain ...I continued to have pain in my arm and I had an appointment with (a physician). [He/she] looked at my arm and told me that this is a serious matter and that I need to write a letter to the Director of Quality Management [DQM] because he/she needs to be informed on what happened. [Physician] told me that I may need to see a surgeon after a follow up with [him/her]. I was treated poorly during my time spent at [facility]."

During an interview on 10/19/21 at 10:55 AM, the Director of Risk Management (DRM) confirmed P12's grievance resolution letter failed to contain the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the investigation per policy.


Patient 13

Review of a grievance submitted by P13 on 04/01/21 at 5:08 PM and written by the RM, indicated, "Patient reports that primary Registered Nurse (RN) who was tall, had blonde hair, and a deep voice, was rude and failed to be compassionate with [him]. [He] reports that this same primary RN who cared for [him] a couple different times was yelling in the hallway about other staff members, complaining about the Supervisor, and yelling about materials that "were laying around." Patient reports that this primary RN made inappropriate comments about why [he] was here and shared that with other staff members in the hallway. [He] reports that [he] could hear them laughing at [him] and they were peaking around the doorway to look at [him]."

Review of P13's grievance response letter sent by the RM and dated 04/12/21, indicated, "Our Risk Management and Compliance department completed a thorough investigation of your concerns."

During an interview on 10/19/21 at 10:55 AM, the DRM confirmed the facility failed to send P13 a letter of acknowledgement within seven working days of receipt of the grievance, failed to inform the patient the investigation would not be completed within 30 working days and that the hospital was still working to resolve the grievance, or that the hospital would follow-up with a written response within a stated number of days. The DRM confirmed the grievance resolution letter failed to contain the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Based on policy review and interview, the facility failed to ensure a policy was developed that included a written procedure for investigating allegations of abuse and neglect, including methods to protect patients from abuse during investigation of allegations of abuse. The hospital failed to ensure the patient rights policy, and the information presented to patients for the acute care setting and the Swing Bed program, included all forms of abuse from which patients were to be free. This failure had the potential to affect all current and future patients in the facility.


Findings Include:


Review of the hospital's policy titled, "Abuse and Neglect," revised 03/27/19, indicated, "Kansas law requires that all health care professional who have reason to suspect that a child or dependent adult has been abused, neglect or abandoned, or exploited are mandated to report that suspicion to the appropriate agency." The policy did not include a procedure for investigating allegations of abuse and neglect, including methods to protect patients from abuse during investigations of allegations. The policy did not address patients that allege abuse against facility staff.


Review of the policy titled, "Patient Rights and Responsibilities," revised 01/08/20, indicated, "Written information containing a copy of patients' rights and patients' responsibilities related to their rights is provided upon admission. . ." The policy did not include the list of patient rights.


Review of the "Patient admission" brochure, presented by Director of Quality Management (DQM) as the hospital's means of informing patients of their rights, indicated it included "Patient rights and responsibilities You have the right to: . . . Receive care in a safe setting and be free from abuse and harassment. . ." The list did not include and inform patients the types of abuse from which the patient was to be free.


Review of the policy titled, "Notice of Rights and Service," revised 12/30/21, indicated, "Each person admitted to the Swing Bed program is informed both orally and in writing in a language that he/she understands the rights entitled to him/her as a patient in the Swing Bed Program . . . Procedure a. Prior to or upon admission to the Swing Bed program, the Swing Bed Coordinator or designee informs the patient of the rights entitled to him/her as a patient in the Swing Bed program. B. A statement is signed by the patient (or responsible party) who indicates the patient and/or family has received a copy of the Patient's Rights applicable to the Swing Bed Program. . ." The policy did not address the specific patient rights.


Review of the policy titled, "Patient Rights," revised 09/10/21, indicated, "Rights of a patient admitted to the Swing Bed Program are: . . . l. Protection from Abuse: The patient has the right to be free from mental or physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for other than the treatment of medical symptoms, under the written order of the physician . . ." The policy did not include verbal abuse in the list of abuse from which the patient has the right to be free, causing the policy not to match the "Patient Letter" presented to patients admitted on the Swing Bed unit.

Review of the "Patient Letter" included in a packet of undated documents given to patients who are admitted to the Swing Bed Program, presented for review by Registered Nurse (RN) 2, the coordinator of the Swing Bed Program, indicated patient rights included patients had the right to be "free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. . . "

The hospital failed to develop a policy that addressed not employing or otherwise engaging the following individuals: 1. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; 2. Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property; 3. Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law, against an employee, which would indicate unfitness for services as a nurse aide or other facility staff; 4. The facility must establish policies and procedures to investigate any such allegations.

During an interview on 10/19/21 at 12:15 PM, the Director of Inpatient Services confirmed the facility failed to develop a policy that included a written procedure for investigating allegations of abuse and neglect, including methods to protect patients from abuse during investigations of allegations.

During an interview on 10/20/21 at 11:03 AM, Director of Quality management (DQM) confirmed the above policies did not have the required information related to patient rights. The DQM confirmed Human resources did not have a policy that addressed the individuals who could not be employed due to charges related to abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents/patients.