HospitalInspections.org

Based on medical record review and interview the facility failed to provide a copy of "An Important Message from Medicare" (IM) to 4 of 10 Medicare patients with stays of 3 days or more, (patients #13, #14, #15 and #16), which could deprive patients of the information necessary to exercise rights. Findings include:

On 5/11/2011 at approximately 9:15 am, it was revealed that the there was no documentation that the IM had been offered to the following Medicare patients:
-patient #13, hospitalized 6/8/13-6/11/13
-patient #14, hospitalized 10/1/12-10/20/12
-patient #15, hospitalized 12/16/12-12/20/12
-patient #16, hospitalized 12/19/13-1/20/13

This finding was confirmed during an interview with staff member #8 on 7/23/13 at 9:20 am.

Based on interview and record review, the facility failed to ensure that 2 of 2 abuse complaints (filed by patients #3 and #8) were investigated in a timely, through manner and that corrective action occurred, increasing the risk of abuse for all patients. Findings include:

Patient #8:

Policy Review:

Patient Rights and Responsibilities, dated 10/22/09, states:
"Patients and their designated representatives have the right to:"
-"Courteous, respective, considerate care that safeguards their personal dignity..."
-"Care received in a safe setting from from harassment or abuse."
-"Be free from chemical or physical restraints, unless medically necessary and as provided by law and facility policy."

Restraints in Psychiatric Setting, dated 6/11/13., states:
"Restraints should only be applied when alternative, less restrictive measures appear insufficient to reduce the serious risk of harm."

Record Review:

1. On 7/24/13 from 1-3 pm, record review revealed: a "Recipient Rights Complaint" form, dated 4/25/13, written by patient #8, states: "5 staff members jumped me to take my shirt of (staff #9, #10, #11, #12 and #13). They all had their hands on me trying to get my shirt of. I was crying and having a panic attack. (Staff #14) the RN heard me crying came into the room and said staff Get Out!!!"
2. On 7/24/13 from 1-3 pm, record review revealed: On 7/23/13 at 12:45 pm review of patient #8's clinical record revealed no documentation of the above incident until 4/26/13.
3. On 7/24/13 from 1-3 pm, record review revealed: A "late entry" note, dated 4/26/13, by Mental Health Assistant #9, stating (patient #8) was informed that she needs to remove the tank top & it would be locked up until discharge. Pt was asked several times & by different staff to locked up tank top. Pt became loud, verbally abusive & started kicking @ staff. Pt was @ this time restrained by staff for safety reasons to pt & staff." (The date and time of this incident was not noted.)

Interview:

On 7/24/13 at 2:30 pm staff #6 stated that she received this complaint and was responsible for responding for investigating and responding. Staff #6 stated that the only staff member interviewed as part of this investigation was Mental Health Assistant #9, who was interviewed on 5/23/13. Staff #6 was asked why RN #14 and the other staff named in the complaint were not interviewed. Staff #6 stated that the complaint was not investigated because she did not retrieve the complaint from the unit's complaint box until 4/30/13 and the patient had been discharged on 4/29/13. Staff #6 stated that she had attempted to contact the patient but was unable to explain why this would interfere with conducting an investigation into the allegations noted in the written complaint.

Patient #3:

Policy Review:

Patient Rights and Responsibilities, dated 10/22/09, states:
"Patients and their designated representatives have the right to:"
-"Courteous, respective, considerate care that safeguards their personal dignity..."
-"Care received in a safe setting from from harassment or abuse."

Behavioral Services 3 Rehab Structure Standards, dated 3/2012, states:

k. "Staffing- Numbers and mix of staff required for census are outlined in a grid...Changes in acuity and/or increase in census may require additional staff."

Record Review:

1. On 7/24/13 from 1-3 pm record review revealed: a "Recipient Rights Complaint" form, dated 3/25/13, written by patient #3, stating: "(Patient #17)...said let me fuck you...grabbed me & tried kissing my neck. I pushed his away & went to nurses station they blew it off and did nothing." The complaint was stamped as received on 3/26/13.
2. On 7/24/13 from 1-3 pm record review revealed: on 3/26/13 staff #6 sent an e-mail to RN #15 asking for a response to the above allegation within 48 hours.
3. On 7/24/13 from 1-3 pm record review revealed: on 3/29/13 RN #15 responded via e-mail, stating:"I vaguely recall some mention of (patient #3's) concern of (patient #17) lingering about in the hallway." RN #15 noted "safety concerns" with the staffing level in effect on 3/24/13.
4. On 7/24/13 from 1-3 pm record review revealed: that on the Midnight shift on 3/24/13 staffing was below the level noted on the "staffing grid," with no provision for covering further reductions during scheduled lunch breaks. On 3/24/13 on the Midnight shift there were 34 patients and the grid called for 4 staff and one .5 time Secretary. Only 4 staff worked that shift, with no provision for additional staff during 4 staff lunch breaks of 30 minutes each.
5. On 7/24/13 from 1-3 pm record review revealed: a note by staff #6 stating that patient #3 stated that her roommate was awake at the time of the alleged incident.

Interview:

On 7/24/13 at 2:45 pm staff #6 stated that she received this complaint and was responsible for investigating and responding. Staff #6 stated that the only persons interviewed in investigating this complaint were the patient and a Charge Nurse, not listed on the staffing roster for 3/24/13 or 3/25.13. Staff #6 was asked why all staff working the night of the complaint and the patient's roommate were not interviewed as part of the investigation. Staff #6 responded that she gets a lot of complaints and can't interview all possible witnesses. Staff #6 was asked if there was any follow-up to Nurse #15's concern regarding low staffing at the time of this allegation. Staff #6 stated that she was "unaware of any follow-up."

Based on medical record review and interview the facility failed to provide a copy of "An Important Message from Medicare" (IM) to 4 of 10 Medicare patients with stays of 3 days or more, (patients #13, #14, #15 and #16), which could deprive patients of the information necessary to exercise rights. Findings include:

On 5/11/2011 at approximately 9:15 am, it was revealed that the there was no documentation that the IM had been offered to the following Medicare patients:
-patient #13, hospitalized 6/8/13-6/11/13
-patient #14, hospitalized 10/1/12-10/20/12
-patient #15, hospitalized 12/16/12-12/20/12
-patient #16, hospitalized 12/19/13-1/20/13

This finding was confirmed during an interview with staff member #8 on 7/23/13 at 9:20 am.

Based on interview and record review, the facility failed to ensure that 2 of 2 abuse complaints (filed by patients #3 and #8) were investigated in a timely, through manner and that corrective action occurred, increasing the risk of abuse for all patients. Findings include:

Patient #8:

Policy Review:

Patient Rights and Responsibilities, dated 10/22/09, states:
"Patients and their designated representatives have the right to:"
-"Courteous, respective, considerate care that safeguards their personal dignity..."
-"Care received in a safe setting from from harassment or abuse."
-"Be free from chemical or physical restraints, unless medically necessary and as provided by law and facility policy."

Restraints in Psychiatric Setting, dated 6/11/13., states:
"Restraints should only be applied when alternative, less restrictive measures appear insufficient to reduce the serious risk of harm."

Record Review:

1. On 7/24/13 from 1-3 pm, record review revealed: a "Recipient Rights Complaint" form, dated 4/25/13, written by patient #8, states: "5 staff members jumped me to take my shirt of (staff #9, #10, #11, #12 and #13). They all had their hands on me trying to get my shirt of. I was crying and having a panic attack. (Staff #14) the RN heard me crying came into the room and said staff Get Out!!!"
2. On 7/24/13 from 1-3 pm, record review revealed: On 7/23/13 at 12:45 pm review of patient #8's clinical record revealed no documentation of the above incident until 4/26/13.
3. On 7/24/13 from 1-3 pm, record review revealed: A "late entry" note, dated 4/26/13, by Mental Health Assistant #9, stating (patient #8) was informed that she needs to remove the tank top & it would be locked up until discharge. Pt was asked several times & by different staff to locked up tank top. Pt became loud, verbally abusive & started kicking @ staff. Pt was @ this time restrained by staff for safety reasons to pt & staff." (The date and time of this incident was not noted.)

Interview:

On 7/24/13 at 2:30 pm staff #6 stated that she received this complaint and was responsible for responding for investigating and responding. Staff #6 stated that the only staff member interviewed as part of this investigation was Mental Health Assistant #9, who was interviewed on 5/23/13. Staff #6 was asked why RN #14 and the other staff named in the complaint were not interviewed. Staff #6 stated that the complaint was not investigated because she did not retrieve the complaint from the unit's complaint box until 4/30/13 and the patient had been discharged on 4/29/13. Staff #6 stated that she had attempted to contact the patient but was unable to explain why this would interfere with conducting an investigation into the allegations noted in the written complaint.

Patient #3:

Policy Review:

Patient Rights and Responsibilities, dated 10/22/09, states:
"Patients and their designated representatives have the right to:"
-"Courteous, respective, considerate care that safeguards their personal dignity..."
-"Care received in a safe setting from from harassment or abuse."

Behavioral Services 3 Rehab Structure Standards, dated 3/2012, states:

k. "Staffing- Numbers and mix of staff required for census are outlined in a grid...Changes in acuity and/or increase in census may require additional staff."

Record Review:

1. On 7/24/13 from 1-3 pm record review revealed: a "Recipient Rights Complaint" form, dated 3/25/13, written by patient #3, stating: "(Patient #17)...said let me fuck you...grabbed me & tried kissing my neck. I pushed his away & went to nurses station they blew it off and did nothing." The complaint was stamped as received on 3/26/13.
2. On 7/24/13 from 1-3 pm record review revealed: on 3/26/13 staff #6 sent an e-mail to RN #15 asking for a response to the above allegation within 48 hours.
3. On 7/24/13 from 1-3 pm record review revealed: on 3/29/13 RN #15 responded via e-mail, stating:"I vaguely recall some mention of (patient #3's) concern of (patient #17) lingering about in the hallway." RN #15 noted "safety concerns" with the staffing level in effect on 3/24/13.
4. On 7/24/13 from 1-3 pm record review revealed: that on the Midnight shift on 3/24/13 staffing was below the level noted on the "staffing grid," with no provision for covering further reductions during scheduled lunch breaks. On 3/24/13 on the Midnight shift there were 34 patients and the grid called for 4 staff and one .5 time Secretary. Only 4 staff worked that shift, with no provision for additional staff during 4 staff lunch breaks of 30 minutes each.
5. On 7/24/13 from 1-3 pm record review revealed: a note by staff #6 stating that patient #3 stated that her roommate was awake at the time of the alleged incident.

Interview:

On 7/24/13 at 2:45 pm staff #6 stated that she received this complaint and was responsible for investigating and responding. Staff #6 stated that the only persons interviewed in investigating this complaint were the patient and a Charge Nurse, not listed on the staffing roster for 3/24/13 or 3/25.13. Staff #6 was asked why all staff working the night of the complaint and the patient's roommate were not interviewed as part of the investigation. Staff #6 responded that she gets a lot of complaints and can't interview all possible witnesses. Staff #6 was asked if there was any follow-up to Nurse #15's concern regarding low staffing at the time of this allegation. Staff #6 stated that she was "unaware of any follow-up."