Bringing transparency to federal inspections
Tag No.: A0118
Based on record review and interview, the facility failed to ensure the process and procedures for prompt resolution of patient grievances in accordance with their Complaint/Grievance policy, for 1 of 1 grievance reviewed regarding Patient #2; who alleged an allegation of physical abuse against a staff member while an inpatient at the facility.
Specifically, on 11/15/21 the facility's Chief Nursing Officer (CNO) was notified by Patient #2's representative of a physical abuse allegation made against facility staff member #4.
The physical abuse allegation was reported to the facility's CNO, who then reported the allegation to the Director of Risk Management (DRM). There was not any evidence the facility addressed these allegations utilizing their grievance policy and procedures.
Findings Included:
Review of the complaint TX00400867 intake information revealed the following allegations alleged by Complainant on behalf of Patient #2: Patient #2 was transferred to the facility and upon admission to the facility, the patient was aggressive and fighting. Patient #2 was biting, kicking, pinching, etc. The staff were trying to do a "take down" [restraint] and "someone punched the patient" in the eye. The patient reported the staff name as; Staff #4. The complainant attempted to reach the charge nurse and left several messages requesting that an incident report be filed, but the complainant never received a call back. On 11/14/21, the complainant spoke to the Chief Executive Officer (CEO) and CNO and they stated they would conduct an investigation.
Review of the facility's Patient Advocacy Complaint/Grievance Log for November 2021 revealed there was no documentation on the log regarding the physical abuse allegation alleged by Patient #2; or on behalf of Patient #2.
Review of the facility's Incident Reports for Patient #2 revealed there was not an incident report completed for the allegation of physical abuse reported on 11/15/21 to the facility's CNO on behalf of Patient #2.
During an interview on 12/13/21 at 2:05 PM with the facility's Director or Risk Management (DRM) stated there was not a full investigation conducted on behalf for Patient #2; where people were interviewed and statements obtained because they were able to review the restraint video from 11/12/21 and conducted a "Camera Review" of the restraint that happened in the seclusion room. The DRM stated he reviewed the video and after the restraint, Patient #2 was given "meds" and went outside with Staff #4 to smoke a cigarette. The DRM stated the restraint video had not been saved and there was not any camera footage available for the surveyor to view. The DRM further stated that the Patient Advocate had been out on leave and that the CNO had handled the follow up with the complainant by phone after he looked at the video of the restraint and determined there was no evidence of physical abuse.
During an interview on 12/13/21 at 3:15 PM with the CNO stated he called the complainant back after he viewed the restraint video from 11/12/21 and reported to the complainant that he did not see any evidence of physical abuse towards Patient #2. The CNO further stated that a written response of the complaint/grievance findings were not sent to the complainant because he was not satisfied with the response provided by the CNO.
Review of the facility's form titled, "Investigation with Camera Review of Event" dated 11/16/21 by the DRM documented the following: CNO spoke with Patient #2's father on 11/15/21 in the conference room. Father stated son was "punched by a [Staff #4] on Friday, (11/12/21). CNO assured father the situation would "be investigated." CNO then spoke with patient who claimed it happened while in seclusion on Friday. CNO then spoke with DRM about the father's complaint and patient's statement; and provided a written statement. CNO spoke with Staff #4, who stated the restraint was a difficult one due to the patient's aggressive behaviors, but was done properly by staff, including himself. Pt and staff did fall to the ground when pt. fought back, so "unintentional face injury could have occurred." Pt went with Staff #4 out for a smoke break after restraint and IM's were given and no further issues reported. Allegation unsubstantiated. All techniques utilized by staff were within proper SAMA [Satori Alternatives for Managing Aggression] procedures.
Review of the CNO statement/email to the DRM dated 11/15/21 revealed that the CNO spoke to Patient #2 on the morning of 11/15/21 about an incident that occurred a few days ago in which Patient #2 claimed "a staff member punched him in the eye." He stated it occurred about 3 days ago in the seclusion room. Patient #2 stated that he "was punched in the eye, he did not give me any staff members names." "I did notice slight bruising under his left eye."
Further review revealed Staff #4 came to speak with the CNO and stated that Patient #2 had been targeting him and that the patient is stating that Staff #4 was the one who "punched him." Staff #4 stated that he was involved in a restraint of this patient on 11/12/21. Staff #4 stated that he never punched the patient, but that it was a difficult restraint and that the patient "could have been unintentionally hit during it."
During an interview on 12/13/21 at 2:30 PM with Staff #4 stated he was called to code on 11/12/21 for Patient #2 who was being aggressive, and he had been escorted to the seclusion room. He stated Patient #2 was then restrained in the seclusion room and that he was holding Patient #2's "upper body" with three other staff members assisting in the hold. Staff #4 stated while he was holding Patient #2; he was biting his forearm and that he "pushed into the bite" as taught in "SAMA" [Satori Alternatives to Managing Aggression] techniques, and pushed his head away using his forearm making contact with his face. Staff #4 stated sometimes people get unintentionally injured during restraints and that Patient #2 may have had an unintentional injury from the restraint. Staff #4 indicated he observed Patient #2's eye after the restraint stating, "he was injured;" he had darkness around his eye. Staff #4 stated he noticed the injury to Patient #2's eye immediately when he was talking to Patient #2 after the restraint during the debriefing. Staff #4 stated he did not complete the restraint paperwork; that Registered Nurse (RN) #17 initiated it.
During an interview on 12/14/21 at 12:00 PM with the Patient Advocate (PA) stated the he was on leave when Patient #2 made a complaint/grievance against Staff #4, and then Patient #2's father came to the facility on 11/15/21 making an allegation of abuse that would automatically be classified as a grievance. The PA stated that with an allegation of abuse it is a grievance and would need to be thoroughly investigated with a formal written response sent to the complainant. The PA stated this complaint/grievance was closed out following the camera review and the CNO called back the complainant to report the findings; stating nothing further is needed.
Review of the facility's policy and procedures titled, Patient Complaint and Grievance Process, last revised 1/25/2017 documented the following:
A patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Condition of Participation or accrediting organization standards.
Further review under procedures indicated:
F. The Patient Advocate will conduct an investigation of the grievance, reviewing the patient's medical record, to obtain information regarding the patient's clinical condition.
G. All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance that requires immediate attention. The Patient Advocate will forward such complaint to the Risk Management Department where a full investigation will be conducted.
I. All grievances receive immediate priority and must be investigated with efforts made toward resolution within 24 hours. If a grievance cannot be resolved within 24 hours, the grievance will be referred as described below. This organization will make every attempt to provide a response within seven (7) days of receiving a grievance.
Review of the CMS guidance and interpretive guidelines at 482.13(a)(2) for patient grievance states the following:
A "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient 's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR §489.
Tag No.: A0145
Based on record review and interview, the facility failed to thoroughly ensure patient's rights to be free from all forms of abuse or harassment by failing to thoroughly investigate and document an allegation of physical abuse alleged by Patient #2 against a staff member while an inpatient at the facility and; in accordance with the facility's policy and procedures.
Specifically,
1.) an allegation of abuse made by Patient #2 was not thoroughly investigated or documented by the facility for the possible identification of physical abuse or mistreatment.
2.) the facility failed to create an Incident Report following the allegation by Patient #2 on 11/12/21, and/or Complainant on 11/14/2021 and subsequent camera review on 11/16/2021 as required by facility policy.
This deficient practice could affect the prevention of possible unidentified abuse, neglect or mistreatment for all patients in the facility; compromising their safety.
Findings Included:
Review of the complaint TX00400867 intake information revealed the following allegations alleged by Complainant on behalf of Patient #2: Patient #2 was transferred to the facility and upon admission to the facility, the patient was aggressive and fighting. Patient #2 was biting, kicking, pinching, etc. The staff were trying to do a "take down" [restraint] and "someone punched the patient" in the eye. The patient reported the staff name as; Staff #4. The complainant attempted to reach the charge nurse and left several messages requesting that an incident report be filed, but the complainant never received a call back. On 11/14/21, the complainant spoke to the Chief Executive Officer (CEO) and CNO and they stated they would conduct an investigation.
Review of the facility's Patient Advocacy Complaint/Grievance Log for November 2021 revealed there was no documentation on the log regarding the physical abuse allegation alleged by Patient #2; or on behalf of Patient #2.
Review Restraints and Incident Reports for Patient #2 revealed that there was an Incident Report completed on 11/12/2021 at 1521 for, "Assault-Peer or Staff, Patient Safety, Behavioral, Property Damage, and Aggressive Behavior". The Nursing documentation noted no injury at the time. The Restraint document from 11/12/2021 beginning at 1521 for Patient #2 states, "no complaints voiced of injury with intervention."
Review of Patient #2's medical records revealed a Nursing Progress Note dated 11/12/2021 at 1545 noted no injury following a restraint on 11/12/2021 at 1521.
Review of the facility's Incident Reports for Patient #2 revealed there was not an incident report completed for the allegation of physical abuse reported on 11/15/21 to the facility's CNO on behalf of Patient #2.
Further review of Patient #2's records and facility incident reports revealed there was not any documentation following the allegation made on behalf or Patient #2 of abuse by a staff member.
During an interview on 12/13/21 at 2:05 PM with the facility's Director or Risk Management (DRM) stated there was not a full investigation conducted on behalf for Patient #2; where people were interviewed and statements obtained because they were able to review the restraint video from 11/12/21 and conducted a "Camera Review" of the restraint that happened in the seclusion room. The DRM stated he reviewed the video and after the restraint, Patient #2 was given "meds" and went outside with Staff #4 to smoke a cigarette. The DRM stated the restraint video had not been saved and there was not any camera footage available for the surveyor to view. The DRM further stated that the Patient Advocate had been out on leave and that the CNO had handled the follow up with the complainant by phone after he looked at the video of the restraint and determined there was no evidence of physical abuse.
During an interview on 12/13/21 at 3:15 PM with the CNO stated he called the complainant back after he viewed the restraint video from 11/12/21 and reported to the complainant that he did not see any evidence of physical abuse towards Patient #2. The CNO further stated that a written response of the complaint/grievance findings were not sent to the complainant because he was not satisfied with the response provided by the CNO.
Review of the facility's form titled, "Investigation with Camera Review of Event" dated 11/16/21 by the DRM documented the following: CNO spoke with Patient #2's father on 11/15/21 in the conference room. Father stated son was "punched by a [Staff #4] on Friday, (11/12/21). CNO assured father the situation would "be investigated." CNO then spoke with patient who claimed it happened while in seclusion on Friday. CNO then spoke with DRM about the father's complaint and patient's statement; and provided a written statement (which was not available at the time of the review). CNO spoke with Staff #4, who stated the restraint was a difficult one due to the patient's aggressive behaviors, but was done properly by staff, including himself. Pt and staff did fall to the ground when pt. fought back, so "unintentional face injury could have occurred." Pt went with Staff #4 out for a smoke break after restraint and IM's were given and no further issues reported. Allegation unsubstantiated. All techniques utilized by staff were within proper SAMA [Satori Alternatives for Managing Aggression] procedures. A memo was attached to the "Investigation with Camera" to update the PA of the allegations. This document noted "slight bruising under his (Patient #2) left eye."
Review of the CNO statement/email to the DRM dated 11/15/21 revealed that the CNO spoke to Patient #2 on the morning of 11/15/21 about an incident that occurred a few days ago in which Patient #2 claimed "a staff member punched him in the eye." He stated it occurred about 3 days ago in the seclusion room. Patient #2 stated that he "was punched in the eye, he did not give me any staff members names." "I did notice slight bruising under his left eye."
Further review revealed Staff #4 came to speak with the CNO and stated that Patient #2 had been targeting him and that the patient is stating that Staff #4 was the one who "punched him." Staff #4 stated that he was involved in a restraint of this patient on 11/12/21. Staff #4 stated that he never punched the patient, but that it was a difficult restraint and that the patient "could have been unintentionally hit during it."
During an interview on 12/13/21 at 2:30 PM with Staff #4 stated he was called to code on 11/12/21 for Patient #2 who was being aggressive, and he had been escorted to the seclusion room. He stated Patient #2 was then restrained in the seclusion room and that he was holding Patient #2's "upper body" with three other staff members assisting in the hold. Staff #4 stated while he was holding Patient #2; he was biting his forearm and that he "pushed into the bite" as taught in "SAMA" [Satori Alternatives to Managing Aggression] techniques, and pushed his head away using his forearm making contact with his face. Staff #4 stated sometimes people get unintentionally injured during restraints and that Patient #2 may have had an unintentional injury from the restraint. Staff #4 indicated he observed Patient #2's eye after the restraint stating, "he was injured;" he had darkness around his eye. Staff #4 stated he noticed the injury to Patient #2's eye immediately when he was talking to Patient #2 after the restraint during the debriefing. Staff #4 stated he did not complete the restraint paperwork; that Registered Nurse (RN) #17 initiated it.
During an interview on 12/17/21 at 11:45 AM with House Supervisor (Staff #18) stated on 11/12/21 she was present during Patient #2's restraint and conducted the face to face assessment after the restraint. Staff #18 stated that "later, on the unit" Patient #2 stated to her, "staff [#4] elbowed me in the face ten times, multiple times." Staff #18 indicated she was literally standing right there when the restraint happened, and she knew that didn't happen; "I was there, he was lying." Staff #18 indicated Patient #2's mother called and was upset about Patient #2's eye being injured making allegations of abuse and said Patient #2 was already blind in one eye.
Further interview with Staff #18 stated Patient #2 was saying "quit hitting me in the face; elbowing, while in the restraint and that Staff #17 wrote this "big note" that Staff #4 was "upset he [Patient #2] was targeting him."
Staff #18 confirmed she did not write a separate incident report following the allegation of abuse reported by Patient #2.
Review of the hospital policy entitled, "Abuse, Neglect, Exploitation or Assault, Reporting, Investigation and Response," last revised 01/01/2019 stated in part:
B. Reporting
2. the Director of Risk Management shall be contacted by the employee, CEO or CNO as soon as possible to ensure an investigation is immediately initiated and reporting to external parties if indicated.
D. Investigation and Documentation
1. An Incident Report shall be completed by the individual witnessing or receiving the report of possible abuse, neglect, exploitation or assault and forwarded to Risk Management per policy.
6. The CEO ensures that investigations are completed in a timely manner and that the required agencies, departments and committees are informed.
Review of the hospital policy entitled, "Incident Report," last revised 01/25/2017 stated in part:
Procedure:
The Incident Report must be completed by the employee(s) who witnessed the event or discovered the event.
The following categories, not limited to, are reported on the Incident Report form:
"Abuse allegation
A brief description of the event is documented with facts on the Incident Report form.
A written statement is provided in addition to the Incident Report form, if requested by Director of Performance Improvement/Risk Management or Administration.
Notifications to Supervisor, Physician, Director PI/RM, next of Kin, guardian as indicated.
All completed Incident Reports should remain at the facility as part of the facility's Performance Improvement/Risk Management Program.
45847
Tag No.: A0629
Based on a review of documentation and interviews, the facility failed to ensure that individual patient nutritional needs were met in accordance with recognized dietary practices and; in accordance with the facility's policy for 1 of 3 patients reviewed (Patient #1) for dietary complaints.
Findings included:
Review of the complaint TX00396202 intake information revealed the following: Patient #1 presented to the facility on 09/12/2021 at 02:00 AM for Mental Health Services. The Complainant stated that Patient #1 was not provided meals during her admission process or on the unit 09/12/2021.
Interview with the complainant on 12/13/21 at 12:35 PM stated Patient #1 did not receive any meals on 9/12/21 while Patient #1 was being held in the Admission area. The Complainant stated once Patient #1 was transferred to the unit later on 9/12/21 from admissions; that she was not allowed to go to the cafeteria to get a meal because she had not see a physician or therapist to allow her to go to the cafeteria and; that there was not any food brought back to Patient #1 on the unit. The complainant stated a friend gave Patient #1 some "M&M's." The complainant stated she called the nurse to report that Patient #1 had not eaten, and the nurse responded; "let me check to see if the cafeteria is open."
Review of Patient #1's records revealed the following:
Patient Intake assessment completed 9/12/21 at 03:18 AM in the Admissions area of the facility.
Admission Orders dated 9/12/21 at 3:21 AM documented Regular Diet.
Patient #1 transferred from Admissions area to the adolescent unit on 9/12/21 at 11:44 AM when the Nursing Admission Assessment was completed.
12 HR (Hour) Daily Nursing Assessment/Progress Note dated 9/12/21 for the 7PM to 7AM (overnight shift) by Registered Nurse (RN) #6 revealed the Dietary Intake documented 100% for Breakfast, 100% for Lunch, 100% for dinner and 100% for snack.
Interview with RN#6 on 12/17/21 at 12:47 PM confirmed she documented 100% dietary intake for Patient #1 on the 12 Hour Nursing Assessment dated 9/12/21 for the 7PM to 7 AM shift. RN #6 confirmed she was not present on 9/12/21 for breakfast, lunch and dinner and further stated she "was told to fill everything out," or we can fill them out by "talking to staff." RN #6 further confirmed that Patient #1 did not arrive to the unit until 11:44 AM on 9/12/21 which was after breakfast and lunch.
12 HR (Hour) Daily Nursing Assessment/Progress Note dated 9/13/21 for the 7AM to 7PM shift by RN #7 revealed the Dietary Intake was blank for Breakfast, Lunch and Dinner with Snack documented as 100%.
12 HR (Hour) Daily Nursing Assessment/Progress Note dated 9/14/21 for the 7AM to 7PM shift by RN #7 revealed the Dietary Intake was blank for Breakfast, Lunch and Dinner with Snack documented as 100%.
Interview with CNO on 12/14/2021 at 1500 revealed that the nurse should have documented dietary intake percentage on the Nursing Progress Notes/Assessments for 9/13/21 and 9/14/21. CNO also stated the lunch is traditionally served at 11:30 AM in the Units.
Interview on 12/29/21 at 11:08 AM with Registered Nurse (RN) #7 stated that the adolescent patients would eat breakfast on the unit and that lunch is served from 10:45 to 11:15 AM on the unit. RN #7 stated that if the patient is on "unit restriction" then the "Tech" or herself would get food brought back to the unit for the patient's on unit restriction. RN #7 confirmed her Daily Nursing Assessments/Progress Notes dated 9/13/21 and 9/14/21 were blank for dietary intake breakfast, lunch and dinner stating she was supposed to fill them out but there were times she had not.
Review of the Patient observation notes for 9/12/21, 9/13/21 and 9/14/21 included an area on the Observation Notes for Meal intake; Ate: percentage for breakfast, lunch, dinner and snack. These areas for percentages of meal intakes for breakfast, lunch, dinner and snacks were blank for 9/12/21, 9/13/21 and 9/14/21.
Review of hospital policy entitled, "Meeting Dietary Needs of all Patients," last revised 01/25/2017 stated in part:
III. PROCEDURE:
2. Monitoring
a. Clinical personnel shall monitor diets at each meal and document the percentage of food eaten on the nursing flow sheet daily.