HospitalInspections.org

Based on review of facility policies and interview with facility staff (EMP), it was determined that the facility failed to abide by the time frames for review of the grievances and the provision of a response as outlined in their policy for three out of five grievances.
Findings include:
On April 29, 2022, review of facility policy titled "BHH-Patient Complaint & Grievance Process" last revised February 1, 2022, revealed "...B. Grievances...3. The person handling the grievance will make every effort to resolve the dispute. A copy of the written grievance and decision will be returned to the patient and/or family within 48 hours. A copy will be filed in the patient's medical record...4. First Level Appeal...a. The DON or nursing designee and MQM will investigate the complaint and present the patient/family with a written decision within ten (10) working days...".
On April 29, 2022, review of facility policy titled "BHH-Grievance and Appeal System" adopted 2020 and utilized until revision on February 1, 2022, per EMP2, revealed, "...3. The person handling the grievance will make every effort to resolve the dispute. A copy of the written complaint and decision will be returned to the patient and/or family within 48 hours. A copy will be filed in the patient's medical record...4. First Level Appeal...a. The DON and MQM will investigate the complaint and present the patient/family with a written decision within ten (10) working days...".
Review of complaints and grievances log from March 2021 through March 2022 revealed five grievances for that period.
On April 29, 2022, review of grievance filed on October 22, 2021, revealed the response letter was not sent until October 25, 2021.
On April 29, 2022, review of grievance filed on October 26, 2021, revealed the response letter was not sent until October 29, 2021.
On April 29, 2022, review of grievance filed on February 3, 2022, revealed the response letter was not sent until February 7, 2022.
Findings confirmed by EMP2 on April 29, 2022, at 11:30am.

Based on a review of facility policy, medical record (MR), and staff interview (EMP), it was determined that the facility failed to ensure patients receive care in a safe setting, which resulted in a patient elopement, for one of one medical records reviewed (MR2).

Findings Include:

On April 29, 2022, Review of " Observation Policy " , last approved on December 30, 2020, revealed: " ... PURPOSE ... C. To provide distinct levels of observation which correlate to the levels of patient acuity and risk ... ROUTINE OBSERVATION ... Constant 1:1 Observation This type of observation is employed for patients who are at high risk for dangerous behaviors. These dangerous behaviors may include suicidal ideation with plan/intent ... extreme elopement risk ... A. Staff maintains constant observation of the patient. Constant 1:1 Observation is defined as staff being within arm's length of the patient at all times. ... " .
Review of MR2 revealed that MR2 was admitted to the facility involuntarily on 12/28/2021 with diagnoses including major depressive disorder, post-traumatic stress disorder and suicide attempts.
Further review of MR2 revealed that MR2 was ordered for Constant 1:1 Observation, and was assessed to be a suicide risk on 4/23/22 at 10:30 AM.
Interview with EMP3 on April 28, 2022, at approximately 11:00 AM, revealed that MR2 eloped on April 23, 2022, at approximately 15:00. EMP3 stated that the sitter responsible for the 1:1 Observation was located in the center of the courtyard, not within arms length of MR2. In addition, MR2 traveled down the elevator and through the front doors, which were unlocked.
Review of a nursing note from EMP10 dated 4/23/22 at 1500, revealed: " Pt. eloped. Code Elvis called. Pt. gone for approximately 20 minutes. Multiple efforts in place to locate patient. Administration notified of elopement. Pt. was returned without incident and no injuries noted. ".
On April 28, 2022, at approximately 11:30 AM, EMP3 confirmed that the sitter was not within arm's length of MR2 when MR2 eloped and stated "the order should have been more specific". EMP3 also confirmed that MR2 traveled down the elevator and through the front doors, which should have been locked.

Based upon a review of facility documents and interview (EMP) it was determined that the hospital ' s governing body failed to assure a Quality Improvement plan that accurately reflected the individual hospital organization and specialized services.
Findings include:
1. On April 28, 2022, a review of Lifecare Hospitals of North Texas and East End Behavioral Health- Quality and Patient Safety Plan (undated) was completed. "Section III. Procedure; D. Types of Data 2. The hospital collects data that measure the performance of each of the following applicable and potentially high risk processes, when provided and may include but is not limited to: a. Medication Management b. Blood and blood product use c. Restraint use d. Seclusion use e. Resuscitation and its outcomes . III. Data Management- #11. An analysis is performed for the following as applicable to the facility: a. Confirmed transfusion reactions ....VII. Patient Safety and Quality Indicators and Performance: 1. Falls with injury; 2. Mortality; 3. Patient Grievances 4. Infection Control activites as applicable A. Central Line Associated Bloodstream Infections (CLABSI); B. Indwelling Urinary Catheter-Associated Urinary Tract Infection (CAUTI) ; C. Hospital Associated Pressure Ulcers (HAPU); D. Employee Influenza. VII. 5. g. Blood and Blood product use; i. Operative/Invasive procedures; j. Resuscitation and outcomes."
2. On April 28, 2022, the quality report to the governing body was reviewed for 2021 and Jan. through March of 2022. Key reportable indicators to the governing body from the department include the following: Patient falls with injury per 1,000 patient days; Hours of physical restraint per 1,000 patient hours; elopement; complaints; grievances; PSRS reportable serious events; and, PA PSRS reportable incidents (Harm Score A-D).
3. On April 28, 2022, at 01:11pm, EMP3 validated that East End Behavioral Health did not perform the following procedures: blood transfusions, electroconvulsive therapy, central lines. EMP3 indicated that the facility did use a foley occasionally.
4. On April 28, 2022, at 2:10PM, EMP2 validated that Lifecare Hospitals of North Texas and East End Behavioral Health- Quality and Patient Safety Plan (undated) was not specific to the organization and the psychiatric services provided. EMP2 indicated that Lifecare Hospitals of North Texas and East End Behavioral Health- Quality and Patient Safety Plan (undated) was a " corporate plan. "
5. On April 28, 2022, the minutes of the Dec. 15, 2021 Governing Board Meeting were reviewed. It is noted in the minutes, Annual Review " The Board was presented with the attached plans for annual review and approval. A. Annual Review of the Performance Improvement Plan - corporate plan. Upon motion duly made and seconded, the Board approved the annual review as presented. "

Based on review of facility documents and interview with facility staff (EMP) it was determined that the program offered by the facility failed to have a consent form that accurately reflected the hospital's services.
Findings include:
On April 29, 2022, review of facility document "East End Behavioral Health Hospital Patient Consent to Treatment Admission Form" revealed, "1. CONSENT TO MEDICAL AND SURGICAL PROCEDURES The patient identified above consents to the procedures that may be performed during this hospitalization or on an outpatient basis, including emergency treatment or services, and which may include but are not limited to laboratory procedures, x-ray examination, medical and surgical treatment or procedures, anesthesia, or hospital services rendered for the patient under the general and special instructions of the patient's physician...".
Interview with EMP3 on April 29, 2022, at 2:00pm revealed that the facility does not offer services such as surgical treatment or procedures or anesthesia. The only emergency services offered are if the patient would need to be transferred for emergent reasons or if 911 would need to be called. They do have the capabilities of having x-ray come in if needed and have the capabilities of running labs on site. At this time EMP3 confirmed the findings of the consent.

Based on a review of facility documents and staff interviews (EMP), it was determined that the facility failed to develop and implement policies and procedures to ensure that agency staff, contractors, vendors, students, and volunteers were fully vaccinated for Covid-19 as evident by the failure to implement ten of ten components of the vaccine mandate.

Findings include:

A review of the facility policy " Covid 19 Pandemic Response - Employees " dated 2/2022, stated, " Purpose: To establish guidelines or hospital staff response to Covid-19 pandemic ... ... Vaccination Response: 1. All current LifeCare employees as of Jan 2022, must have their vaccination status uploaded to Paycom. 2. By January 27, 2022, all current LifeCare Employees must receive, at minimum, the first does of a two-dose (Moderna or Pfizer) or one dose of Johnson & Johnson vaccine or a qualifying exception from filled out and approved ....4. By February 28, 2022, all LifeCare employees must be fully vaccinated with a record of vaccination or an approved qualifying exception on file and approved ...8. Tracking of vaccinated employees will be reported to all local, state, and federal agencies in charge of pandemic response who mandate reporting of this information. "

1. A review of facility documents revealed that there were no policies or processes in place for ensuring that agency staff, contractors, vendors, students, and volunteers have received, at a minimum, a single-dose Covid-19 vaccine, or the first dose of the primary vaccination series for a multi-dose Covid-19 vaccine prior to staff providing any care, treatment, or other services for the hospital and/or its patients.

2. A review of facility documents revealed that there were no policies or processes in place for ensuring agency staff, contractors, vendors, students, and volunteers were fully vaccinated for Covid-19, except for those who have been granted exceptions to the vaccination requirements, or those for whom Covid-19 vaccination must be temporarily delayed.

3. A review of facility documents revealed that there were no policies or processes in place for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of Covid-19, for agency staff, contractors, vendors, students, and volunteers who are not fully vaccinated for COVID-19.

4. A review of facility documents revealed that there were no policies or processes in place for tracking and securely documenting the COIVD-19 vaccination status of agency staff, contractors, vendors, students, and volunteers.

5. A review of facility documents revealed that there were no policies or processes in place for tracking and securely documenting the COVID-19 vaccination status of agency staff, contractors, vendors, students, and volunteers who have obtained any booster doses as recommended by CDC.

6. A review of facility documents revealed that there were no policies or processes in place by which agency staff, contractors, vendors, students, and volunteers may request an exception from the staff COVID-19 vaccination requirements.

7. A review of facility documents revealed that there were no policies or processes in place for tracking and securely documenting information provided by agency staff, contractors, vendors, students, and volunteers who have requested an exception from the staff COVID-19 vaccination requirements.

8. A review of facility documents revealed that there were no policies or processes in place for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19, and which supports agency staff, contractors, vendors, students, and volunteers request for medical exemptions from vaccination, had been signed and dated by a licensed practitioner, who was not the individual requesting the exception, and who was acting within their respective scope of practice.

9. A review of facility documents revealed that there were no policies or processes in place for ensuring the tracking and secure documentation of the vaccination status of agency staff, contractors, vendors, students, and volunteers for whom COVID-19 vaccination must be temporarily delayed, due to clinical precautions and considerations.

10. A review of facility documents revealed that there were no policies or processes for contingency plans for agency staff, contractors, vendors, students, and volunteers who are not fully vaccinated for COVID-19.

During an interview on April 29, 2022 at 12:45 PM, EMP1 confirmed that the facility's COVID 19 Pandemic Response policy is specific to hospital staff and does not address agency staff, contractors, vendors, students, and volunteers.