The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SAMARITAN LEBANON COMMUNITY HOSPITAL 525 N SANTIAM HIGHWAY LEBANON, OR 97355 June 15, 2016
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, documentation in 1 of 1 ED record reviewed of a patient about who the CAH received an allegation of patient abuse (Patient 2), review of medical record and grievance records for 2 of 2 ED patients who submitted grievances, (Patients 2 and 3), and review of policies and procedures, it was determined the CAH failed to implement policies and procedures it had adopted addressing allegations of patient abuse; and policies and procedures it had adopted to ensure that patients/patient representatives received appropriate written responses to grievances.
* Allegations of patient abuse were not investigated, documented, and reported to appropriate CAH staff and other individuals;
* Written responses to patient grievances were not submitted or did not include all required elements.

Findings include:

1. The policy and procedure titled "Unusual Occurrence Reports" dated last revised "05/2014" reflected the following: "The reporting of unusual occurrences is part of the hospital's risk management and quality program...An unusual occurrence includes, but is not limited to...an unintended event that causes actual or potential harm to a patient...any undesirable event that is inconsistent with the routine care of the patient or routine operation of the facility..." The implementation section reflected "...An unusual occurrence report (UOR) shall be completed...by the member of the workforce or medical staff who is most directly involved in the occurrence, who first observed the occurrence, or who first became aware of the occurrence...An unusual occurrence that is sensitive or urgent in nature should be reported immediately. The supervisor will notify Risk Management immediately, when appropriate...Unusual Occurrences may be reported directly to Risk Management by any physician or staff member at any time...The appropriate manager(s), supervisor, or administrator will review and investigate the occurrence and provide appropriate follow-up documentation to the risk manager...Reports with manager/supervisor follow-up should be forwarded to Risk Management within ten (10) working days."

The policy and procedure titled "Complaint or Grievance, Patient/Family" dated last revised 02/22/2016 reflected the following: "...A patient grievance is a written or verbal complaint communicated by a patient...regarding the patient's care, abuse, neglect..." Appendix 1 reflected that when a complaint or grievance was brought to the attention of staff they were to "...Document issue with pertinent information on the Patient/Family Concern Form...Hand deliver to Department Manager/Patient Experience Coordinator (or designee) within one (1) business day...Gather information to further investigate and resolve...Other managers/administration are consulted, as appropriative...A written response to patient/representative is required within seven (7) business days whether the concern is resolved or not resolved..." Appendix 3 required that the written response to the patient included the following: "Date and send letter within seven (7) days of grievance receipt...Result of grievance process...Steps taken on behalf of the patient to investigate the grievance...Name and telephone number of contact person."

2. The medical record of Patient 2 reflected the patient (MDS) dated [DATE] at 0229 with a chief complaint of shortness of breath and abdominal pain.

Physician notes dated 04/19/2016 at 0245 reflected "...When I went to evaluate the patient , [he/she] did not want to talk to me, [he/she] refuses an EKG...This was a very difficult encounter, I had difficulty assessing this patient properly due to [his/her] behavior."

RN notes dated 04/19/2016 at 0246 reflected "[Patient] very defensive, unwilling to allow us to do an EKG d/t 'last time I was here they sexually assaulted me...'"

The record reflected the patient left the CAH against medical advice on 04/19/2016 at 0341.

3. An interview was conducted with the ED Manager on 06/15/2016 beginning at 1200. The ED Manager stated he/she was aware that Patient 2 reported an allegation of sexual abuse but could not remember when he/she found out about it. He/she stated "I heard about it vaguely after the fact." The ED Manager stated that Patient 2 (MDS) dated [DATE] and reported to the Charge Nurse that he/she had been sexually assaulted by an RN and touched inappropriately by a Radiology Tech during a previous ED visit on 04/14/2016. The ED Manager stated that when an allegation of patient sexual abuse is reported to the CAH, staff should notify the police, notify a supervisor, complete an incident report, and conduct an investigation. He/she stated that no incident report had been completed, and no investigation had been conducted of Patient 2's allegation of sexual abuse.

An interview was conducted with the SHS R&C Manager on 06/15/2016 at 1215. He/she stated that no grievance form was completed for Patient 2's report of sexual abuse in accordance with the CAH's grievance policy. He/she stated "I didn't know about it."

An interview was conducted with the ED Manager on 06/15/2016 at 1445. He/she stated that the CAH did not notify the police of Patient 2's allegations of sexual abuse.

An interview was conducted with the Quality Director on 06/15/2016 at 1600. He/she stated the CAH did not submit a written response to Patient 2 addressing his/her allegation of sexual abuse. The Quality Director stated "There has been no follow-up actions because we didn't know about it."

4. Grievance records for Patient 3 who had an ED visit on 02/07/2016, were reviewed with the VP of Patient Care Services on 06/15/2015 at 1330. During an interview conducted at the time of the review, the VP of Patient Care Services stated the patient submitted a complaint on 02/23/2016 about his/her 02/07/2016 ED visit. The VP of Patient Care Services stated the patient's complaint was about lab results and "poisoned food"

A written notice dated 02/24/2016 about the patient's complaint was reviewed. The notice was addressed to the patient and reflected the following: "I understand you came to the Emergency Department to see the doctor for a problem regarding abdominal pain and then some concerns with something you had been eating. I am sorry that you didn't feel well cared for...We are working with our staff to improve the care we are giving to our patients." There was no documentation in the notice reflecting the steps taken on behalf of the patient to investigate the grievance or the results of the grievance process.
VIOLATION: POLICY - EMERGENCY SERVICES Tag No: C0274
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, documentation reviewed in 1 of 4 ED records of patients (Patient 4), and review of policies and procedures, and other documentation, it was determined the CAH failed to implement policies and procedures it had adopted for ensuring transportation was evaluated, arranged, and confirmed for ED patients prior to discharge.

Findings include:

1. A Lippincott Procedures document titled "Discharge" dated last revised 04/03/2015 reflected "...effective discharge requires careful planning and continuing assessment of the patient's needs...Discharge planning aims to...provide instructions for home care...It can also include arranging for transportation, follow-up care...If the patient's family can't arrange transportation, notify the social services department...Always confirm arranged transportation..."

2. The medical record of Patient 4 was reviewed and reflected the patient (MDS) dated [DATE] at 2333 with a chief complaint of abdominal pain.

The record reflected the patient had a medical history that included cardiac dysrhythmias, asthma, knee and ankle injuries, arthritis, psychosis, schizoaffective disorder, and psychiatric care.

An ambulance "Sweet Home Fire and Ambulance District" report dated 02/03/2016 at 2349 reflected the patient was transported to the CAH from his/her residence in Sweet Home, Oregon. The report reflected "[Patient] with...abd [pain]...[Patient] says [he/she] was seen this morning at the urgent care for psychiatric evaluation. [Patient] says [he/she] just got out of the [psychiatric ward] a few days ago."

The record reflected that the patient was administered morphine (a narcotic pain medication) 2 mg IV on 02/04/2016 at 0024.

Physician notes dated 02/04/2016 at 0124 reflected "...[Patient] is discharged home with instructions to stop using street drugs and contact [his/her] doctor in the morning for a follow up appointment..." The notes contained no evidence that the patient's discharge transportation was evaluated, arranged or confirmed.

A physician "Discharge Instructions" form dated 02/04/2016 at 0136 was reviewed and contained no information related to where the patient was discharging to, and no evidence that the patient's transportation was evaluated, arranged or confirmed.

RN flowsheet documentation on 02/04/2016 at 0138 reflected the patient's mobility at discharge was "Ambulatory" and the "Departure Mode" was "By self." There was no documentation reflecting where the patient was discharging to, or that the patient's transportation was evaluated, arranged or confirmed.

The "ED Disposition" reflected the patient was discharged to "home/self care."

The record reflected the patient was discharged on [DATE] at 0148.

There was no documentation in the record reflecting the patient's discharge transportation was evaluated, arranged or confirmed; and no assessment of the patient's ability to arrange his/her own transportation including consideration of the patients's arrival by ambulance, history of physical and psychiatric conditions, administration of potentially sedating medications in the ED, and distance from the CAH to the patient's home.

3. During an interview with the ED Manager on 06/15/2016 at 1500, he/she stated the "Discharge" Lippincott Procedure document was the CAH's policy and procedure for addressing patients who were discharged from the ED.

An interview was conducted with the Quality Director on 06/15/2016 at 1515. The Quality Director stated "The nurse should've asked the patient how [he/she] was getting home." The Quality Director acknowledged the record contained no documentation reflecting that the nurse evaluated or arranged transportation for the patient.

During an interview with the SHS R&C Manager on 06/15/2016 at 1545, he/she stated that on 06/02/2016 the patient reported being discharged from the ED on "02/03/2016" at approximately 0200 without transportation arrangements. The SHS R&C Manager stated the patient reported he/she walked to a grocery store 2 miles away from the CAH, then "got a ride" to Sweet Home, Oregon, and did not get home until 02/04/2016 at 0400.

4. Mapquest reflects Samaritan Lebanon Community Hospital is 16 miles from Sweet Home, Oregon with an estimated driving time of 24 minutes and estimated walking time of 6.5 hours.