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.

SAINT ALPHONSUS REGIONAL MEDICAL CENTER 1055 NORTH CURTIS ROAD BOISE, ID 83706 Oct. 21, 2011
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on review of hospital policies, grievance documentation, and staff interview, it was determined the facility failed to ensure time frames were established for the review of grievances and provision of a resolution response. This impacted 12 of 12 patients/representatives (#9, #10, #11, #12, #15, #22, #23, #24, #25, #26, #27, and #33) whose grievances were reviewed, and had the potential to impact all patients/representatives who submitted grievances. Failure to define time frames for communication regarding ongoing investigations and resolution of grievances led to extended periods of time between the submission of a grievance and the next communication to the complainant. Findings include:

1. The "CONCERN AND GRIEVANCE MANAGEMENT PROGRAM" policy, dated 3/28/11, was reviewed. The policy stated that, "Within 7 days of receiving the grievance notification, the complainant and/or family...will be sent a written communication acknowledging the receipt of the grievance and explaining how the investigation will be conducted and who the contact person will be during the investigation." The policy did not contain a time frame for the resolution of grievances, or intervals in which the patient/family would be notified that the investigation was still in process.

The Patient Relations Supervisor was interviewed on 10/20/11 at 11:35 AM. She confirmed that an acknowledgement letter was sent to the patient or their representative upon receipt of the grievance. She stated if the investigation and resolution of the grievance occurred within the 7 day timeframe, then the acknowledgement letter and resolution letter would be combined into one and the grievance would be closed. She stated the policy did not contain time frames for the resolution of grievances or for notifying the patients or their representatives if the grievances were not able to be investigated and resolved within 7 days.

Grievance documentation related to grievances submitted by Patients #9, #10, #11, #12, #15, #22, #23, #24, #25, #26, #27, and #33 were reviewed. Without a policy to direct the timelines of investigation and response there was the potential for a delay in communication regarding the investigation and completion of the investigation process.

The hospital did not have specified timelines for the investigation and completion of the grievance process or for maintaining communication with patients/representatives during the process.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure nursing care plans were developed for 4 of 12 behavioral health patients (#2, #16, #18, and #21), whose records were reviewed. This prevented nursing staff from providing care in a consistent manner. Findings include:

1. The policy "PLAN OF CARE, INTERDISCIPLINARY," revised 9/07, stated "All patients admitted to Saint Alphonsus Regional Medical Center will have an Interdisciplinary Plan of Care (IDPC) initiated within 24 hours of admission. Any discipline is able to initiate the IDPC but it is the responsibility of the RN to ensure initiation within 24 hours." The policy stated it applied to all patients.

The policy "MULTIDISCIPLINARY TREATMENT PLANNING: INPATIENT," revised 4/07, was labeled "Behavioral Health." The policy did not mention nursing plans of care. The policy stated the multidisciplinary plan was to be completed within 72 hours of admission.

The Nurse Manager for Behavioral Health was interviewed on 10/21/11 at 2:55 PM. She stated the Behavioral Health Unit did not follow the "PLAN OF CARE, INTERDISCIPLINARY" policy. She stated she was not aware of a policy that addressed nursing plans of care on the behavioral unit.

The Behavioral Health Unit did not follow the hospital's policy "PLAN OF CARE, INTERDISCIPLINARY" which included nursing care plans as follows:

a. Patient #2's medical record documented a [AGE] year old female who was hospitalized from [DATE] to 1/08/11 with diagnoses of [DIAGNOSES REDACTED]

- A "Consultation," dictated by the psychiatrist and dated 12/31/10, stated Patient #2 was depressed and suicidal. The consultation stated Patient #2 also complained of chronic pain. She was admitted with orders for a Fentanyl patch and Percocet (narcotic pain medications) as needed. The consultation did not describe the pain Patient #2 experienced.

- A "History & Physical" by a physician assistant, dated 12/31/10, stated Patient #2 had a history of panic disorder, anxiety, and chronic pain issues. The "History & Physical" stated Patient #2's current medications included Fentanyl and Percocet. The "History & Physical" did not document assessment her pain or state the location of her pain.

- The "Behavioral Medicine Admission Profile" form, written by an RN and dated 12/31/10 at 1:20 AM, stated Patient #2 complained of pain at a level of 9 of 10. The location of her pain was described as "Other."

- A "Behavioral Medicine Progress Note" by a nurse, dated 12/31/10 at 10:53 AM, stated the patient was crying and sobbing and stated she was "...tired of coping with chronic pain..." Medication administration records documented Patient #2 received Percocet 27 times for break-through pain during her stay.

Also, a "Behavioral Medicine Progress Note" by a nurse, dated 1/01/11 at 10:42 PM, stated Patient #2 said "I am having these panic attacks all the time and doctor does not want to do anything." A "Behavioral Medicine Progress Note" by a nurse, dated 1/04/11 at 11:10 AM, stated Patient #2 reported panic attacks.

A nursing care plan was not present in the medical record. Instead, a "Psychiatric Treatment Plan," dated 12/31/10, was present. The plan listed 1 problem, increased depression with suicidal ideation. Patient #2's treatment plan did not mention her chronic pain or her panic attacks.

The Charge Nurse on the Behavioral Health Unit was interviewed on 10/19/11 beginning at 1:20 PM. She confirmed Patient #2's treatment plan did not address her pain or her panic attacks.

A nursing care plan was not developed for Patient #2.

b. Patient #18's medical record documented a [AGE] year old female who was hospitalized from [DATE] to 3/16/11 with a diagnosis of [DIAGNOSES REDACTED]

- The "Behavioral Medicine Admission Profile" form, written by an RN and dated 3/12/11 at 6:22 AM, stated she "...is reported to be gravely disabled, not caring for herself. Reportedly not bathing, not following medical advice. Reportedly had retarded motor activity, unbalanced gait, and slurred speech...possible issues with inhospitable living conditions. Pt reportedly had bedbugs, had feces in her nails and hair, reportedly has a lot of cats and smells of cat urine."

- A "Psychiatric Treatment Plan," dated 3/14/11 but not timed, stated the reason for admission was "Overall [decrease] in functioning." Under the "Liabilities/Barriers" section of the plan was listed "Difficulties [with] self care, gravely disabled." The plan directed nurses to "Assess patient's ability to care for self each shift. Cue patient and/or assist if needed to complete ADLs." However, the plan was written more than 48 hours after Patient #18 was admitted .

The Charge Nurse on the Behavioral Health Unit was interviewed on 10/19/11 beginning at 1:20 PM. She confirmed Patient #18's treatment plan did not address her ADL issues for more than 48 hours after admission.

A nursing care plan for Patient #18 was not developed in a timely manner and in accordance with the hospital's "PLAN OF CARE, INTERDISCIPLINARY" policy.

c. Patient #16's medical record documented a [AGE] year old male who was hospitalized from [DATE] to 2/28/11 with a diagnosis of [DIAGNOSES REDACTED]

- The "PSYCHIATRIC INTAKE," dictated by the physician and dated 2/23/11, stated the history of Patient #16's present illness included "...Patient having more falls, poor self care."

- The "Behavioral Medicine Admission Screening" form, written by an RN and dated 2/22/11 at 9:56 PM, stated he had a history of falls. The screen stated Patient #16 used "Crutches/cane/walker" for ambulation.

- A "Behavioral Medicine Progress Note," dated 2/23/11 at 10:16 AM, stated Patient #16 was a fall risk and was using a walker to ambulate.

- A "Behavioral Med Progress Note Form," dated 2/23/11 at 2:00 PM, stated Patient #16 was "...found lying in the hall with his glasses sitting beside him."

- A "Handoff Form," written by an RN and dated 2/23/11 at 9:56 PM, stated Patient #16 requested to use a scooter and this was denied.

- A "Behavioral Medicine Progress Note," dated 2/24/11 at 6:06 PM, stated Patient #16 "...ambulated today without the assist of a walker."

A nursing care plan was not present in the medical record. A "Psychiatric Treatment Plan," dated 2/24/11, listed 1 problem, increased audio/visual hallucinations. Patient #16's problems with ambulation and direction to staff regarding use of a walker were not included in his treatment plan.

The Charge Nurse on the Behavioral Health Unit was interviewed on 10/19/11 beginning at 1:20 PM. She confirmed Patient #16's treatment plan did not address his mobility problems.

A nursing care plan was not developed for Patient #16.

d. Patient #21's medical record documented a [AGE] year old male who was hospitalized from [DATE] to 10/14/11 with diagnoses of [DIAGNOSES REDACTED]

- A "History & Physical" by a physician assistant, dated 10/08//11, stated Patient #21 used a walker slowly and appeared to be stable.

- A "PSYCHIATRIC EVALUATION," dated 10/08/11, stated Patient #21 "Continues to appear unstable, does need to walk with a walker in regards to his balance and does overall appear psychomotor retarded in his presentation."

- A "Behavioral Medicine Progress Note" by a nurse, dated 10/08/11 at 11:30 AM, stated "Pt's roommate just shared that pt fell in their room at 0330 and made him promise not to tell anyone."

Patient #21's "Psychiatric Treatment Plan," dated 10/10/11, did not address mobility issues or the use of a walker.

The Charge Nurse on the Behavioral Health Unit was interviewed on 10/19/11 beginning at 1:20 PM. She confirmed Patient #21's treatment plan did not address his mobility problems or the use of a walker.

A nursing care plan was not developed for Patient #21.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, hospital policies, and QAPI documents, it was determined the hospital failed to ensure adverse patient events were tracked for 3 of 3 adverse events that were documented in Behavioral Health Unit patient records (#3, #16, and #21). These omissions prevented the hospital from investigating incidents of adverse patient events. Findings include:

1. Patient #16's medical record documented a [AGE] year old male who was hospitalized from [DATE] to 2/28/11 with a diagnosis of [DIAGNOSES REDACTED]#16 used "Crutches/cane/walker" for ambulation. A "Behavioral Med Progress Note," dated 2/23/11 at 2:00 PM, stated Patient #16 "...was found lying in the hall with his glasses sitting beside him. Pt stated he was feeling sedated." The note did not state why Patient #16 was lying in the hall.

The policy "Fall Risk Assessment and Prevention," dated 11/29/10, stated "A fall is an unplanned descent to the floor...with or without injury."
An incident report corresponding to the above event was requested from the Regulatory Accreditation Coordinator on 10/18/11 at 11:55 AM. She looked at a computer screen and stated an incident report for the event was not documented and an investigation of the event was not documented.

2. Patient #21's medical record documented a [AGE] year old male who was hospitalized from [DATE] to 10/14/11 with diagnoses of [DIAGNOSES REDACTED]"Behavioral Medicine Progress Note" by a nurse, dated 10/08/11 at 11:30 AM, stated "Pt's roommate just shared that pt fell in their room at 0330 and made him promise not to tell anyone."

The Regulatory Accreditation Coordinator was interviewed on 10/26/11 at 8:00 AM. She stated an incident report for the event was not documented.





3. Patient #3's medical record documented a [AGE] year old male who was hospitalized from [DATE] to 11/10/10 with a diagnosis of [DIAGNOSES REDACTED].

In a "History & Physical," dated 11/03/10, a physician dictated "Patient showed me his left arm had ecchymosis, required to have mechanical restraint on him, ...patient complaining of having back, knee and arm pain from physical restraint a couple days ago."

An incident report reflecting the allegation of injury during restraint was requested from the Regulatory Accreditation Coordinator on 10/18/11 at 11:55 AM. She stated an incident report had not been generated.

In an interview on 10/20/11 at 3:00 PM, the Charge Nurse reviewed the record and stated she had been aware of the bruising to Patient #3's arm, but chose not to take action because "He just had bruising, and bruising was not a severe injury that can lead to a poor outcome. Bruising was just a light injury."

The facility failed to track an alleged injury by staff.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, hospital policies and procedures, and staff interviews, it was determined the hospital failed to ensure physician's orders were completed for 3 of 6 patients reviewed (#3, #6, and #31) for whom restraint and seclusion were used. This resulted in the lack of appropriate physician oversight in the use of seclusion and restraints. Findings include:

1. The hospital's policy titled "Restraint and Seclusion," dated 2/22/11, stated "An order from the patient's physician, clinical psychologist or other LIP responsible for the care of the patient must be obtained as soon as possible and within one hour of initiating the restraint and/or seclusion." Patients were restrained and/or placed in seclusion without physician's orders as follows:

a. Patient #3's medical record documented a [AGE] year old male who was hospitalized from [DATE] to 11/10/10 with the diagnoses of psychosis and violent behavior. A form titled "Handoff Form," dated 11/02/10 at 11:00 PM, documented Patient #3 had been placed in seclusion for interrupting the Therapeutic Milieu, and was held (manually restrained) for medication administration.

In an interview on 10/20/11 at 2:30 PM, the Charge Nurse described the process of a manual restraint and placing a patient in seclusion. She stated patients would frequently be in an agitated state and would need to be manually restrained for medication administration, then placed in seclusion. The Charge Nurse stated an order would be obtained for the restraint and/or seclusion. The Charge Nurse reviewed Patient #3's medical record and confirmed Patient #3 was manually restrained and no order had been obtained for the manual restraint.

b. Patient #31's medical record documented a [AGE] year old male who was hospitalized from [DATE] to 7/07/11 with a diagnosis of psychosis. A "Behavioral Med Progress Note Form," dated 6/30/11 at 8:02 PM, documented Patient #31 had been throwing things around in his room, including his mattress. The record documented Patient #31 was unable to go to the quiet room (seclusion room) by himself, and the staff had to take him to the room. The record documented Patient #31 was held (manually restrained) by staff for the administration of medications. The order for seclusion was written on 6/20/11 at 8:37 PM. There was no order for manual restraint.

During an interview on 10/20/11 at 2:30 PM, the Charge Nurse reviewed Patient #31's record and stated he had been placed in seclusion and had four extremities manually restrained. The Charge Nurse stated Patient #31 was administered medication during the time of the manual restraint. She stated the order for seclusion had been obtained, but not the restraint. The Charge Nurse stated the order for restraint and seclusion was an order entry problem with the electronic medical record, and two separate orders should have been entered.

c. Patient #6's medical record documented a 7 year old female who was hospitalized from [DATE] to 10/07/11 with diagnoses of post-traumatic stress disorder and oppositional defiant disorder. A "Restraint/Seclusion Violent Form," dated 10/05/11 at 7:05 PM, was noted in Patient #6's record. There was no evidence of an order for seclusion.

During an interview on 10/20/11 at 2:45 PM, the Charge Nurse reviewed Patient #6's record and confirmed she had been placed in seclusion and no orders had been obtained.

The hospital failed to obtain orders for restraints and seclusion.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of grievance documentation, hospital policies, and staff and patient interview, it was determined the facility failed to ensure a letter of resolution, containing the steps of the investigation process and the resolution of the grievance, was sent to 7 of 12 patients/representatives (#9, #15, #23, #24, #26, #27, and #33) whose grievances were reviewed. This failure resulted in a lack of clarity and closure regarding the resolution of grievances, and had the potential to interfere with patients/representatives understanding and satisfaction. Findings include:

1. Patient #23 submitted a grievance related to ER physician and nursing care on 8/22/11. An acknowledgement letter was sent to Patient #23 on 8/22/11. Documentation in the acknowledgement letter indicated the concerns related to physician care were referred to the independent contracting service and the issues related to nursing staff were shared with the Emergency Services Manager. There was no documentation of a letter of resolution sent to Patient #23.

The Patient Relations Supervisor was interviewed on 10/19/11 11:30 AM. She reviewed the grievance information for Patient #23. She confirmed a letter of resolution was not sent to Patient #23 because she had spoken with the complainant and, in addition to the acknowledgement letter, verbally explained his concerns were being handled by the appropriate individuals.

2. Patient #24 submitted a grievance related to ER physician care on 7/28/11. An acknowledgement letter was sent to Patient #24 on 8/02/11. The letter contained documentation indicating that since the physician was not a hospital employee but was an independent provider, the concerns were referred to the independent contracting service who would follow up directly with Patient #24. There was no letter of resolution sent to Patient #24.

The Patient Relations Supervisor was interviewed on 10/19/11 at 11:30 AM. She confirmed she could not guarantee a letter regarding the steps of investigation and resolution of the grievance process was sent to Patient #24.

3. Patient #26's family submitted a grievance related to lengthy wait time in the ER and ER physician care on 8/15/11. An acknowledgement letter was sent to Patient #26 on 8/17/11. The letter contained documentation indicating that since the physician was not a hospital employee but was an independent provider, the concerns were referred to the independent contracting service who would follow up directly with Patient #26. There was no letter of resolution sent to Patient #26.

The Patient Relations Supervisor was interviewed on 10/19/11 at 11:30 AM. She reviewed Patient #26's grievance documentation and confirmed a letter addressing the steps taken to investigate the grievance issues and the resolution of the investigation was not sent to Patient #26. She confirmed that while the issues related to the physician care had been referred to the independent contracting service, the issues related to the extended wait time in the ER had not been addressed.

4. On 7/21/11, Patient #27 submitted a grievance related to a long wait time in the ER and ER physician and nursing care. An acknowledgement letter was sent to Patient #27 on 7/21/11. The letter indicated concerns related to nursing care and her experience in the ER were shared with the Manager of Emergency Services. According to the letter, as the physician was not an employee of the hospital, the concerns related to physician care were referred to the independent contracting service for investigation.

The next communication on behalf of the hospital with Patient #27 was a letter dated 9/08/11. The letter reiterated that the concerns presented by Patient #27 were shared with the Manager of Emergency Services who "reviewed and addressed" the concerns with her "associates in a professional and confidential manner." However, the details of the investigation were unable to be shared with Patient #27 due to "peer protection and confidentiality." In addition, the letter referenced the concerns related to ER physician care had been referred to the independent contracting service and they would follow up directly with Patient #27.

The letter of resolution did not adequately address the steps taken in the investigation of the grievance or the results of the grievance process.

The Patient Relations Supervisor was interviewed on 10/19/11 at 11:30 AM. She reviewed the grievance documentation for Patient #27 and stated that it was sometimes difficult to discuss the steps of investigation and the results of the investigation without divulging too much confidential information.

5. On 9/01/11, a grievance related to ER physician care was submitted by Patient #33. An acknowledgement letter was sent to Patient #33 on 9/01/11, and indicated the physician was not an employee of the hospital and the concerns were referred to the independent contracting service. There was no letter of resolution sent to Patient #33.

The Patient Relations Supervisor was interviewed on 10/18/11 at 9:10 AM. She reviewed the grievance documentation for Patient #33 and confirmed a letter regarding the steps taken for the investigation and the resolution of the grievance process was not sent. She stated this information was sent to Patient #33 by the independent contracting service and the hospital did not routinely request this information.

6. On 9/02/11, Patient #15 submitted a grievance related to ER physician care. An acknowledgement letter was sent to Patient #15 on 9/03/11, and indicated the physician was not an employee of the hospital and the concerns were referred to the independent contracting service.

The Patient Relations Supervisor was interviewed on 10/18/11 at 9:10 AM. She reviewed the grievance documentation for Patient #15 and confirmed a letter regarding the steps taken for the investigation and the resolution of the grievance process was not sent. She stated this information was sent to Patient #15 by the independent contracting service and the hospital did not routinely request this information.





7. The hospital's grievance documentation included a written complaint, dated 9/15/09, from Patient #9. He reported complaints about the care he received during a hospitalization in June of 2009. He stated he was not assisted with bathing during hospitalization , he was not provided adequate nutrition leading to weight loss, he was given medication he was sensitive to leading to adverse reactions, his call light was not within reach prior to a fall, and he was transfused with blood without adequate consent.

An acknowledgement letter, dated 11/25/09 (two months after receipt of the complaint), was present in the grievance documentation. It was written by the Risk Manager and stated "I have begun an investigation based on the information you provided and can assure you I will personally discuss your concerns and areas you identified for improvement with the Manager and staff who were responsible for your care."

There was no follow-up letter, after investigation, to inform Patient #9 the steps taken on his behalf to investigate the grievance, the results of the grievance process, and the date of completion.

The Risk Manager was interviewed on 10/18/11 at 10:00 AM. When asked why a follow-up letter had not been sent after investigation, he stated he had talked with Patient #9 on the phone and he did not feel Patient #9 wanted a follow-up, that his concerns had been addressed. He stated the grievance was old and he no longer had his notes on the grievance.

Patient #9 was interviewed by telephone on 10/19/11 at 9:50 AM. He stated he never received an explanation about any investigation that occurred as a result of his grievance. He stated he wanted to know what the hospital had done to correct issues so other people would not be affected by the same issues.

The hospital did not provide written notice to Patient #9 explaining the steps taken to investigate the grievance and the results of the grievance process.

The hospital failed to ensure a letter indicating the steps taken during the grievance investigation and the results of this investigation was sent in response to all submitted grievances.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff and patient interview, it was determined medical record entries were incomplete for 4 of 31 patients (#3, #9, #28, and #29) whose medical records were reviewed. This resulted in a lack of clarity as to the course of patient care. Findings include:

1. Hygiene care on the following orthopedic patients was not documented as provided or offered and refused:

a. Patient #28 was a [AGE] year old male admitted on [DATE] for orthopedic surgery. He was a current patient as of the time of the survey. The following hygiene activities were documented:

10/02/11 - bed bath provided with total assistance
10/03/11 - oral care and perineal care were done independently by the patient
10/04/11 - set up was provided for a bed bath
10/05/11 - minimal assistance was provided for a bed bath and oral care
10/07/11 - total assistance was provided with perineal care
10/08/11 - minimal assistance was provided with bedbath
10/09/11 - set up was provided for a bedbath and oral care
10/10/11 - set up for bed bath
10/16/11 - total assistance with bathing and perineal care
10/18/11 - bed bath and oral care offered and refused

There was no documentation hygiene care had been provided or offered for 7 of 21 days (10/06/11, 10/11/11, 10/12/11, 10/13/11, 10/14/11, 10/15/11, 10/17/11). There was no documentation oral care had been offered or provided for 13 of 21 days (10/02/11, 10/04/11, 10/06/11, 10/07/11, 10/08/11, 10/10/11, 10/11/11, 10/12/11, 10/13/11, 10/14/11, 10/15/11, 10/16/11, 10/17/11). There was also no documentation to indicate Patient #28 was independent in hygiene care.

b. Patient #29 was a [AGE] year old male who was admitted on [DATE] for orthopedic surgery after fracturing his arm in a dirt bike accident. He was discharged on [DATE]. The following hygiene activities were documented:

9/11/11 - he was assisted by his wife with a bed bath, oral care and perineal care
9/12/11- he was set up for a bed bath and shampoo
9/15/11 - his hair was shampooed
9/16/11 - he was offered and refused a bath
9/17/11 - he was given a bed bath
9/18/11 - he bathed independently
9/19/11 - he showered independently
9/20/11 - he was provided assistance with a bed bath
9/21/11 - he was provided a bed bath

There was no documentation oral care had been provided or offered for 12 of 12 days, 9/12/11 through discharge on 9/23/11. There was no documentation to indicate Patient #29 was independent in oral care.

c. Patient #9 was an [AGE] year old male who was admitted on [DATE] for knee surgery. He was discharged on [DATE]. The following hygiene activities were documented:

6/12/09 - self-care
6/15/09 - face wash and oral care for thrush
6/16/09 - self-care
6/17/09 - assisted with shower and shampoo

There was no documentation of hygiene care on 6/13/09 or 6/14/09. There was no documentation as to hygiene care required for "thrush" documented on 6/15/09.

Patient #9 and his spouse were interviewed by telephone on 10/18/11 at 9:50 AM. They both stated he (Patient #9) was not assisted with bathing activities until the last day after he complained to his physician that staff had not helped him bathe or brush his teeth. Patient #9 described himself as "pretty out of it" and "needing help" during his hospitalization .

The Orthopedic Nurse Manager and Orthopedic Charge Nurse were interviewed together on 10/18/11 after 9:55 AM. They both stated it was standard care to provide or offer daily hygiene care, including oral care. They stated it was possible staff were falling short on documenting hygiene activities. They expressed confidence hygiene care was being provided consistently to patients on their unit. They acknowledged the referenced records lacked documentation to support daily hygiene care.

Documentation related to the provision of hygiene care was incomplete.





2. Patient #3's medical record documented a [AGE] year old male who was hospitalized from [DATE] to 11/10/10 with diagnoses of psychosis and violent behavior.

Patient #3's record was not complete as follows:

a. A form, titled "Handoff Form" dated 11/02/10 at 11:00 PM, documented Patient #3 had been placed in seclusion for interrupting the Therapeutic Milieu and was physically held for medication administration.

Patient #3's record indicated he was placed in seclusion on 11/02/10 from 3:00 PM to 4:00 PM. A form, titled "Restraint/Seclusion Violent Form," dated 11/02/10 at 3:01 PM documented Patient #3 had behaviors of loud profanity, threatening to kill the RN, and smashing a sandwich against a window. The form stated Patient #3 was placed in seclusion, but did not state specifics on how Patient #3 was moved into the seclusion room.

In an interview on 10/19/11 at 1:35 PM, the RN, who had been present during Patient #3's behaviors, reviewed Patient #3's record and confirmed she witnessed Patient #3's violent behavior, which led up to his placement in seclusion. However, she stated she did not witness Patient #3 being moved to seclusion. She stated Patient #3's behavior and seclusion happened at the time of shift change, and she assumed the oncoming RN, who assisted in moving Patient #3 to seclusion, would complete the remainder of the narrative note. She acknowledged documentation related to Patient #3's seclusion was incomplete. The RN stated the oncoming RN no longer worked at the facility and was unavailable for interview.

The facility did not document details describing how a patient was taken to seclusion.

b. Seven forms, titled "Patient Daily Record/Assessments," were noted in Patient #3's record, two of which were dated (11/02/10 and 11/05/10). Five of the forms were not dated.

In an interview on 10/18/11 at 2:55 PM, the Nurse Manager of the Behavioral Health Unit reviewed Patient #3's record and confirmed the assessments were not dated. She stated the documentation of the dates should have been completed.

The facility did not ensure all documents in Patient #3's medical record were dated.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on review of hospital policies, grievance documentation, and staff interview, it was determined the facility failed to ensure the grievance process, including the investigation and resolution of grievances, was completed for all grievances related to independent providers of the hospital. This directly impacted 6 of 12 patients/representatives (#15, #23, #24, #26, #27, and #33) whose grievances were reviewed and had the potential to impact all patients/representatives submitting grievances related to independent providers. Lack of oversight related to the grievance process impeded the hospital from ensuring grievances were investigated and resolved appropriately and that a resolution letter was sent to the patient/representative. Findings include:

1. The grievance documentation for Patients #15, #23, #24, #26, #27, and #33 were reviewed. The grievance documentation indicated the grievances were no longer under investigation and that each patient/representative reported concerns related to ER physician care. Each patient received an acknowledgement letter which notified them that the ER physicians were not hospital employees but were contract providers and explained the complainants' concerns were referred to the independent contracting service. According to the letter, the independent contracting service would follow up directly with the patient/representative regarding the concerns. The letter contained the phone number to contact the organization for further information.

The Patient Relations Supervisor was interviewed on 10/18/11 at 9:05 AM. She explained that it was the hospital's practice to refer the investigation of certain physician-related concerns to the individual providers. She stated the hospital did not routinely request a copy of the resolution letters sent to patients/representatives after the investigation had been completed. She stated the investigation information was available on request. She was not able to explain how the hospital maintained supervision of the grievance process when this responsibility was delegated to contract providers.

The Patient Relations Representative was interviewed on 10/18/11 at 1:00 PM. She stated they refer complaints against the ER physicians to their independent contracting service and then close out the account. She stated the hospital can ask the independent contracting service for a copy of the resolution letter but do not routinely do this.

The Compliance Officer for the independent contracting service was interviewed on 10/19/11 at 2:00 PM. She confirmed that the independent contracting service does have an established process for review of grievances referred from the hospital. She stated a resolution letter was sent to all complainants at the completion of the investigation. She stated she did not provide the hospital a copy of the letter. Instead the physician who completed the review of the grievance documented on a "Physician Complaint Form," which was forwarded to Patient Relations at the hospital. She stated the physician noted on this form the steps taken during the investigation, the outcome of the investigation, and the date the resolution letter was completed.

The Patient Relations Supervisor was interviewed on 10/19/11 at 3:15 PM. She stated she was not familiar with the "Physician Complaint Form." She stated she was not aware of their department receiving this information. She stated if another department, such as Risk Management, received the forms they would have been scanned in as attachments and printed out with the grievance documentation presented for surveyor review.

The Patient Relations Supervisor was interviewed again on 10/20/11 at 11:35 AM. She confirmed that the hospital did not have a process in place to ensure that the independent contracting service was investigating and responding to complainants. She was unable to provide documentation indicating this responsibility had been delegated to the independent contracting service.

The hospital was not able to ensure the grievance process was followed for grievances submitted related to contract providers.