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.

UNIVERSITY OF KENTUCKY HOSPITAL 800 ROSE STREET LEXINGTON, KY 40536 Aug. 10, 2012
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, medical record review, facility document review, and facility policy review, it was determined the facility failed to ensure it identified grievances appropriately as evidenced by an oral complaint regarding abuse being treated as a complaint instead of a grievance for one (1) of ten (10) patients (Patient #1).

The findings include:

Review of the facility policy, "Patient Complaints and Grievances," policy number A01-025, effective date 12/2008, revealed oral complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are grievances. The policy also stated that with grievances the Customer Service Representative (CSR) would remain in contact with the complainant regarding the status of the grievance via phone and written correspondence.

Review of the medical record of Patient #1 revealed he/she was admitted on [DATE] with diagnoses which included a left femoral fracture and mild mental retardation. The record further revealed the sister of Patient #1 verbally reported an incident of abuse suffered by Patient #1 to Registered Nurse (RN) #1, the nurse caring for Patient #1. Further review of the medical record showed the University of Kentucky Hospital Security and the University of Kentucky Police Department (UKPD) were called to investigate the incident. The "UK Healthcare Security Activity Report," dated 06/12/12, and "The University of Kentucky Hospital Security Dispatch Log Report," dated 06/12/12 at 8:41 PM corroborated the incident.

Review of "Office of Service Excellence Internal Page," last modified 06/13/12 at 3:01 PM, revealed the Chief Administrative Officer (CAO) and the Customer Relations Specialist (CRS) made a visit to see Patient #1, on 06/13/12 at 8:00 AM. This document further revealed both the CAO and CRS gave Patient #1 business cards and offered apologies for the incident. Additional review of Patient #1's complaint file revealed he/she did not receive any written correspondence concerning the abuse incident.

Interview with the CAO, on 08/10/12 at 1:27 PM, revealed she did visit Patient #1 on 06/13/12. The CAO stated she gave Patient #1 her business card with mobile telephone number in case Patient #1 had additional concerns about the abuse incident, and she offered an apology. The CAO further stated she did not hear anything after this visit from Patient #1 or his/her family about this incident.

Interview with the CRS, on 08/10/12 at 3:37 PM, revealed she visited Patient #1 twice on 06/13/12 to follow-up on the incident and to ensure all concerns were handled at the bedside. She also confirmed that no written correspondence was given to Patient #1 or his/her family. The CRS acknowledged the "Patient Complaints and Grievances" policy content, but stated she thought the incident was a complaint because it had been resolved at the bedside and because the matter had been turned over to the UKPD.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, medical record review, facility document review, and facility policy review, it was determined the facility failed to ensure it provided a written response to a grievance as evidenced by a patient/family, after voicing a grievance concerning abuse, not receiving any written correspondence on the investigation and status of the grievance for one (1) of ten (10) patients (Patient #1).

The findings include:

Review of the facility policy, "Patient Complaints and Grievances," policy number A01-025, effective date 12/2008, revealed oral complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are grievances. The policy also stated that with grievances the Customer Service Representative (CSR) would remain in contact with the complainant regarding the status of the grievance via phone and written correspondence.

Review of the medical record of Patient #1 revealed he/she was admitted on [DATE] with diagnoses which included a left femoral fracture and mild mental retardation. The record further revealed the sister of Patient #1 verbally reported an incident of abuse suffered by Patient #1 to Registered Nurse (RN) #1, the nurse caring for Patient #1. Further review of the medical record showed the University of Kentucky Hospital Security and the University of Kentucky Police Department (UKPD) were called to investigate the incident. The "UK Healthcare Security Activity Report," dated 06/12/12, and "The University of Kentucky Hospital Security Dispatch Log Report," dated 06/12/12 at 8:41 PM corroborated the incident.

Review of "Office of Service Excellence Internal Page," last modified 06/13/12 at 3:01 PM, revealed the Chief Administrative Officer (CAO) and the Customer Relations Specialist (CRS) made a visit to see Patient #1, on 06/13/12 at 8:00 AM. This document further revealed both the CAO and CRS gave Patient #1 business cards and offered apologies for the incident. Additional review of Patient #1's complaint file revealed he/she did not receive any written correspondence concerning the abuse incident.

Interview with the CAO, on 08/10/12 at 1:27 PM, revealed she did visit Patient #1 on 06/13/12. The CAO stated she gave Patient #1 her business card with mobile telephone number in case Patient #1 had additional concerns about the abuse incident, and she offered an apology. The CAO further stated she did not hear anything after this visit from Patient #1 or his/her family about this incident.

Interview with the CRS, on 08/10/12 at 3:37 PM, revealed she visited Patient #1 twice on 06/13/12 to follow-up on the incident and to ensure all concerns were handled at the bedside. She also confirmed that no written correspondence was given to Patient #1 or his/her family. The CRS acknowledged the "Patient Complaints and Grievances" policy content, but stated she thought the incident was a complaint because it had been resolved at the bedside and because the matter had been turned over to the UKPD.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, medical record review, facility policy review, and review of Kentucky Revised Statute (KRS) 209.030, it was determined the facility failed to ensure that suspected abuse was reported to the Cabinet for Health and Family Services (CHFS) as evidenced by failure to report suspected abuse of a patient to the CHFS for one (1) of ten (10) patients (Patient #1).

The findings include:

Review of the facility's policy, "Protection of Adults: Reporting Abuse, Neglect, or Exploitation," policy number HP06-08, effective date 11/2009, revealed the employee must report by phone and then in writing all suspected cases of abuse to the CHFS. It further revealed the social worker assigned to the particular service would be notified of the suspected abuse.

Review of KRS 209.030 revealed in cases of suspected abuse an oral or written report shall be made immediately to the CHFS.

Review of the medical record of Patient #1 revealed he/she was admitted on [DATE] with diagnoses which included a left femoral fracture and mild mental retardation. The record further revealed the sister of Patient #1 verbally reported an incident of abuse suffered by Patient #1 on 06/12/12 to Registered Nurse (RN)#1, the nurse caring for Patient #1. Further review of the medical record showed the University of Kentucky Hospital Security and the University of Kentucky Police Department (UKPD) were called to investigate the incident. The "UK Healthcare Security Activity Report," dated 06/12/12 and the "University of Kentucky Hospital Security Dispatch Log Report" dated 06/12/12 at 8:41 PM corroborated the incident.

Interview with the Hospital Safety Officer, on 08/09/12 at 3:41 PM, revealed she believed per hospital policy the the CHS should have been notified.

Interview with the Hospital Operations Administrator (HOA), on 08/10/12 at 8:00 AM, revealed she did not contact, on 06/12/12 after the incident, the CHFS hotline and did not know that in this case it was required.

Interview with RN #1, on 08/10/12 at 8:45 AM, revealed she was Patient #1's nurse on 06/12/12 when the abuse incident occurred. RN #1 further revealed she was told by the HOA to only fill out an incident report (IR), and she assumed whoever got the IR would contact the required people. RN #1 stated she thought the case became a police matter. Therefore, additional reporting was not required because the incident was turned over to the UKPD.

Interview with the Patient Care Manager for 5 East, on 08/10/12 at 11:31 AM, revealed she was covering for the Patient Care Manager for 5 West and 5 South on 06/12/12. She stated, in hindsight and to close the loop, the CHFS should have been contacted immediately.