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.

LAKE CHARLES MEMORIAL HOSPITAL 1701 OAK PARK BLVD LAKE CHARLES, LA 70601 Oct. 12, 2011
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interviews, the hospital failed to ensure the patient and/or patient's representative had the right to participate in the development and implementation of his or her plan of care when Patient #9's representative requested to speak with the physician throughout his hospitalized from [DATE] to 08/17/11 for 1 of 10 sampled records reviewed, (Patient #9).
Findings:

Review of the medical record revealed Patient #9 was admitted on [DATE] at 5:55 p.m. (1755) to the Geriatric/Elderly 10 West Tower under the care of S70Psychiatrist. Further review revealed there was no documented evidence S70Psychiatrist met with Patient #9's representative during his hospitalized from [DATE] through 08/19/11.

The "Multidisciplinary Assessment" of Patient #9 revealed S70Psychiatrist visited the patient on 08/06/11, 08/08/11, 08/10/11 and 08/11/11.

In an interview held on 10/10/11 at 4:05 p.m. to 4:40 p.m., S5Case Manager indicated Patient #9's representative requested to speak with the physician throughout the patient's hospitalized from [DATE] to 08/19/11. Further, Patient #9's representative was contacted on 08/17/11 to schedule a meeting with the physician and treatment team on 08/18/11 at 3:15 p.m., but the representative was unable to attend. Patient #9's representative was updated at the treatment team meeting on 08/18/11 at 10:48 a.m. A meeting was scheduled between Patient #9's representative and S69MD, Psychiatrist. No meeting was scheduled between Patient #9's representative and the admitting Psychiatrist, S70 from 08/04/11 through 08/19/11 as requested during the patient's hospitalization . S5Case Manager indicated S70Psychiatrist indicated on 08/08/11 he would meet with Patient #9's representative during his daily rounds. Further, the Case Manager indicated S70Psychiatrist does not have a daily schedule time that he makes rounds on the unit in order to schedule a time for Patient #9's representative to meet with him as requested during the patient's hospitalization .

During an interview on 10/10/11 from 3:50 p.m. through 4:00 p.m., S69Psychiatrist indicated he was the Medical Director for the Geriatric/Elderly 10 West Tower. S69Psychiatrist verified he met with Patient #9's representative on 08/19/11 as per request from a staff member on 08/17/11. S69Psychiatrist stated a team meeting was held on 08/18/11 and Patient #9's representative was unavailable. S69Psychiatrist indicated a request from a patient and/or representative to meet with a physician should be done as soon as possible. There are no scheduled times that a meeting should be held between a patient and/or representative. A request from a patient and/or representative to meet with a physician should be scheduled as soon as possible. Expect all physicians/psychiatrist to meet with the patient and/or representative as soon as possible. S69Psychiatrist indicated all patients and/or representatives are involved in the treatment plan from admission through discharge as per policy.

In a telephone interview on 10/12/11 from 1:30 p.m. to 2:15 p.m., S70Psychiatrist indicated he had reviewed Patient #9's medical record. S70Psychiatrist stated he covered for S69Psychiatrist, who was on vacation, from 08/04/11 through 08/15/11. Further S70 indicated Patient #9 was admitted under his care on 08/04/11. S70Psychiatrist recalled staff requesting a meeting with Patient #9's representative. He denied knowledge of who the staff member was that informed him of the request from Patient #9's representative. Further S70Psychiatrist recalled staff members requesting a meeting with Patient #9's representative several times during his assessments of the patient on 08/06/11, 08/08/11, 08/10/11 and 08/11/11. S70 recalled a staff member informing him that Patient #9's representative wanted to meet with him, so he (S70) informed the staff member to schedule an appointment for Monday, 08/15/11 with S69Psychiatrist. Further S70Psychiatrist indicated S69Psychiatrist would return from vacation and could meet with Patient #9's representative. S70Psychiatrist further indicated he will meet with a patient and/or representative as needed.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews and staff interview the hospital failed to ensure all patient's right to be free from all forms of abuse policy was initiated and implemented for an allegation of abuse from Patient #9's representative who had "...concerns that patient is being abused here..." during a telephone conversation on 08/10/11 at 12:42 p.m. with S5Case Manager for 1 of 10 sampled records reviewed, (Patient #9).
Findings:

Review of the medical record for Patient #9 revealed a "Group Note" by S5Case Manager dated/timed 08/10/11 at 12:42 p.m. read in part, "...(Patient's representative named) called...Family concerned that patient is being abused here. "His shoulder is messed up and he has bruising and skin hanging from his fingers...". Further review revealed there was no documentation of a detailed description of the location, time, and victim's appearance when the incident occurred documented in Patient #9's medical record as per policy. There was no documented evidence Patient #9 was observed and assessed by staff for injuries as per policy.

The policy titled, "Alleged Abuse (Patient) Psychiatric Area", with no policy number, Revised & Review date(s) of 4/2011, presented as the hospital's current "Abuse" policy per fax on 10/12/11 at 10:48 a.m., revealed it was the responsibility of staff for reporting and conducting internal investigation of all alleged incidents of patient abuse in a manner that will protect the rights and dignity of alleged victim. Abuse is defined as the infliction of physical and mental injury by other parties including but not limited to such means as physical abuse to such an extent that their health, self determination or emotional well being is endangered. Upon being informed of alleged patient abuse (within reasonable interpretations of the above definition), notify the Program Director and Nurse Manager. If physical abuse is alleged, take immediate steps to preserve evidence. Observe the victim, clothing, room, and anything that may seem out of ordinary; note time, location. Statements from witnesses. Full statement or taped interview of the alleged assailant. Detailed description of the location, time, the victim's appearance when the incident occurred. Risk Management will assume the responsibility of notifying the proper authorities and/or agencies. Call the physician and request that the patient be transported to emergency room (stat). If the alleged assailant is a staff member, remove from the patient care area and inform Security to detain until Hospital Administration, Legal Authorities, or Director is notified and release authorization is given. The Program Director or Nurse Manager will notify the Administration on call of the alleged assault. The Administrator on call has the authorization to notify the outside Legal Authorities to conduct an internal investigation of the alleged incident. The complainant will be interviewed, as soon as possible, by the Program Director or Nurse Manager to obtain a written or taped interview as to the occurrence. The complainant will be assessed by the psychiatrist/case manager as soon as possible. The Medical Director will be notified immediately. The Program Director and Nurse Manager are responsible for all internal investigations of alleged abuse reports. The investigation should include:
1) Statement of victim - written or taped,
2) Statements from witnesses,
3) Full statement or taped interview of the alleged assailant, and
4) Detailed description of the location, time, the victim's appearance when the incident
occurred.

Review of the "Patient Complaint/Grievance Resolution Procedure", with no policy number, date issued of May 2000, last date revised of April 2008, with no reviewed date, (MDS) dated [DATE] at 5:40 p.m. as the hospital's current Grievance policy indicated all grievances concerning situations that endanger the patient such as abuse will be reviewed and investigated immediately, and handled in accordance with hospital policy and procedures and other regulatory standards. All grievances are documented in writing using the Complaint/Grievance Resolution Form. A copy should be sent to the Manager or Department Head where the complaint was lodged.

There was no complaints/grievance logs presented during the survey conducted from 10/04/11 through 10/12/11. Review of the " Incidents 10T (10 tower) West 7/15/11 " form for incidents that occurred on 10T West from 07/15/11 through 10/04/11 revealed hand written documentation that read in part, " ...no complaints for 10T West for 7/15/2011 forward ... " signed by S71Risk Management on 10/05/11. There was no documentation of a formal Complaint/Grievance Resolution Form completed from Patient #9 ' s representative on 10/12/11 as per policy.

During an interview on 10/05/11 from 1:20 p.m. to 1:30 p.m., S3Director of Psychiatric Services indicated there were no grievances alleged from 07/15/11 to 10/4/11 for the Geriatric/Elderly 10 West Tower unit.

The "Incident Report", with no date documented that the form was completed by S7RN (Registered Nurse) Charge Nurse, was reviewed. Further review revealed an incident occurred in the dining room on Ten (10) West (location of the unit) on 08/07/11 at 10:15 p.m. (2215) with Patient #9. S7RN Charge Nurse and S8MHT (Mental Health Technician) did a "take down" of Patient #9 due to the patient attacking staff. There was a handwritten piece of paper attached to the "Incident Report" form that read in part, "...the Incident Report was not completed on 8/7/11. It was completed on 8/8/11...". There was no documented evidence of an observation and assessment of the patient's (#9's) injuries, clothing, and room was conducted by staff as per policy. Further there was no documented evidence of statements obtained from the witnesses was performed by staff as per policy. There was no documented evidence of a full statement or taped interview of the alleged assailant was done for this alleged allegation of abuse by staff as per policy. Further there was no documented evidence of a detailed description of the location, time, and the victim's appearance when the incident occurred was conducted by staff for this alleged allegation of abuse as per policy. There was no documented evidence the complainant was interviewed as soon as possible by the Program Director or Nurse Manager to obtain a written or taped interview as to the occurrence performed as per policy. Further there was no documentation the patient was assessed by the psychiatrist/case manager as soon as possible as per policy.

In an interview on 10/10/11 at 4:05 p.m. through 4:40 p.m., S5Case Manager verified there was a telephone call made by Patient #9's representative with concerns that the patient (#9) was being abused at the facility, had messed up his shoulder, had bruising, and had skin hanging from his fingers documented on 08/10/11 at 12:42 p.m. The Case Manager recalled reporting the incident verbally to her immediate supervisor, S6Social Worker, S4Nurse Manager, S3Director of Psychiatric Services and S7RN Charge Nurse that same day, (08/10/11) as per policy. Further S5Case Manager indicated she had concerns regarding staff abusing Patient #9 on 08/07/11 and expressed her concerns to her immediate supervisor (S6Social Worker), S3Director of Psychiatric Services, S4Nurse Manager, and S7RN Charge Nurse on 08/10/11 as per policy.

An interview was conducted on 10/10/11 at 4:40 p.m. through 5:05 p.m., with S6Social Worker. The Social Worker indicated there was no grievance and/or abuse by staff for Patient #9 on 08/07/11 because his shoulder was x-rayed on 08/09/11-two (2) days after staff took the patient down to the floor for assaulting staff. Further S6 indicated Patient #9's forearms and/or face did not have any bruising observed by her (social worker) from 08/07/11 through 08/15/11 during her sessions with the patient. S6Social Worker further indicated Patient #9 had no obvious signs of bruising to his forearms and/or face, so there was no need to initiate the protocols for the grievance and/or abuse policies.

During an interview held on 10/10/11 from 5:05 p.m. through 5:35 p.m., S3Director of Psychiatric Services and S4Nurse Manager both verified Patient #9 representative's called S5Case Manager with concerns that the patient was being abused at the hospital on [DATE]. Both S3 and S4 indicated the Case Manager (S5) and Social Worker (S6) failed to initiate and follow the abuse protocols for the allegation of abuse reported by Patient #9 representative on 08/10/11. S3Director of Psychiatric Services and S4Nurse Manager both verified there was no documented evidence Patient #9's injuries, clothing, and room were observed and assessed by staff for the allegation of abuse reported on 08/10/11 as per policy. Further S3 and S4 verified there was no documented evidence of statements obtained from the witnesses for the allegation of abuse for Patient #9 performed as per policy. The Director of Psychiatric Services (S3) and Nurse Manager (S4) both confirmed there was no documented evidence of a full statement or taped interview of the alleged assailant done for this alleged allegation of abuse for Patient #9 done by staff as per policy. Further S3 and S4 both verified there was no documented evidence of a detailed description of the location, time, and the victim's appearance when the incident occurred conducted by staff for this alleged allegation of abuse for #9 as per policy. The Director of Psychiatric Services (S3) and Nurse Manager (S4) both confirmed there was no documented evidence the complainant (Patient #9's representative) was interviewed as soon as possible by the Program Director or Nurse Manager to obtain a written or taped interview as to the occurrence performed as per policy. Both S3Director of Psychiatric Services (S3) and S4Nurse Manager verified there was no documentation the patient (#9) was assessed by the psychiatrist/case manager as soon as possible as per policy.
VIOLATION: PATIENT RIGHTS: GRIEVANCE PROCEDURES Tag No: A0121
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews and interviews, the hospital failed to ensure a grievance with allegations of abuse was investigated immediately and a follow up letter to the complainant that included the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution within 7 days as per hospital policy for 1 of 1 grievance regarding allegations of abuse out of a total sample of 10 patients, (Patient #9). Findings:

Review of the medical record for Patient #9 revealed a "Group Note" documented by S5Case Manager dated/timed 08/10/11 at 12:42 p.m. for Patient #9 read in part, "...(Patient's representative named) called...Family concerned that patient is being abused here. His shoulder is messed up and he has bruising and skin hanging from his fingers...".

Review of the "Patient Complaint/Grievance Resolution Procedure", no policy number, date issued of May 2000, date last revised April 2008; no date last reviewed, (MDS) dated [DATE] at 5:40 p.m. as the hospital's current Grievance policy, revealed: "it is the policy of this hospital to make reasonable efforts to resolve patient complaints and grievances as quickly as possible. A complaint is a verbal or written expression of displeasure with a clinical process or person that can be resolved promptly by the staff present. A grievance is a formal or informal written or verbal complaint that is made by a patient/significant other when a patient's issue cannot be resolved promptly by staff present. Investigation of complaints/grievances will occur when the Hospital is in receipt of notification by the patient or representative of dissatisfaction with issues that have been unresolved. The notification may be by phone call. All grievances concerning situations that endanger the patient such as abuse will be reviewed and investigated immediately, and handled in accordance with hospital policy and procedures and other regulatory standards. All grievances are documented in writing using the Complaint/Grievance Resolution Form. A patient grievance may come in the form of a phone call. In such case the employee who receives the grievance will complete the Complaint/Grievance Resolution Form. A copy should be sent to the Manager or Department Head where the complaint was lodged. Complaints that cannot be immediately and effectively identified, investigated and resolved by an individual staff member are considered grievances and should be directed up the chain of command to the level required for the most complete resolution possible. All grievances are documented using the Patient Complaint Resolution/Grievance form. The investigation must be completed within a period of seven (7) days. Once the investigation process is completed, the Manager or Department Director will complete the Complaint/Grievance Resolution Form and forward the response to Quality Management Director and Patient Representative. The written notice to the complainant will include the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution.

There was no documentation a "Complaint/Grievance Resolution Form" for the allegation of abuse alleged by Patient #9's representative on 08/10/11 at 12:42 p.m. was completed by staff presented during the survey conducted from 10/04/11 to 10/12/11 as per policy. Further review revealed there was no documentation a follow up letter to the complainant that contained the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution completed for the alleged allegation of abuse for Patient #9 on 08/10/11 presented during the survey conducted from 10/04/11 to 10/12/11 as per policy.

The policy titled, "Alleged Abuse (Patient) Psychiatric Area", with no policy number, Revised & Review date(s) of 4/2011, presented as the hospital's current "Abuse" policy per fax on 10/12/11 at 10:48 a.m., revealed it was the responsibility of staff for reporting and conducting internal investigation of all alleged incidents of patient abuse in a manner that will protect the rights and dignity of alleged victim. Abuse is defined as the infliction of physical and mental injury by other parties including but not limited to such means as physical abuse to such an extent that their health, self determination or emotional well being is endangered. Upon being informed of alleged patient abuse (within reasonable interpretations of the above definition), notify the Program Director and Nurse Manager. If physical abuse is alleged, take immediate steps to preserve evidence. Observe the victim, clothing, room, and anything that may seem out of ordinary; note time, location. Statements from witnesses. Full statement or taped interview of the alleged assailant. Detailed description of the location, time, the victim's appearance when the incident occurred. Risk Management will assume the responsibility of notifying the proper authorities and/or agencies. Call the physician and request that the patient be transported to emergency room (stat). If the alleged assailant is a staff member, remove from the patient care area and inform Security to detain until Hospital Administration, Legal Authorities, or Director is notified and release authorization is given. The Program Director or Nurse Manager will notify the Administration on call of the alleged assault. The Administrator on call has the authorization to notify the outside Legal Authorities to conduct an internal investigation of the alleged incident. The complainant will be interviewed, as soon as possible, by the Program Director or Nurse Manager to obtain a written or taped interview as to the occurrence. The complainant will be assessed by the psychiatrist/case manager as soon as possible. The Medical Director will be notified immediately. The Program Director and Nurse Manager are responsible for all internal investigations of alleged abuse reports. The investigation should include:
1) Statement of victim - written or taped,
2) Statements from witnesses,
3) Full statement or taped interview of the alleged assailant, and
4) Detailed description of the location, time, the victim's appearance when the incident
occurred.

The "Incident Report", with no date documented that the form was completed by S7RN (Registered Nurse) Charge Nurse, was reviewed. Further review revealed an incident occurred in the dining room on Ten (10) West (location of the unit) on 08/07/11 at 10:15 p.m. (2215) with Patient #9. S7RN Charge Nurse and S8MHT (Mental Health Technician) did a "take down" of Patient #9 due to the patient attacking staff. There was a handwritten piece of paper attached to the "Incident Report" form that read in part, "...the Incident Report was not completed on 8/7/11. It was completed on 8/8/11...". There was no documented evidence of an observation and assessment of the patient's (#9's) injuries, clothing, and room was conducted by staff as per policy. Further there was no documented evidence of statements obtained from the witnesses was performed by staff as per policy. There was no documented evidence of a full statement or taped interview of the alleged assailant was done for this alleged allegation of abuse by staff as per policy. Further there was no documented evidence of a detailed description of the location, time, and the victim's appearance when the incident occurred was conducted by staff for this alleged allegation of abuse as per policy. There was no documented evidence the complainant was interviewed as soon as possible by the Program Director or Nurse Manager to obtain a written or taped interview as to the occurrence performed as per policy. Further there was no documentation the patient was assessed by the psychiatrist/case manager as soon as possible as per policy.

In an interview on 10/10/11 at 4:05 p.m. through 4:40 p.m., S5Case Manager verified a telephone call was made by Patient #9's representative with concerns that the patient (#9) was being abused at the facility, had messed up his shoulder, had bruising, and had skin hanging from his fingers at 12:42 p.m. on 08/10/11. The Case Manager recalled reporting the allegation of abuse for Patient #9 verbally to her immediate supervisor, (S6Social Worker), S4Nurse Manager, S3Director of Psychiatric Services and S7RN Charge Nurse that same day, (08/10/11) as per the grievance and abuse protocols. S5Case Manager stated she had concerns regarding staff abusing Patient #9 during the "take down" on 08/10/11 and expressed her concerns to her immediate supervisor (S6Social Worker), S3Director of Psychiatric Services, S4Nurse Manager, and S7RN Charge Nurse that same day on 08/10/11 as per the policy. S5Case Manager denied completing a "Complaint/Grievance Resolution Form " for the allegation of abuse from Patient #9 ' s representative on 08/10/11 as per policy.

An interview was conducted on 10/10/11 at 4:40 p.m. through 5:05 p.m., with S6Social Worker. The Social Worker (S6) indicated there were no grievance and/or abuse by staff for Patient #9 because an x-ray was performed two (2) days after the patient was taken down by staff on 08/07/11. Further S6 recalled performing an assessment of Patient #9's forearms and he did not have any bruising observed by her (social worker) during her daily group sessions from 08/07/11 through 08/15/11. The Social Worker (S6) indicated Patient #9 had no obvious signs of bruising by staff on his forearms, so there was no need for her (S6) to initiate the grievance policy to investigate the allegation of abuse for Patient #9 immediately as per the grievance and/or abuse policies. S6Social Worker decided on her own that this allegation of abuse from Patient #9's representative on 08/10/11 was not a grievance because an Xray of his (#9) right shoulder was done and the patient (#9) did not have obvious signs of bruising observed by her (S6) from 08/07/11 to 08/15/11. S6Social Worker denied completing a "Complaint/Grievance Resolution Form" for the allegation of abuse reported from Patient #9's representative on 08/10/11 as per policy.

During an interview held on 10/10/11 from 5:05 p.m. through 5:35 p.m., S3Director of Psychiatric Services and S4Nurse Manager both verified there was an allegation of abuse called into S5Case Manager by Patient #9's representative at 12:42 p.m. on 08/10/11. S3 and S4 both indicated the Case Manager (S5) and Social Worker (S6) failed to initiate the Grievance policy by completing a "Complaint/Grievance Resolution Form" for the allegation of abuse for Patient #9 on 08/10/11 to be investigated immediately as per policy. Both S3 and S4 indicated there was no formal investigation conducted for the allegation of abuse reported for Patient #9 conducted as per policy. The Director of Psychiatric Services (S3) and Nurse Manager (S4) both indicated there was no documentation of a follow up letter to the complainant that contained the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution completed for the alleged allegation of abuse for Patient #9 on 08/10/11 completed for the allegation of abuse from Patient #9's representative as per policy.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews and interviews, the hospital failed to measure analyaze, and track an allegation of abuse from Patient #9's representative that assessed the processes of care, the hospital services and operations the patient received by:
1) failing to identify there was no "Complaint/Grievance Resolution Form" completed by staff for the allegation of abuse reported from Patient #9's representative at 12:42 p.m. on 08/10/11 as per policy for 1 of 10 sampled records reviewed, (Patient #9),
2) failing to identify there was no investigation completed for the allegation of abuse reported by Patient #9's representative at 12:42 p.m. on 08/10/11 as per policy, and
3) failing to identify a written letter that included the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution within 7 days was not done as per hospital policy for 1 of 10 sampled records reviewed, (Patient #9). Findings:

Review of the medical record for Patient #9 revealed a "Group Note" documented by S5Case Manager dated/timed 08/10/11 at 12:42 p.m. for Patient #9 read in part, "...(Patient's representative named) called...Family concerned that patient is being abused here. His shoulder is messed up and he has bruising and skin hanging from his fingers...".

Review of the "Patient Complaint/Grievance Resolution Procedure", no policy number, date issued of May 2000, date last revised April 2008; no date last reviewed, (MDS) dated [DATE] at 5:40 p.m. as the hospital's current Grievance policy, revealed: "it is the policy of this hospital to make reasonable efforts to resolve patient complaints and grievances as quickly as possible. A complaint is a verbal or written expression of displeasure with a clinical process or person that can be resolved promptly by the staff present. A grievance is a formal or informal written or verbal complaint that is made by a patient/significant other when a patient's issue cannot be resolved promptly by staff present. Investigation of complaints/grievances will occur when the Hospital is in receipt of notification by the patient or representative of dissatisfaction with issues that have been unresolved. The notification may be by phone call. All grievances concerning situations that endanger the patient such as abuse will be reviewed and investigated immediately, and handled in accordance with hospital policy and procedures and other regulatory standards. All grievances are documented in writing using the Complaint/Grievance Resolution Form. A patient grievance may come in the form of a phone call. In such case the employee who receives the grievance will complete the Complaint/Grievance Resolution Form. A copy should be sent to the Manager or Department Head where the complaint was lodged. Complaints that cannot be immediately and effectively identified, investigated and resolved by an individual staff member are considered grievances and should be directed up the chain of command to the level required for the most complete resolution possible. All grievances are documented using the Patient Complaint Resolution/Grievance form. The investigation must be completed within a period of seven (7) days. Once the investigation process is completed, the Manager or Department Director will complete the Complaint/Grievance Resolution Form and forward the response to Quality Management Director and Patient Representative. The written notice to the complainant will include the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution.

There was no documentation a "Complaint/Grievance Resolution Form" for the allegation of abuse alleged by Patient #9's representative on 08/10/11 at 12:42 p.m. completed by staff presented during the survey conducted from 10/04/11 to 10/12/11 as per policy. Further review revealed there was no documentation a follow up letter to the complainant that contained the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution completed for the alleged allegation of abuse for Patient #9 on 08/10/11 presented during the survey conducted from 10/04/11 to 10/12/11 as per policy.

The policy titled, "Alleged Abuse (Patient) Psychiatric Area", with no policy number, Revised & Review date(s) of 4/2011, presented as the hospital's current "Abuse" policy per fax on 10/12/11 at 10:48 a.m., revealed it was the responsibility of staff for reporting and conducting internal investigation of all alleged incidents of patient abuse in a manner that will protect the rights and dignity of alleged victim. Abuse is defined as the infliction of physical and mental injury by other parties including but not limited to such means as physical abuse to such an extent that their health, self determination or emotional well being is endangered. Upon being informed of alleged patient abuse (within reasonable interpretations of the above definition), notify the Program Director and Nurse Manager. If physical abuse is alleged, take immediate steps to preserve evidence. Observe the victim, clothing, room, and anything that may seem out of ordinary; note time, location. Statements from witnesses. Full statement or taped interview of the alleged assailant. Detailed description of the location, time, the victim's appearance when the incident occurred. Risk Management will assume the responsibility of notifying the proper authorities and/or agencies. Call the physician and request that the patient be transported to emergency room (stat). If the alleged assailant is a staff member, remove from the patient care area and inform Security to detain until Hospital Administration, Legal Authorities, or Director is notified and release authorization is given. The Program Director or Nurse Manager will notify the Administration on call of the alleged assault. The Administrator on call has the authorization to notify the outside Legal Authorities to conduct an internal investigation of the alleged incident. The complainant will be interviewed, as soon as possible, by the Program Director or Nurse Manager to obtain a written or taped interview as to the occurrence. The complainant will be assessed by the psychiatrist/case manager as soon as possible. The Medical Director will be notified immediately. The Program Director and Nurse Manager are responsible for all internal investigations of alleged abuse reports. The investigation should include:
1) Statement of victim - written or taped,
2) Statements from witnesses,
3) Full statement or taped interview of the alleged assailant, and
4) Detailed description of the location, time, the victim's appearance when the incident
occurred.

The "Incident Report", with no date documented that the form was completed by S7RN (Registered Nurse) Charge Nurse, was reviewed. Further review revealed an incident occurred in the dining room on Ten (10) West (location of the unit) on 08/07/11 at 10:15 p.m. (2215) with Patient #9. S7RN Charge Nurse and S8MHT (Mental Health Technician) did a "take down" of Patient #9 due to the patient attacking staff. There was a handwritten piece of paper attached to the "Incident Report" form that read in part, "...the Incident Report was not completed on 8/7/11. It was completed on 8/8/11...". There was no documented evidence of an observation and assessment of the patient's (#9's) injuries, clothing, and room was conducted by staff as per policy. Further there was no documented evidence of statements obtained from the witnesses was performed by staff as per policy. There was no documented evidence of a full statement or taped interview of the alleged assailant was done for this alleged allegation of abuse by staff as per policy. Further there was no documented evidence of a detailed description of the location, time, and the victim's appearance when the incident occurred was conducted by staff for this alleged allegation of abuse as per policy. There was no documented evidence the complainant was interviewed as soon as possible by the Program Director or Nurse Manager to obtain a written or taped interview as to the occurrence performed as per policy. Further there was no documentation the patient was assessed by the psychiatrist/case manager as soon as possible as per policy.

In an interview on 10/10/11 at 4:05 p.m. through 4:40 p.m., S5Case Manager verified a telephone call was made by Patient #9's representative with concerns that the patient (#9) was being abused at the facility, had messed up his shoulder, had bruising, and had skin hanging from his fingers at 12:42 p.m. on 08/10/11. The Case Manager recalled reporting the allegation of abuse for Patient #9 verbally to her immediate supervisor, (S6Social Worker), S4Nurse Manager, S3Director of Psychiatric Services and S7RN Charge Nurse that same day, (08/10/11) as per the grievance and abuse protocols. S5Case Manager stated she had concerns regarding staff abusing Patient #9 during the "take down" on 08/10/11 and expressed her concerns to her immediate supervisor (S6Social Worker), S3Director of Psychiatric Services, S4Nurse Manager, and S7RN Charge Nurse that same day on 08/10/11 as per the policy. S5Case Manager denied completing a "Complaint/Grievance Resolution Form " for the allegation of abuse from Patient #9 ' s representative on 08/10/11 as per policy.

An interview was conducted on 10/10/11 at 4:40 p.m. through 5:05 p.m., with S6Social Worker. The Social Worker (S6) indicated there were no grievance and/or abuse by staff for Patient #9 because an x-ray was performed two (2) days after the patient was taken down by staff on 08/07/11. Further S6 recalled performing an assessment of Patient #9's forearms and he did not have any bruising observed by her (social worker) during her daily group sessions from 08/07/11 through 08/15/11. The Social Worker (S6) indicated Patient #9 had no obvious signs of bruising by staff on his forearms, so there was no need for her (S6) to initiate the grievance policy to investigate the allegation of abuse for Patient #9 immediately as per the grievance and/or abuse policies. S6Social Worker decided on her own that this allegation of abuse from Patient #9's representative on 08/10/11 was not a grievance because an Xray of his (#9) right shoulder was done and the patient (#9) did not have obvious signs of bruising observed by her (S6) from 08/07/11 to 08/15/11. S6Social Worker denied completing a " Complaint/Grievance Resolution Form " for the allegation of abuse reported from Patient #9's representative on 08/10/11 as per policy.

During an interview held on 10/10/11 from 5:05 p.m. through 5:35 p.m., S3Director of Psychiatric Services and S4Nurse Manager both verified there was an allegation of abuse called into S5Case Manager by Patient #9's representative at 12:42 p.m. on 08/10/11. S3 and S4 both indicated the Case Manager (S5) and Social Worker (S6) failed to initiate the Grievance policy by completing a "Complaint/Grievance Resolution Form" for the allegation of abuse for Patient #9 on 08/10/11 to be investigated immediately as per policy. Both S3 and S4 indicated there was no formal investigation conducted for the allegation of abuse reported for Patient #9 conducted as per policy. The Director of Psychiatric Services (S3) and Nurse Manager (S4) both indicated there was no documentation of a follow up letter to the complainant that contained the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution completed for the alleged allegation of abuse for Patient #9 on 08/10/11 completed for the allegation of abuse from Patient #9's representative as per policy. S3Director of Psychiatric Services and S4Nurse Manager both indicated the allegation of abuse from Patient #9's representative was not incorporated into the Performance Improvement to measure, analyze, track quality indicators that assessed the processes of care, the hospital services and operations the patient received. Both S3 and S4 indicated the system failed by failing to initiate and follow the policies for grievance and abuse.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews and interviews, the hospital failed to measure analyaze, and track an allegation of abuse from Patient #9's representative that assessed the processes of care, the hospital services and operations the patient received by:
1) failing to identify there was no "Complaint/Grievance Resolution Form" completed by staff for the allegation of abuse reported from Patient #9's representative at 12:42 p.m. on 08/10/11 as per policy for 1 of 10 sampled records reviewed, (Patient #9),
2) failing to identify there was no investigation completed for the allegation of abuse reported by Patient #9's representative at 12:42 p.m. on 08/10/11 as per policy, and
3) failing to identify a written letter that included the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution within 7 days was not done as per hospital policy for 1 of 10 sampled records reviewed, (Patient #9). Findings:

Review of the medical record for Patient #9 revealed a "Group Note" documented by S5Case Manager dated/timed 08/10/11 at 12:42 p.m. for Patient #9 read in part, "...(Patient's representative named) called...Family concerned that patient is being abused here. His shoulder is messed up and he has bruising and skin hanging from his fingers...".

Review of the "Patient Complaint/Grievance Resolution Procedure", no policy number, date issued of May 2000, date last revised April 2008; no date last reviewed, (MDS) dated [DATE] at 5:40 p.m. as the hospital's current Grievance policy, revealed: "it is the policy of this hospital to make reasonable efforts to resolve patient complaints and grievances as quickly as possible. A complaint is a verbal or written expression of displeasure with a clinical process or person that can be resolved promptly by the staff present. A grievance is a formal or informal written or verbal complaint that is made by a patient/significant other when a patient's issue cannot be resolved promptly by staff present. Investigation of complaints/grievances will occur when the Hospital is in receipt of notification by the patient or representative of dissatisfaction with issues that have been unresolved. The notification may be by phone call. All grievances concerning situations that endanger the patient such as abuse will be reviewed and investigated immediately, and handled in accordance with hospital policy and procedures and other regulatory standards. All grievances are documented in writing using the Complaint/Grievance Resolution Form. A patient grievance may come in the form of a phone call. In such case the employee who receives the grievance will complete the Complaint/Grievance Resolution Form. A copy should be sent to the Manager or Department Head where the complaint was lodged. Complaints that cannot be immediately and effectively identified, investigated and resolved by an individual staff member are considered grievances and should be directed up the chain of command to the level required for the most complete resolution possible. All grievances are documented using the Patient Complaint Resolution/Grievance form. The investigation must be completed within a period of seven (7) days. Once the investigation process is completed, the Manager or Department Director will complete the Complaint/Grievance Resolution Form and forward the response to Quality Management Director and Patient Representative. The written notice to the complainant will include the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution.

There was no documentation a "Complaint/Grievance Resolution Form" for the allegation of abuse alleged by Patient #9's representative on 08/10/11 at 12:42 p.m. completed by staff presented during the survey conducted from 10/04/11 to 10/12/11 as per policy. Further review revealed there was no documentation a follow up letter to the complainant that contained the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution completed for the alleged allegation of abuse for Patient #9 on 08/10/11 presented during the survey conducted from 10/04/11 to 10/12/11 as per policy.

The policy titled, "Alleged Abuse (Patient) Psychiatric Area", with no policy number, Revised & Review date(s) of 4/2011, presented as the hospital's current "Abuse" policy per fax on 10/12/11 at 10:48 a.m., revealed it was the responsibility of staff for reporting and conducting internal investigation of all alleged incidents of patient abuse in a manner that will protect the rights and dignity of alleged victim. Abuse is defined as the infliction of physical and mental injury by other parties including but not limited to such means as physical abuse to such an extent that their health, self determination or emotional well being is endangered. Upon being informed of alleged patient abuse (within reasonable interpretations of the above definition), notify the Program Director and Nurse Manager. If physical abuse is alleged, take immediate steps to preserve evidence. Observe the victim, clothing, room, and anything that may seem out of ordinary; note time, location. Statements from witnesses. Full statement or taped interview of the alleged assailant. Detailed description of the location, time, the victim's appearance when the incident occurred. Risk Management will assume the responsibility of notifying the proper authorities and/or agencies. Call the physician and request that the patient be transported to emergency room (stat). If the alleged assailant is a staff member, remove from the patient care area and inform Security to detain until Hospital Administration, Legal Authorities, or Director is notified and release authorization is given. The Program Director or Nurse Manager will notify the Administration on call of the alleged assault. The Administrator on call has the authorization to notify the outside Legal Authorities to conduct an internal investigation of the alleged incident. The complainant will be interviewed, as soon as possible, by the Program Director or Nurse Manager to obtain a written or taped interview as to the occurrence. The complainant will be assessed by the psychiatrist/case manager as soon as possible. The Medical Director will be notified immediately. The Program Director and Nurse Manager are responsible for all internal investigations of alleged abuse reports. The investigation should include:
1) Statement of victim - written or taped,
2) Statements from witnesses,
3) Full statement or taped interview of the alleged assailant, and
4) Detailed description of the location, time, the victim's appearance when the incident
occurred.

The "Incident Report", with no date documented that the form was completed by S7RN (Registered Nurse) Charge Nurse, was reviewed. Further review revealed an incident occurred in the dining room on Ten (10) West (location of the unit) on 08/07/11 at 10:15 p.m. (2215) with Patient #9. S7RN Charge Nurse and S8MHT (Mental Health Technician) did a "take down" of Patient #9 due to the patient attacking staff. There was a handwritten piece of paper attached to the "Incident Report" form that read in part, "...the Incident Report was not completed on 8/7/11. It was completed on 8/8/11...". There was no documented evidence of an observation and assessment of the patient's (#9's) injuries, clothing, and room was conducted by staff as per policy. Further there was no documented evidence of statements obtained from the witnesses was performed by staff as per policy. There was no documented evidence of a full statement or taped interview of the alleged assailant was done for this alleged allegation of abuse by staff as per policy. Further there was no documented evidence of a detailed description of the location, time, and the victim's appearance when the incident occurred was conducted by staff for this alleged allegation of abuse as per policy. There was no documented evidence the complainant was interviewed as soon as possible by the Program Director or Nurse Manager to obtain a written or taped interview as to the occurrence performed as per policy. Further there was no documentation the patient was assessed by the psychiatrist/case manager as soon as possible as per policy.

In an interview on 10/10/11 at 4:05 p.m. through 4:40 p.m., S5Case Manager verified a telephone call was made by Patient #9's representative with concerns that the patient (#9) was being abused at the facility, had messed up his shoulder, had bruising, and had skin hanging from his fingers at 12:42 p.m. on 08/10/11. The Case Manager recalled reporting the allegation of abuse for Patient #9 verbally to her immediate supervisor, (S6Social Worker), S4Nurse Manager, S3Director of Psychiatric Services and S7RN Charge Nurse that same day, (08/10/11) as per the grievance and abuse protocols. S5Case Manager stated she had concerns regarding staff abusing Patient #9 during the "take down" on 08/10/11 and expressed her concerns to her immediate supervisor (S6Social Worker), S3Director of Psychiatric Services, S4Nurse Manager, and S7RN Charge Nurse that same day on 08/10/11 as per the policy. S5Case Manager denied completing a "Complaint/Grievance Resolution Form " for the allegation of abuse from Patient #9 ' s representative on 08/10/11 as per policy.

An interview was conducted on 10/10/11 at 4:40 p.m. through 5:05 p.m., with S6Social Worker. The Social Worker (S6) indicated there were no grievance and/or abuse by staff for Patient #9 because an x-ray was performed two (2) days after the patient was taken down by staff on 08/07/11. Further S6 recalled performing an assessment of Patient #9's forearms and he did not have any bruising observed by her (social worker) during her daily group sessions from 08/07/11 through 08/15/11. The Social Worker (S6) indicated Patient #9 had no obvious signs of bruising by staff on his forearms, so there was no need for her (S6) to initiate the grievance policy to investigate the allegation of abuse for Patient #9 immediately as per the grievance and/or abuse policies. S6Social Worker decided on her own that this allegation of abuse from Patient #9's representative on 08/10/11 was not a grievance because an Xray of his (#9) right shoulder was done and the patient (#9) did not have obvious signs of bruising observed by her (S6) from 08/07/11 to 08/15/11. S6Social Worker denied completing a " Complaint/Grievance Resolution Form " for the allegation of abuse reported from Patient #9's representative on 08/10/11 as per policy.

During an interview held on 10/10/11 from 5:05 p.m. through 5:35 p.m., S3Director of Psychiatric Services and S4Nurse Manager both verified there was an allegation of abuse called into S5Case Manager by Patient #9's representative at 12:42 p.m. on 08/10/11. S3 and S4 both indicated the Case Manager (S5) and Social Worker (S6) failed to initiate the Grievance policy by completing a "Complaint/Grievance Resolution Form" for the allegation of abuse for Patient #9 on 08/10/11 to be investigated immediately as per policy. Both S3 and S4 indicated there was no formal investigation conducted for the allegation of abuse reported for Patient #9 conducted as per policy. The Director of Psychiatric Services (S3) and Nurse Manager (S4) both indicated there was no documentation of a follow up letter to the complainant that contained the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution completed for the alleged allegation of abuse for Patient #9 on 08/10/11 completed for the allegation of abuse from Patient #9's representative as per policy. S3Director of Psychiatric Services and S4Nurse Manager both indicated the allegation of abuse from Patient #9's representative was not incorporated into the Performance Improvement to measure, analyze, track quality indicators that assessed the processes of care, the hospital services and operations the patient received. Both S3 and S4 indicated the system failed by failing to initiate and follow the policies for grievance and abuse.