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NORTHWEST MISSISSIPPI MEDICAL CENTER 1970 HOSPITAL DRIVE CLARKSDALE, MS 38614 Nov. 10, 2015
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0021
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on medical record review, signed statement review, staff interview, and policy review, the facility failed to ensure that a complaint of neglect and abuse of Patient #1, one (1) of 10 patients reviewed, was reported to the Mississippi State Department of Health as required to remain in compliance with Federal laws related to patient health and safety.


Findings include:


On 11/5/2015 the Mississippi State Department of Health received a complaint from Patient #1's daughter which stated, "My father was admitted on [DATE] with breathing complications... On Oct. 28, 2015, between the hours of 7pm and 7:30 pm, a respiratory therapist (Respiratory Therapist #1) was assigned to my father... to give a breathing treatment with an oxygen mask. (Respiratory Therapist #1) proceeded to enter into my father's room while he was on the floor, in urine due to his cather (catheter) tube coming loose from the bag, and in pain. (Respiratory Therapist #1) proceeded to yell at him while he was on the floor in pain "are you gonna take this treatment or not?!" My dad was in such pain and refused the treatment and told (Respiratory Therapist #1) he was in pain and to wait. The therapist said she didn't have time to wait, and placed the oxygen mask on his face while he was still on his knees, in urine. (Respiratory Therapist #1) walked off and left him on his knees. A nurse finally came to assist him after about 10-15 mins (minutes). He did not say anything to the nurse about what happened because he was in severe pain. However on 10/29/15 (Respiratory Therapist #1) came back into my father's room, while visitors were present and began to yell @ (at) him while again after he was asking why did she treat him bad yesterday. My twin sister... immediately notified the house supervisor and (Respiratory Therapist #1) was removed from him room for providing care..."


There was no documented evidence that the facility reported this complaint of neglect and abuse to the Mississippi State Department of Health as required.



Record review revealed that Patient #1 was a [AGE]-year-old male patient who was admitted to facility on 10/23/15. The patient's history and physical documented that Patient #1 presented to the emergency department where he was initially noted with a blood pressure of 162/102, heart rate of 60, oxygen saturation of 98 % (percent) on two (2) liters of oxygen by nasal cannula. Admissions orders included Atrovent Nebulizer Solution 0.02% (ipratropium bromide) 0.5 mg (milligram) Inhalation q 4H (every four hours) per Respiratory Therapy; and Oxygen via nasal cannula at 2 liters per minute.


A telephone interview with the House Supervisor on 11/10/15 at 8:20 a.m. revealed that she had been called to Patient #1's room in response a complaint. The patient told the House Supervisor that Respiratory Therapist #1 was rude to him. He said he fell on the floor and Respiratory Therapist #1 put an oxygen mask on him while he was on the floor. The patient's sister told the House Supervisor that the patient was on the floor praying. No fall was reported. The patient said he did not fall. The House Supervisor later talked to the patient's daughter in her office. The daughter told her that she wanted Respiratory Therapist #1 fired 'now'. The daughter told the House Supervisor that the patient was praying on the floor beside his bed.


A signed statement by the Director of Cardiopulmonary (DCP) contained the following information:
On October 29, 2015 at 9:37 p.m., the House Supervisor informed her of complaints from Patient #1 and his family regarding Respiratory Therapist #1. The House Supervisor had talked to the patient, his family and Respiratory Therapist #1. Respiratory Therapist #1 was very upset. The DCP received another call from the House Supervisor on October 30, at 6:14 a.m. stating that the family was irate and wanting Respiratory Therapist #1 fired. The House Supervisor stated the family had said the patient was on the floor and Respiratory Therapist #1 did not help to get him up. Respiratory Therapist #1 gave the patient his breathing treatment on the floor. It was also reported on 10/30/15 that the family had called the department cursing and accusing Respiratory Therapist #1 of patient neglect. The DCP went to the patient's room at 7:45 a.m. that morning and talked to the family. She told them that the facility would investigate their complaint and thanked them for giving her the complaint. The family stated that he had not fallen, he was praying. The daughters thanked her for coming. The DCP assured them that she would be checking back with them. She went back to visit Patient #1 that afternoon. "The patient stated that the staff had gone above and beyond."


During an interview with Respiratory Therapist #1 on 11/10/15 at 8:00 a.m. she denied the allegations. She also said she had never met the patient's family.


An interview with the Chief Nursing Officer on 11/10/15 at 12:15 p.m. confirmed that the complaint regarding neglect and abuse of Patient #1 was not reported to the Mississippi State Department of Health Complaint Department.



Review of the facility's "Complaint/Grievance" policy (Revised Date: 11/14) revealed that the policy did not address the Federal requirement to notify the State Department of Health of patient/family complaints of abuse.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure that that Patient #1/Complainant was provided a hospital contact person, steps taken to investigate the grievance, the result of the grievance process, and the date of completion of the investigation of the complaint of abuse.


Findings include:


On 11/5/2015 the Mississippi State Department of Health received a complaint from Patient #1's daughter which stated, "My father was admitted on [DATE] with breathing complications... On Oct. 28, 2015, between the hours of 7pm and 7:30 pm, a respiratory therapist (Respiratory Therapist #1) was assigned to my father... to give a breathing treatment with an oxygen mask. (Respiratory Therapist #1) proceeded to enter into my father's room while he was on the floor, in urine due to his cather (catheter) tube coming loose from the bag, and in pain. (Respiratory Therapist #1) proceeded to yell at him while he was on the floor in pain "are you gonna take this treatment or not?!" My dad was in such pain and refused the treatment and told (Respiratory Therapist #1) he was in pain and to wait. The therapist said she didn't have time to wait, and placed the oxygen mask on his face while he was still on his knees, in urine. (Respiratory Therapist #1) walked off and left him on his knees. A nurse finally came to assist him after about 10-15 mins (minutes). He did not say anything to the nurse about what happened because he was in severe pain. However on 10/29/15 (Respiratory Therapist #1) came back into my father's room, while visitors were present and began to yell @ (at) him while again after he was asking why did she treat him bad yesterday. My twin sister... immediately notified the house supervisor and (Respiratory Therapist #1) was removed from him room for providing care..."



Record review for Patient #1 revealed he was a [AGE] year old male who was admitted to the facility on [DATE] with the chief complaint of Chest Pain and Shortness of Breath. Review of his History and Physicial revealed, "It is noted that the patient's urine was positive for cocaine. However, he reports he did not use cocaine and it is drifting through air vents and he is getting it secondarily. His medical history included: Ischemic [DIAGNOSES REDACTED], Chronic Heart Failure, and Chronic Artery Disease. The patient also has a very long history of noncompliance, both with medications and follow-ups." Review of a physician's 10/28/15 consultation report revealed, "...admitted with chest pain and shortness of breath. This turned out to be evidently due to small airway spasm due to cocaine ingestion or associated with cocaine ingestion... He has been asking for Demerol on a regular basis and receiving it and his drug screen was positive for cocaine and opiates on admission..." Admission orders included Atrovent Nebulizer Solution 0.02% (ipratropium bromide) 0.5 mg Inhalation q 4H per Respiratory Therapy; and Oxygen via nasal cannula at 2 liters per minutes.


A signed statement by the Director of Cardiopulmonary (DCP) contained the following information:
On October 29, 2015 at 9:37 p.m., the House Supervisor informed her of complaints from Patient #1 and his family regarding Respiratory Therapist #1. The House Supervisor had talked to the patient, his family and Respiratory Therapist #1. Respiratory Therapist #1 was very upset. The DCP received another call from the House Supervisor on October 30, at 6:14 a.m. stating that the family was irate and wanting Respiratory Therapist #1 fired. The House Supervisor stated the family had said the patient was on the floor and Respiratory Therapist #1 did not help to get him up. Respiratory Therapist #1 gave the patient his breathing treatment on the floor. It was also reported on 10/30/15 that the family had called the department cursing and accusing Respiratory Therapist #1 of patient neglect. The DCP went to the patient's room at 7:45 a.m. that morning and talked to the family. She told them that the facility would investigate their complaint and thanked them for giving her the complaint. The family stated that he had not fallen, he was praying. The daughters thanked her for coming. The DCP assured them that she would be checking back with them. She went back to visit Patient #1 that afternoon. "The patient stated that the staff had gone above and beyond."



During an interview with Respiratory Therapist #1 on 11/10/15 at 8:00 a.m. she denied the allegations. She also said she had never met the patient's family.



An interview with the Chief Nursing Officer on 11/10/15 at 12:15 p.m. confirmed that the complaint regarding neglect and abuse of Patient #1 was not reported to the Mississippi State Department of Health Complaint Department.



Review of the facility's "Complaint/Grievance" Policy (Revised Date: 11/14) revealed:
"Purpose - The purpose of this policy is to: ...2. Provide a process to review, investigate, and resolve a patient's/patient representative's complaint / greivance within a reasonable time frame.
Policy -
1. Patients have the right to express concerns and expect resolution in a timely manner...
3. The patient/family shall be informed of whom to contact to file a complaint/grievance...
4. The Community Cares Director ensures the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance within 7 days of the hospital's receipt of the grievance, even though the hospital's resolution need not be complete within-in the seven-day limit...
7. The Department Manager completes any investigation, identifying if the issue has been resolved or not resolved, corrective actions taken and any needed notification of other personnel for follow up. The Department Manager then signs and dates where indicated on the form.
8. The Hospital CEO (Chief Executive Officer), or designee if the CEO is unavailable, shall receive the report form within a reasonable time frame (the goal is to have the CEO in receipt of the completed sections within 72 hours) to proceed with written response to the patient/representative...
12. The CEO is responsible for completing and sending a letter to the complainant in response to a complaint/grievance. The letter shall include the name of the Hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion...
14. The response letter shall be forwarded to the patient or patient representative no later than 7 days after receipt of the grievance even though the hospital's resolution need not be completed within the seven-day limit..."