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.

KAISER SUNNYSIDE MEDICAL CENTER 10180 SE SUNNYSIDE ROAD CLACKAMAS, OR 97015 April 15, 2016
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on interview, documentation reviewed in the medical record of a patient (Patient 4) who was handcuffed by security personnel, physically restrained, and had skin alterations, and review of policies and procedures and other documentation it was determined the hospital failed to ensure the patient's restraints were managed in accordance with appropriate physician orders and hospital policies and procedures.

Findings include:

Refer to the findings at Tag A167, CFR 482.13(e)(4)(ii), Patient Rights: Restraint or Seclusion. That deficiency reflects the hospital's failure to ensure Patient 4 who was handcuffed, physically restrained, and had skin alterations was managed in a safe and appropriate manner in accordance with appropriate physician orders and hospital policies and procedures.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, documentation in 2 of 2 medical records reviewed of patients (Patients 6 and 7), about whom complaints/grievances were expressed or filed, and review of hospital policies and procedures and other documentation, it was determined that the hospital failed to provide written notice of follow-up investigation and resolution that contained the required elements, including the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

1. Review of the record for Patient 7 reflected he/she was admitted on [DATE] and was discharged on [DATE].

A case investigative report with an "Incident Discovery Date" of 02/08/2016 was reviewed. It reflected that Patient 7 reported an allegation of assault that occurred while he/she was at the hospital. The report reflected the allegation was investigated by the hospital and the results of the investigation were "inconclusive." However, there was no evidence of a written response to the patient about his/her complaint.

An email from the AR&L Consultant dated 04/04/2016 at 1717 reflected that Patient 7 was at the hospital on [DATE] holding a sign indicating he/she had been assaulted at the hospital. In relation to whether the hospital provided the patient with a written response to his/her complaint, the email reflected "We failed to officially enter it into the grievance system..." There was no evidence of follow-up or further communication, verbal or written, with the patient about his/her complaint.

2. Review of the record for Patient 6 reflected he/she was admitted on [DATE] and was discharged on [DATE].

Refer to the deficiency cited at Tag A145, CFR 482.13(c)(3), Patient Rights: Free From Abuse/Harassment. That deficiency reflects that Patient 6 submitted a complaint to the hospital of an allegation of abuse on 02/02/2016, and the hospital failed to investigate the complaint in a timely manner in accordance with hospital policies and procedures.

A written response addressed to the patient related to his/her complaint of abuse dated 02/09/2016 reflected "Thank you for your telephone call on February 2, 2016, during which you described your concern(s) about your interaction with [RN], during your recent stay at Kaiser Sunnyside Medical Center (KSMC)...senior leaders have initiated but not yet completed, an investigation of the alleged misconduct...the senior leaders require additional time to complete the investigation...Once they have completed their investigation, you will be notified...As of today we have completed our review of your concerns within the complaint process." There was no evidence of follow-up or further communication, verbal or written, with the patient about his/her complaint.

3. The policy titled "Allegations of Abuse, Neglect or Misconduct by Staff" dated last revised "12/15" was reviewed and reflected "All allegations of abuse, misconduct or neglect shall be appropriately investigated and documented in a timely manner with a written response to the complainant....Hospital Compliance Officer responsibility...Develop written reports and responses...Complainant response includes actions taken to investigate allegation and outcomes..."

The policy titled "Member/Patient Complaint Policy" dated last revised "12/14" was reviewed and reflected "The written notice shall include each element of the member/patient's complaint and address each of those concerns...The goal of the department is to resolve...complaints within 7 calendar days...If a...complaint cannot be resolved in 7 calendar days, document why the need for an extension and why it is in the best interest of the member/patient. Provide prompt notification in writing to the member/patient...The written resolution notice must be in an approved template with the following applicable attributes...Summary of patient perspective...The steps taken to investigate the complaint...Disposition/actions taken on the member's behalf...The results of the process...The date of completion of the complaint process...Apology/Empathy, if appropriate...Contact information, including name, phone number, hours of operation...Reference to the complaint process in the Evidence of Coverage...QIO rights (if a Medicare quality of care)..."
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, documentation in 1 of 1 medical record reviewed of a patient (Patient 1) for whom a physician order for labwork was not carried out, and review of policies and procedures and other documents it was determined that the hospital failed to ensure the patient's right to participate in the development and implementation of his/her plan of care to meet his/her medical needs. The patient was not informed that physician's orders for a wound culture had not been implemented.

Findings include:

1. The medical record of patient 1 was reviewed and reflected the patient (MDS) dated [DATE] at 1552 with a chief complaint of "back left head cyst."

A physician order electronically signed by the physician and dated 02/22/2014 at 1803 reflected an order for a wound culture.

A physician note electronically signed by the physician and dated 02/22/2014 at 1828 reflected "Unclear [cause] for...scalp lesion...Pt consented to aspiration...scant bloody fluid...sent to lab for [culture]."

The physician discharge instructions dated 02/22/2014 at 1824 reflected "We have sent a sample to the lab for further studies. Please have your doctor follow up on the results."

The record reflected the patient was discharged on [DATE] at 1836.

On 02/22/2014 at 1903, the physician order for the wound culture reflected that an invalid specimen was sent to the lab and the order was discontinued.

An outpatient clinic record related to Patient 1's wound culture reflected the following:
* PAS notes on 02/24/2014 at 1621 reflected "...Results requested: pt states [he/she] had a wound culture done in the ER on 02/22. Pt states PCP told [him/her] they were still waiting for the results..."
* DO notes on 02/24/2014 at 1853 reflected "...please call patient and tell [him/her] that unfortunately the aspirate from [his/her] head was sent to the lab but not run since the wound culture kit was expired..."
* MA notes on 02/25/2014 at 0912 reflected "...Message given to Patient. Patient is very upset and frustrated that an expired kit was used..."

There was no documentation reflecting the patient was informed and provided the opportunity to participate in his/her plan of care related to the wound culture order until three days after the order was discontinued when he/she inquired about the results.

2. During an interview on 03/23/2016 at 1435 the Director of Laboratory Services stated that if a physician order for a lab test was not carried out, then a physician or the lab staff should notify the patient.

3. An email was received from the Director of AR&L on 03/30/2016 at 1409. In response to a request for documentation reflecting the patient was informed that his/her wound culture was not processed as ordered, the email reflected "...I have no evidence that the patient was notified."

4. The policy and procedure titled "Resulting and Reporting of Laboratory Tests," dated 06/24/2014 reflected "If a lab test cannot be performed or is unable to be completed, laboratory staff will notify the clinician."

The policy and procedure titled "Emergency services manual-Labs results, follow-up after patient is discharged or leaves without being seen," dated as last revised "10/12" was reviewed. It reflected the following: "...Results are forwarded to ED physician's in-basket electronically...Physician evaluates lab results...ED physician...follows-up with patient via telephone, mail or through PCP...Documents follow-up care..."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, review of documentation in 1 of 2 medical records of patients (Patient 6), about who the hospital received allegations of patient abuse, and review of policies and procedures and other documentation, it was determined the hospital failed to ensure the patient's right to be free of abuse. The hospital failed to investigate the patient's allegation of abuse in a timely manner in accordance with hospital policies and procedures.

Findings include:

1. The medical record of Patient 6 reflected that the patient was admitted on [DATE] and was discharged on [DATE].

2. An interview was conducted on 03/24/2016 at 1615 with the Director of ED, Respiratory and Critical Care. The director stated he/she received a report on 02/02/2016 from a "Kaiser continuing care" individual that Patient 6 reported he/she was assaulted while at the hospital.

3. A "Research Note" document related to Patient 6's allegation of abuse was reviewed and reflected it was completed by a customer concern manager. The notes reflected the following:
* "02/03/2016...verified member encounter on 1/20/16 with [RN]...The nurse noted that [he/she] performed a manual [disimpaction]. [He/she] also documented that post procedure, 'pt crying and upset'...Patient allegation of abuse has been escalated...for investigation."
* The next entry was on 02/09/2016 at 1140 and it reflected "The chief of staff, hospital administrator, and safety (sic) officer were immediately made aware of [patient] allegation. These senior leaders have initiated, but not yet completed, an investigation of the alleged misconduct. Patient Safety Officer...will write member a separate letter once their investigation is complete."
There was no documentation of follow-up or further investigation.

4. A "Current Summary" document dated 02/08/2016 related to Patient 6's hospitalization was reviewed and reflected it was completed by a regional risk management individual. Hospital staff indicated the summary was an incident report related to Patient 6's allegation of sexual abuse.

The "Event Occurrence" date on the summary was recorded as 01/19/2016 and the "Brief Factual Description" reflected "Patient alleges that one of the clinical staff performed a digital disimpaction on [him/her] that was very rough and when [he/she] was crying, the clinical staff told [him/her] to 'suck it up' and 'that's just how life is'."
The following sections on the summary were followed by "Not Specified":
* Party Involved/Notified/Witnesses; and
* Follow-Up Actions.

The following sections on the summary were not completed and were blank:
* Contributing Factors (Reported);
* Immediate Actions (Reported);
* "Time (00:00);
* Location Description;
* Resolutions and outcomes;
* Severity Level (Actual);
* Contributing Factors (Actual);
* Organization Outcome;
* Marked as a [Potential Compensable Event] on;
* Recommendations for System;
* Improvement; and
* Resolution Comment(s).
There was no evidence of follow-up or further investigation related to the allegation of abuse.

5. An undated case investigation report related to Patient 6's hospitalization was reviewed. Hospital staff indicted the report was an investigation of the patient's allegation of abuse.

The report reflected the following: "Patient reports that on the first day [he/she] was in the CVICU the night shift RN assigned to [patient's] care put two fingers into [patient's] rectum without giving [patient] advanced notice...leaving [patient] feeling violated...[Patient] notified [his/her] [physician] about the incident. [Patient] also talked to another RN...Based on interviews conducted and the evidence presented, the allegation that [RN] touched the patient in an inappropriate manner is unsubstantiated."

The "Investigative Narrative" section on the report reflected the incident was reported to an RN Director and the "Incident Discovery Date" was 02/03/2016. There was no evidence of follow-up or further investigation until 02/12/2016 when the report reflected interviews were conducted with hospital staff.

6. During an interview on 04/04/2016 at 1100, the AR&L Consultant stated the hospital's policy was that an allegation of patient abuse should be investigated immediately once the hospital became aware of it.

7. An email from the AR&L Consultant dated 04/04/2016 at 1717 related to Patient 6's allegation of abuse reflected "... [02/03/2016] SMC was notified of allegation of abuse...No evidence of documented formal investigation until [02/12/2016]. That is correct."

8. The policy titled "Allegations of Abuse, Neglect or Misconduct by Staff" dated last revised "12/15" was reviewed and reflected "All allegations of abuse, misconduct or neglect shall be appropriately investigated and documented in a timely manner...Hospital Compliance Officer responsibility...Begin official investigation...Document all steps taken in the investigation in the compliance tracking system...Hospital Compliance Officer responsibility...record keeping of formal documentation (include steps taken to investigate the allegation)."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, documentation reviewed in the medical record of a patient (Patient 4) who was handcuffed by hospital security personnel, physically restrained, and had skin alterations, and review of policies and procedures and other documentation it was determined the hospital failed to ensure the patient's restraints were managed in a safe and appropriate manner.
* Hospital security personnel used handcuffs to restrain the patient which was contradictory to hospital policies and procedures and physician orders; and
* Patient assessments related to the use of handcuffs, restraints and skin alterations were not conducted by the RN in accordance with hospital policies and procedures.

Findings include:

1. The ED record of Patient 4 was reviewed. The record reflected the patient (MDS) dated [DATE] at 1926 with a chief complaint of [Emergency Psychiatric Services].

A physician order electronically signed by the physician on 01/12/2015 at 2106 reflected an order for "Hard/Velcro 4-point" restraints. There were no other physician orders for restraints.

The ED RN notes on 01/12/2015 at 2117 reflected "Patient scene (sic) eloping from room...asked to return to ER room...Patient refused and ran through ER waiting room doors. This nurse restrained patient to the the ground. Security called and patient [handcuffed] by security. Brought to standing position from ground and to ER stretcher where patient was put in 4 point restraints."

ED Notes recorded by "Support Staff" on 01/12/2015 at 2136 reflected "Patient removed from restraints..." There was no documentation reflecting when or if the handcuffs were removed.

ED Flowsheet documentation recorded by "Support Staff" on 01/12/2015 at 2136 reflected "...abrasions on both elbows. Cleaned." This was the first documentation reflecting the patient's skin abrasions.

The next ED RN note was on 01/12/2015 at 2141 and it was a neurological and a behavior assessment.

The record reflected the patient was discharged on [DATE] at 1345.

There was no documentation that the RN conducted an initial or on-going assessment of the patient in relation to the use of the handcuffs and 4 point restraints. There was no RN assessment of the patient's skin abrasions including the cause of the abrasions with respect to the handcuffs and 4 point restraints. There was no documentation reflecting the physician was notified that handcuffs were used to restrain the patient or that the physician was notified about the patient's skin abrasions.

2. Review of a "Safety/Security" report dated 01/12/2015 related to Patient 4 was reviewed. It reflected "At around 20:53 hours security was dispatched to an eloped patient who was being restrained in the ED parking lot...[Patient] was immediately placed in handcuffs. [He/she] was very resistant and was able to tuck [his/her] arms under [his/her] body several times...Staff assisted [patient] onto the bed and [his/her] ankles were immediately restrained...handcuffs were removed and [he/she] was placed in wrist restraints."

3. During an interview on 03/23/2016 at 1200 the ED Manager stated it was required that the RN conduct an initial assessment of the patient after restraints were applied, including completion of a restraint flowsheet, a head to toe assessment, skin integrity and circulation assessments. The ED Manager stated there was no documentation that the RN assessed the patient in relation to the use of restraints as required. In addition, the ED Manager acknowledged there was no documentation that the RN assessed the patient's skin abrasions or notified the physician of the abrasions.

4. The policy titled "Security Officer Role in Managing Violent or Disruptive Behavior" dated last revised "12/15" was reviewed and reflected "Use of weapons prohibited...At all Kaiser Permanente Northwest facilities...Law Enforcement tools/actions such as Pepper spray, Handcuffs...may only be used to handle criminal activity. In these situations...Law enforcement must be contacted, activity reported, and a request made to take the person into custody..."

The policy titled "Restraint, Seclusion, Use of (Application, Removal and Patient Care)" dated last revised "11/14" was reviewed and reflected "Documentation Requirements "When a restraint or seclusion is used, there must be documentation in the patient's medical record of the following...Physician's order...Initial assessment by the RN...if restraint or seclusion is used to manage violent or self-destructive behavior...Any injury the patient sustained related to restraint use and treatment of the injuries will be documented as a note...Any unanticipated changes in the patient's condition will be documented as a note...RN...Reassess and care for the patient on an on-going basis...Document in the patient record at least every two hours, or more frequently as determined by age, medical condition, and other associated risks for each individual episode of restraint...Ongoing monitoring using the restraint flow sheet...Significant changes in the patient's condition."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on interview, documentation reviewed in the medical record of a patient (Patient 4) who was handcuffed by hospital security personnel, physically restrained, and had skin alterations, and review of policies and procedures and other documentation it was determined the hospital failed to ensure the patient's restraints were appropriately assessed and monitored in accordance with hospital policies and procedures.

Findings included:

Refer to the deficiency cited at Tag A167, CFR 482.13(e)(4)(ii), Patient Rights: Restraint or Seclusion. That deficiency reflects the hospital's failure to ensure that Patient 4 who was handcuffed, physically restrained and had skin alterations was appropriately monitored and evaluated by the RN in accordance with hospital policies and procedures.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview, documentation reviewed in the medical record of a patient (Patient 4) who was handcuffed by hospital security personnel, physically restrained and had skin alterations, and review of policies and procedures and other documentation it was determined the hospital failed to ensure the RN supervised and evaluated the patient's care needs initially and on-going in relation to:
* Physical restraints, including handcuffs and 4-point restraints; and
* Skin alterations

Findings included:

1. Refer to the findings at Tag A167, CFR 482.13(e)(4)(ii), Patient Rights: Restraint or Seclusion. That deficiency reflects the hospital's failure to ensure that the RN evaluated and supervised the nursing care of Patient 4 who was handcuffed, physically restrained and had skin alterations in accordance with hospital policies and procedures.

2. The policy and procedure titled "Standard of Care" dated last revised "02/11" reflected "This policy applies to all Registered Nurses that provide patient care at the Kaiser Sunnyside Medical Center (KSMC) Emergency Department...emergency nurse initiates accurate and ongoing assessment of physical and psychological concerns of patients within the emergency care system..." The "Implementation" section reflected "...The emergency nurse implements a plan of care based on assessment, nursing diagnoses and/or collaborative problems, and outcome identification...Documentation will include...Patient contact and documentation of vital signs and patient re-assessment will occur minimally every two hours...The RN will verbally notify the physician of...acute changes in...condition at any time during their ED visit...All procedures, medications, and interventions with patient response." The "Evaluation" section of the policy reflected "...Evaluation of patient's progress will occur among members of the health care team including nurses, physicians, consulting physicians and services. Revisions to the plan of care are instituted if indicated. The nurse assures open and timely communication with emergency patients...team members..."