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.

REGIONAL HEALTH RAPID CITY HOSPITAL 353 FAIRMONT BLVD POST OFFICE BOX 6000 RAPID CITY, SD 57701 Aug. 19, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






A. Based on record review and interview, the provider failed to ensure safety precautions were developed and implemented on the progressive care unit (PCU) for patients placed on mental health hold to prevent the elopement for one of one sampled patient (7) that eloped. Findings include:

1. Review of patient 7's electronic medical record revealed:
*She had (MDS) dated [DATE] at 11:07 p.m. with diagnoses of clinical depression, Benadryl and alcohol overdose, and mental changes.
*She was admitted as an inpatient on 8/11/14 at 2:02 a.m. and prior to her transfer on 8/12/14 at 11:15 a.m. to the hospital's Behavioral Health Unit the physician had initiated a mental health hold for psychiatric evaluation.

Interview during the provider's Emtala investigation on 8/12/14 at 2:30 p.m. with the risk management directors C, D, and vice-president of professional services revealed to the survey team on 8/12/14 patient 7 had eloped from the PCU at 1:25 p.m. She had eloped after her physician had explained the mental health hold order and the need to have a psychiatric evaluation. The provider had initiated their elopement protocol and were actively searching for the patient, but she had not been found in the hospital or on hospital property. An investigation of the event would be conducted, and a plan of action would be completed.

Interview on 8/14/14 at 11:26 a.m. with the PCU director revealed once a patient was placed on a mental health hold the staff were informed of that status. That was referred to as heightened awareness by the staff. The PCU did not conduct one-to-one observation of patients on hold; that was reserved for patients on suicide precautions. The PCU director revealed patient 7 had stated she was not attempting suicide but only trying to get high. Patient 7's physician had not ordered suicide precautions.

Refer to A144, finding 1.

B. Based on record review and interview, the provider failed to ensure a physician's order had been received prior to or after the use of four-point restraints for one of three sampled patients (8) with restraints. Findings include:

1. Review of patient 8's electronic medical record revealed:
*The patient had been admitted to the intensive care unit (ICU) on 12/24/13 and transferred on 12/29/13 to the Behavioral Health Unit for psychiatric patients.
*Diagnoses included but were not limited to delirium tremens (body shakes from alcohol withdrawal), status post exploratory laparotomy for self-inflicted abdominal stab wounds, and a history of traumatic brain injury.
*The nursing restraint documentation for 12/24/13 revealed the patient was in four-point restraints (patient arms and legs were restrained restricting movement).
*The physician order dated 12/24/13 at 11:23 a.m. was for soft wrist restraints to the upper right and upper left extremities to maintain safe endotracheal tube (breathing tubing inserted through the mouth) placement.

Refer to A168, finding 1.

C. Based on record review and interview, the provider failed to ensure:
*Patients were notified of the investigation status or completion of the grievance process within five days after submission as indicated in the facility policy for four of four reviewed patients' (9, 11, 12, and 13) grievances.
*An investigation had been conducted and documented for the grievance filed for one of four sampled patients (9) who had submitted grievances.
Findings include:

1. Review of the provider's grievance process and grievances submitted by patients 9, 11, 12, and 13 revealed the notification regarding the status of the investigation or the resolution of the grievance had not been sent to those patients. It would have been sent within five days as outlined in the provider's December 2013 Patient Complaint and Grievance Process policy.

Refer to A122, findings 1, 2, 3, and 4.

2. Review of the customer service staff documentation for patient 9 revealed:*A handwritten grievance note (undated) regarding her 6/19/14 emergency department (ED) visit. The note indicated she had not received pain medication until 4 1/2 hours after her ED assessment..
*There was no documentation in the grievance file that allegation had been investigated.
*There was no documentation the provider had sent the patient an update notification letter informing her of the status of the investigation/notification of closing the case.

Interview on 8/18/14 at 1:43 p.m. with the customer service staff members G and H, the ED director, and risk management director D regarding patient 9's grievance revealed:
*The ED director was responsible for investigating grievances that involved the ED.
*The ED stated he had not received notification of patient 9's grievance.
*After prompting by risk management director D, the ED director opened his e-mail and found the grievance file sent from customer service dated 6/19/14.
*The timeframe for conducting the investigation and notifications to the patient regarding the complaint status were not within five days as stated in the grievance policy.

Refer to A122, finding 2.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and policy review, the provider failed to ensure:
*Patients were notified of the investigation status or completion of the grievance process in five days after submission as indicated in the facility policy for four of four sampled patients' (9, 11, 12, and 13) grievances.
*An investigation had been conducted and documented for the grievance filed for one of four sampled patients (9) who had submitted grievances.
Findings include:

1. Review of patient 11's grievance report revealed:
*The provider was notified of the complaint on 4/2/14.
*The patient complained of an extended emergency department wait for a ruptured appendix.
*The complaint was entered into the system on 4/7/14.
*A letter dated 5/27/14 sent to the patient of the complaint findings.
*A letter dated 7/31/14 of the Grievance Committee review findings.

2. Review of patient 12's grievance report revealed:
*The provider was notified of the complaint on 6/30/14.
*The complaint was entered into the system on 7/1/14.
*A letter dated 8/7/14 sent to the patient of the complaint findings.

3. Review of patient 13's grievance report revealed:
*The provider was notified of the complaint on 3/14/14.
*The complaint was entered into the system on 3/18/14.
*A letter dated 3/26/14 was sent to the patient of the complaint findings.

4. Review of the customer service staff documentation for patient 9 revealed:*A handwritten grievance attached to the second page of her ED discharge instruction dated 6/19/14. The note stated "Need I say service sucks 4 1/2 hrs [hours] before pain med given. Build more ER [emergency room ] space hire more DR's (doctors) and nurses. Be pro-active instead of miserly. The whole of West River area would Benefit from proper staff and space."
*There was no documentation in the grievance file that allegation had been investigated.
*There was no documentation the provider had sent the patient an update notification letter informing her of the status of the investigation/notification of closing the case.

Review of patient 9's electronic medical record nurses' notes revealed:
*The patient (MDS) dated [DATE] at 2:15 p.m., was triaged at 3:02 p.m., and was seen by the physician at 3:55 p.m.
*The patient presented with a two day history of dysuria (painful urination) and right flank, low back, and pelvic pain.
*On a numeric scale of 0 to 10 (0 no pain and 10 being the worst) she had rated her pain a 10.
*The physician ordered intravenous (IV) morphine at 3:55 p.m.
*The patient had refused IV morphine at 4:11 p.m. and had requested Dilaudid (narcotic pain reliever). The patient had stated she only took Dilaudid.
*The nurse documented she had made the physician aware of the patient's refusal at 4:11 p.m. and at 5:36 p.m., and she would be seen by a family practice physician for further care and treatment.
*At 6:29 p.m. the family practice physician had ordered Dilaudid, and the mediation was administered at 6:32 p.m. Dilaudid was administered approximately 2 1/2 hours after the morphine refusal and 4 1/2 hours after the patient's arrival.

Interview on 8/18/14 at 1:43 p.m. with the customer service staff members G and H, the ED director, and director of risk management D regarding patient 9's grievance revealed:
*They considered the handwritten note from patient 9 a formal grievance.
*The ED director was responsible for investigating grievances that involved the ED.
*The ED director stated he had not received notification of patient 9's grievance.
*After prompting by risk management director D, the ED director opened his e-mail and found the grievance file sent from customer service dated 6/19/14.
*The timeframe for conducting the investigation and notifications to the patient regarding the complaint status was not within five days as stated in the grievance policy.





5. Review of the provider's December 2013 reviewed Patient Complaint and Grievance Process policy revealed:
*A letter would be sent to the patient within seven days of the steps taken on behalf of the patient to investigate the grievance, and the results of the vice president and/or the chief executive officer's review.
*If the grievance remained unresolved the Grievance Committee would review the grievance and respond to the patient within five working days.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and policy review, the provider failed:
*To develop and implement comprehensive safety measures and policies facility wide to prevent the elopement of all hospital inpatients placed on a mental health hold.
*To implement safety measures to prevent the elopement for one of one sampled patient (7) on a mental health hold for psychiatric evaluation.
Findings include:

1. Review of patient 7's emergency department (ED) record revealed:
*She had (MDS) dated [DATE] with diagnoses of clinical depression, Benadryl and alcohol overdose, and mental changes.
*She was admitted to the progressive care unit (PCU) on 8/11/14 and prior to her transfer on 8/12/14 to the hospital's Behavioral Health Unit the physician had initiated a mental hold for psychiatric evaluation.

Review of patient 7's nursing assessment dated [DATE] revealed the patient had been identified as a high elopement risk.

Review of patient 7's care plan revealed elopement and alcohol/drug withdrawal had been identified as problems. The care plan did not address one-to-one observation of the patient, putting her in green scrubs (used for patients placed on mental hold when transferred to Behavioral Health), or securing her personal belongings.

Interview on 8/12/14 at 1:25 p.m. with risk management directors C, D, and vice-president of professional services regarding patient 7's elopement revealed:
*On 8/12/14 she had eloped from the PCU at 1:25 p.m. after her physician had explained the mental health hold order and the need to have a psychiatric evaluation.
*The PCU staff had initiated the elopement protocol and notified security of the elopement.
*The hospital and hospital campus had been searched, but she had not been found.
*The elopement protocol developed and initiated in the emergency department that required one-to-one observation and placing patients on a mental health hold in green scrubs, and securing the patient's personal property had not been initiation on other units.
*They would have to implement a protocol for the hospital inpatients placed on a mental health hold to prevent elopement.
*An investigation of the event would be conducted and a plan of action would be developed.

Review of the provider's immediate action plan communicated to the South Dakota Department of Health Complaint Coordinator dated 8/14/14 at 8:31 a.m. revealed:
*"Constant Observation of all inpatients with Mental Hold initiated in the inpatient setting.
*Patients to be placed in green scrubs upon placement of Mental Hold in the inpatient setting.
*Message to Leadership from Vice President of Patient Care informing staff of new processes immediately in effect."

Interview on 8/14/14 at 11:26 with the PCU director revealed once a patient was placed on a mental hold the staff were informed of that status. That was referred to as heightened awareness by the staff. The PCU did not conduct one-to-one observation of patients on a mental health hold that was reserved for patients on suicide precautions. The PCU director revealed patient 7 had stated she was not attempting suicide but only trying to get high. Patient 7's physician had not ordered suicide precautions which required patients to have a sitter (one-to-one observation) to monitor their activity for safety concerns.

Interview on 8/14/14 at 9:00 a.m. with health unit clerk (HUC) E regarding patient 7's elopement revealed:
*He had been on duty and was observing the patient in conjunction with registered nurse (RN) F.
*He was aware the patient had been placed on a mental health hold and was being transferred to the hospital's Behavioral Health Unit.
*There was no policy stating or a physician's order for one-to-one observation of the patient. It was something he just did.
*The patient and her family had been standing in a group in the hallway, and he was able to view them from his work station.
*RN F had received a phone call that diverted his attention from the patient and her family. His attention was momentarily diverted from the patient with his work.
*He received a phone call informing him another staff member had seen the patient get on the elevator.
*He immediately initiated elopement procedures and notified security.
*A search of the hospital had been conducted, but the patient was not located on the property.
*Some time later the patient's family had located her and returned her to the hospital.

Interview on 8/18/14 at 3:00 p.m. with RN F regarding patient 7's elopement revealed:
*He was responsible for the patient's care that morning.
*The patient's current mental heath had expired, he had informed the physician the patient wanted to leave against medical advice.
*The physician ordered a mental health hold and transfer to the Behavioral Health Unit.
*The physician conducted a care conference with the patient and her family explaining the mental health hold, the need to have a psychiatric evaluation, and her transfer to the hospital's Behavorial Health Unit.
*The patient was not agreeable to the transfer.
* Prior to the patient's elopement she and her family had been standing in the hallway saying goodbye.
*He had received a phone call from another patient and took his eyes momentarily off the patient and her family.
*He had not requested another nurse monitor the patient while he took the phone call.
*HUC E also had eyes on the patient.
*HUC E had received a phone call that informed them the patient had been seen getting on the elevator.
*He had been informed by the family the patient stated she wanted to go around the corner to blow her nose. The elevators were located around the corner.
*He had informed the patient and her family several times she was not to leave the floor and all voiced their understanding.
*He had thought she was safe with her family.

Review of the provider's January 2013 Legal Holds and 24-Hour Holds policy revealed:
*"Enacting a Twenty-four Hour Hold is utilized when, after an exam by a qualified mental health professional, the patient is deemed to be severely mental ill and in need of immediate intervention to protect the patient from harm to self or others."
*The Twenty-Four Hour Hold will detain the patient at the facility for observation and/or emergency treatment."
*The patient may be involuntarily detained at the facility for up to 24 hours from initiation of the order."

Review of the provider's May 2013 Assessment of Patient Elopement Risk policy revealed:
*Risk factors to evaluate during the admission assessment for elopement included but was not limited to:
-The patient has exhibited confusion related to dementia, traumatic brain injury, history of current alcohol or drug abuse.
-The patient was a danger to self and others.
*If the patient had been assessed an elopement risk the patient's plan of care should include interventions for elopement that included but not limited to:
-Placing the patient close to the nurse's station.
-Request the family or volunteer to stay with the patient.
-Conduct frequent patient location cheeks.
-Constant supervision if the patient was a high risk for elopement.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record review, interview, and policy review, the provider failed to ensure a physician's order had been received prior to or after the use of four-point restraints for one of three sampled patients (8) with restraints. Findings include:

1. Review of patient 8's electronic medical record revealed:
*The patient had been admitted to the intensive care unit (ICU) on 12/24/13 and transferred on 12/29/13 to the West unit for psychiatric patients.
*Diagnoses included but were not limited to delirium tremens, status post exploratory laparotomy for self-inflicted abdominal stab wounds, and a history of traumatic brain injury.
*The nursing restraint documentation for 12/24/13 revealed the patient was in four-point restraints (patient arms and legs were restrained restricting movement).
*The physician order dated 12/24/13 at 11:23 a.m. had an order for soft wrist restraints to maintain safe endotracheal tube (breathing tubing inserted through the mouth) placement.

Review and interview on 8/18/14 at 5:00 p.m. with the ICU certified resource nurse (CRN) B and director of risk management C confirmed a physician order for the four-point extremity restraints could not be found in the electronic medical record CRN B revealed an order should have been in the patient's medical record, and she did not know why an order for the four-point restraints had not been documented. CRN B revealed the soft wrist restraint would have been used. The provider had no leather restraints.

Review of the provider's October 2013 Restraint and Seclusion Use policy revealed:
*"Only Registered Nurses will be responsible for the initiation and discontinuation of restraint, assessment and reassessment of patients.
*The decision to restrain/seclude a patient is made by the LIP (licensed independent practitioner). In emergency situations when the LIP is not present and restraint/seclusion is required to manage the unanticipated behavior of a violent or aggressive patient, RNs (registered nurses) or a Behavioral Health staff member having demonstrated this competence, may make the decision to use restraint/seclusion, and then the RN immediately notifies the LIP, and obtains a verbal order for restraint/seclusion."
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record review, policy review, and interview, the provider failed to ensure the emergency departments left without being seen (LWBS) patient visits log and patient records with long times for patients to be seen by a physician were analyzed for all possible causes for one of one emergency departments (ED). Findings include:

1. Review the provider's LWBS log for January 2014 through August 19, 2014 revealed:
*33 LWBS for January.
*22 LWBS for February.
*26 LWBS for March.
*41 LWBS for April.
*48 LWBS for May.
*78 LWBS for June.
*77 LWBS for July.
*59 LWBS for August.

Review of the provider's emergency department dashboard revealed the median (middle value in a list of numbers) value for time for a patient to be seen by a physician was tracked on a monthly basis. No documentation of patient chart review for patient wait time or LWBS could be found.

Review of the provider's June 2014 reviewed Performance Improvement Plan and Participation policy revealed:
*"Departments, programs, and service lines will monitor, evaluate, and improve services and performances."
"Assessment efforts will focus on identifying variation and reducing special cause variation in the underlying processes. When analysis detects special cause variation in performance, an assessment may be completed to identify the contributory cause(s) and action plan(s) for improvement.

Interview on 8/14/14 at 11:10 a.m. with the ED medical director revealed:
*The provider monitored the daily patient average, the median time for patient visit time, and the median time for the patient to be seen by the physician.
*The median time for the patient to be seen by the physician and for patient visit time had increased in June, July, and August.
*Any outlier (times noticeably higher than the median average) patient records were not evaluated for any other causes. He felt the increase in patient load was the cause for any increases in patient wait times.
*Staffing levels in the emergency department were determining the hourly flow of patients in the emergency department.

Interview on 8/19/14 at 9:20 a.m. with the vice president of professional services revealed:
*He was not aware if outlier patient charts were evaluated to assess the cause. He could see how that would be useful.
*He knew there was a random process to evaluate LWBS but was not sure if it was documented.
*Staff turnover had been a problem for the provider.
* Provider had been using traveling nurses and float pools for staffing. Orientation of the traveling nurses and the float pool staff had been a problem. Regular staff would have to precept newer staff.

Interview on 8/19/14 at 12:45 p.m. with the director of the emergency department revealed:
*He looked at patient volume to see what was causing increases in time for the patient to be seen by the physician.
*Outlier patient charts were not reviewed for other causes for patient's increase in wait time or LWBS.
*He felt increase in patient's wait time and LWBS was strictly due to the increase in patient volume.

Interview on 8/19/14 at 2:30 p.m. with the director of risk management D revealed she thought the review of the outlier charts could have given a better understanding of what had caused the increase in LWBS.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and policy review, the provider failed to ensure emergency room staff members:
*Completed hand hygiene after completing an assessment and an intravenous (IV) start for one of two sampled (14) patients.
*Disinfected the vial rubber septum and IV port prior to administering IV medications to one of two (14) observed IV starts.
*Disinfected the glucometer after completing a fingerstick blood glucose for one of one sampled patient (14).
*Completed hand hygiene after completing a non-surgical procedure for one of one sampled patient's (15) procedure.
Findings include:

1. Observation on 8/18/14 at 1:15 p.m. of patient 14's emergency room admission revealed:
*Staff member A entered the patient's room, removed her stethoscope from around her neck, and listened to the patient's breath sounds. After completion of the process she did not disinfect the stethoscope and put it back around her neck. Staff member A then proceeded to:
-Put on a pair of clean gloves, started the patient's IV, obtained a blood sample for laboratory (lab) testing, during the process her gloves became bloody, she removed her contaminated gloves, and did not perform hand hygiene.
-Withdrew medications for pain and nausea from vials, did not clean the rubber septum on the vials, did not disinfect the IV port with alcohol, and administered IV medication for nausea and pain.
-Placed the blood glucose monitor on the patient's bed, obtained her blood sugar reading, and did not disinfect the glucometer.
-After completing the patient care exited the room without completing hand hygiene, placed the patient's chart in the physician box, and put the glucometer in the docking (charging) base.
*Two laboratory staff members entered the room during the above process, put on gloves, labeled the blood sample, removed their gloves, did not perform hand hygiene, and exited the room.

2. Observation on 8/19/14 at 9:00 a.m. of patient 15's non-surgical, closed reduction of the left patella/left tibial reduction procedure by physicians I and J revealed:
*After completing monitored anesthesia administration Physician I removed his contaminated gloves but did not do hand hygiene.
*The patient was drowsy after conclusion of the monitored anesthesia administration and physician I stepped to the side of the patient's bed, vigorously rubbed her chest, and loudly spoke the patient's name.
*The patient continued to slowly recover from anesthesia, and physician I proceeded to document on the patient's paper chart.
*Physician J at the conclusion of the patient's left patella/tibial reduction applied a left leg brace, removed his gloves, handled the patient's paper chart, and exited the room without performing hand hygiene.

3. Interview on 8/19/14 at 9:40 a.m. with the ED director regarding findings 1 and 2 confirmed:
*Staff should have disinfected the IV port with an alcohol wipe before administering medications.
*Staff should have disinfected the rubber septum on the medication vials with an alcohol wipe prior to withdrawing medications.
*The provider's handwashing compliance rate was fifty percent last month.
*All staff were expected to perform hand hygiene after removing their gloves.
*Staff should have disinfected the glucometer prior to docking it in the charger.

Review of the provider's September 2008 Hand Hygiene policy revealed:
*"Hand hygiene is generally considered the most important procedure in preventing nosocomial (infections contracted while hospitalized ) infections."
*Indications for handwashing and waterless hand cleaners include but were not limited:
-When hands were visibly dirty or contaminated with body substances.
-Before having direct contact with patients.
-After contact with a patient's intact skin.
-After removing gloves
-After contact with body fluids or excretions, mucous membranes non-intact skin, and wound dressings.
-After contact with inanimate objects in the immediate vicinity of the patient.

Review of the provider's July 2014 Point-of-Care Testing Program revealed "All shared POC (point of care) equipment must be disinfected between patients by using a germicidal wipe."