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.

SOUTHSIDE REGIONAL MEDICAL CENTER 200 MEDICAL PARK BOULEVARD PETERSBURG, VA 23805 Sept. 27, 2012
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, document review, and staff interview, the facility staff failed to ensure the use of a Posey enclosed bed restraint was used in accordance with a written plan of care for one of two patients observed in restraints, Patient # 12.

Findings:

Patient # 12 was observed on 9/25/2012 at 2:50 p.m. inside a Posey enclosed bed. The patient was agitated and hitting himself on top of his head. Patient # 12 was also observed 9/26/2012 at 3:00 p.m. inside the Posey enclosed bed, calm and was in no distress. RN # 8 was interviewed at this time and she stated the Posey enclosed bed was a restraint, and was used for the patient's safety due to "wandering." The patient was admitted on [DATE] and the original order for a physical restraint was dated 8/04/2012.

The patient's clinical record was reviewed and it included physician's orders for the Posey enclosed bed restraint for patient safety. The clinical record did not include interventions or alternate methods used to reduce the use of the restraint. The patient's plan of care stated that the restraint was discontinued on 8/15/2012. The physician's orders and restraint flow sheets evidenced the patient remained in the Posey enclosure bed after that date through 9/26/2012. The RN Unit Manager (RN # 8) stated the restraint was discontinued for a short period of time when the patient was transferred to the ICU unit, but was in continuous use while on Unit 5. The Unit Manager stated the care plan did not include the use of the Posey enclosure bed. The clinical record also did not evidence documentation of the patient's release from the restraint, frequent ambulation with staff, activity or alternates attempted to reduce the use of the restraint.

The facility policy (Restraint Seclusion) stated: "...6. Use of restraints shall be added to the patient's plan of care." The facility policy "Nursing Plan of Care" stated all patient care was based on a comprehensive assessment completed by a registered nurse. No reason was provided during the survey related to the deletion/omission of the use of a restraint on Patient # 12's plan of care.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on a review a review of the grievance process, record review and interview, the facility staff failed to ensure patient grievances were investigated, reviewed or delegated appropriately. The Governing Body failed to ensure an effective operation of the grievance process.

Findings:

1. The facility's governing body did not ensure an adequate process was implemented for the hospital's grievance process and did not provide an adequate overview of the process. The governing body appointed the Performance Improvement Committee as responsible for the oversight of patient grievances. The Performance Improvement Committee did not include the Director of Patient Relations-the individual identified as being responsible for the entire grievance policy implementation. The facility did not have a formal Grievance Committee that routinely met to review or to track and trend grievances and complaints. The Grievance Committee was an "ad hoc" committee that met when the Director of Patient Relations "needed guidance."

2. Grievances were not investigated, documented, and a written response to the allegations were not sent to the complainant. Five grievances filed by patient's or family's were reviewed with the Director of Patient Relations. The Director of Patient Relations stated she was the person responsible for a written response to the complainants. No evidence of this process being completed was presented during the survey. During the course of a complaint investigation, the facility's grievance process was reviewed. The grievance log was requested on 9/25/2012. On 9/26/2012 at 8:30 a.m. the Director of Patient Relation was interviewed and she identified herself as responsible for processing patient complaint/grievances. The grievance log was again requested.

The Director of Patient Relations was interviewed on 9/26/2012 at 2:35 p.m. and presented grievances she identified as having received. The grievances included allegations reported by Patient # 1's family member. The documented grievance stated Patient # 1's family verbally complained of the patient's care. The grievance did not include an investigation of the allegations related to inadequate care. The Director of Patient Relations stated she spoke in person to Patient # 1's family, and she stated "I vaguely remember he may have called back after the patient was discharged ." This telephone interaction was not documented by the Director of Patient Relations. No evidence of an investigation was presented during the survey. Evidence of an investigation of the family member's allegations was requested. The Patient Relations Director stated she did not document the investigation, she "told" the ICU nurse of the allegations. The Director also stated that she felt the family member was her son-in-law, who "seemed to know a lot about" the patient, including wound and personal information. No further evidence of an investigation of a family members allegations were presented during the survey. The documents presented by the Director of Patient Relations did not evidence an investigation of the Complainants allegations, steps taken by the hospital to investigate the allegations, a contact person, further steps the Complainant may take if not satisfied, or a date of completion of the grievance process.

Patient # 16 filed a grievance, an allegation she was "pushed" by a nurse. Patient # 16's allegation of abuse was not investigated. On 12/15/2011 Patient # 16 filed a grievance and spoke with the Director of Patient relations. Patient # 16 alleged that her nurse pushed her. The complaint investigation was not documented in the grievance file. The investigation and resolution was requested of the Director of Patient Relations. The Director stated she did not investigate it as an abuse allegation, and sent the grievance information to the Unit Manager to review. Evidence that this patient's allegation of a nurse pushing her was investigated, was requested. No evidence of an investigation was presented during the survey. No evidence that the Administrator was informed of an abuse allegation was presented during the survey. The complaint intake form documented the Director of Patient Relations did not contact the patient regarding her grievance until "1/02/12", and the complaint was documented as resolved this same date. No reason for the delay in contacting the complainant was provided. The facility policy stated a written response to complaints/grievances would completed within 7 days. No evidence was presented that this patient received written notification of her allegations, a date of resolution, steps to take if not satisfied with the investigation, or a person to contact if needed. The Director of Patient Relations stated "I didn't take it that way", when asked why Patient # 16's allegation of abuse was not investigated or processed as an allegation of abuse.

Patient # 17's family filed a grievance on 2/20/12 regarding pain control, care, and an allegation of a nurse diverting narcotics prescribed to this patient. These allegations were not investigated. The grievance did not include evidence the allegations were investigated and no written response was sent to the Complainant. Additional evidence was requested of the Director of Patient Relations, but was not presented during the survey.

No Complainant reviewed received a written response to his/her allegations. Patient/family grievances were not investigated, allegations and grievance intake was not documented, and Complainants were not given a written resolution to complaints. The Complainants were not given additional information regarding the nature of the complaint/grievance investigation, the steps taken to investigate their allegations, a hospital contact person, and a date of resolution.

The facility's policy "Patient Concerns and Complaints" stated that within a patient's issue cannot be resolved at the time of receipt, a written response will be provided within 7 days, unless extenuating circumstances prevented completion of this time frame. No extenuating circumstances were documented for any reviewed grievance. The policy stated that with each written response would also include the name of the hospital contract person, steps taken to investigate the grievance, results of the process and a date of completion. No reason for not implementing this policy was provided.

3. The Grievance Committee consisted of one individual responsible for reviewing and investigating and the documentation of a complaints/grievances resolution-the Director of Patient Relations. The Grievance Committee was an "ad hoc" committee that did not meet regularly, did not review complaints/grievances for tracking and trending of complaints or appropriateness of action taken. The facility's Administrator did not provide oversight of the grievance process. The Director of Patient Relations reported directly to the Administrator. The Director of Patient Relations was interviewed on 9/26/2012 and she stated the Grievance Committee is convened only "When I need input", is "convened as needed." The Administrator (CEO) was interviewed on 9/26/2012 at 3:40 p.m. and he stated he did not review every grievance and was only aware "as needed basis", if the grievance reached a higher level of required investigation. The CEO stated that he was unaware of Patient # 16's allegations that a nurse pushed her-as he did not review this allegation and was not informed by the Grievance Committee-the Director of Patient Relations. The CEO was not knowledgeable that written response to filed grievances was not being completed.

No further information was provided to evidence compliance with the ensuring the grievance process and complaint resolution process was appropriately reviewed and processed.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on a complaint investigation, interviews and document review, the hospital staff failed to ensure each patient or their representative was provided a written notice of grievance decisions, hospital contact person's name, steps taken to investigate the grievance, the results of the process and the date of completion for five of 5 grievances reviewed.

Findings:

The facility's grievance procedure was reviewed during an onsite inspection 9/25/12 through 9/28/2012.

Grievances were not investigated, documented, and a written response to the allegations were not sent to the complainant. Five grievances filed by patient's or family's were reviewed with the Director of Patient Relations. The Director of Patient Relations stated she was the person responsible for a written response to the complainants. No evidence of this process being completed was presented during the survey.

The Director of Patient Relations was interviewed on 9/26/2012 at 2:35 p.m. and presented grievances she identified as having received. The grievances included allegations reported by Patient # 1's family member. The documented grievance stated Patient # 1's family verbally complained of the patient's care. The grievance did not include an investigation of the allegations related to inadequate care. The Director of Patient Relations stated she spoke in person to Patient # 1's family, and she stated "I vaguely remember he may have called back after the patient was discharged ." This telephone interaction was not documented by the Director of Patient Relations. No evidence of an investigation was presented during the survey. Evidence of an investigation of the family member's allegations was requested. The Patient Relations Director stated she did not document the investigation, she "told" the ICU nurse of the allegations. The Director also stated that she felt the family member was her son-in-law, who "seemed to know a lot about" the patient, including wound and personal information. No further evidence of an investigation of a family members allegations were presented during the survey. The documents presented by the Director of Patient Relations did not evidence an investigation of the Complainants allegations, steps taken by the hospital to investigate the allegations, a contact person, further steps the Complainant may take if not satisfied, or a date of completion of the grievance process.

Patient # 16 filed a grievance, an allegation she was "pushed" by a nurse. Patient # 16's allegation of abuse was not investigated. On 12/15/2011 Patient # 16 filed a grievance and spoke with the Director of Patient relations. Patient # 16 alleged that her nurse pushed her. The complaint investigation was not documented in the grievance file. The investigation and resolution was requested of the Director of Patient Relations. The Director stated she did not investigate it as an abuse allegation, and sent the grievance information to the Unit Manager to review. Evidence that this patient's allegation of a nurse pushing her was investigated -was requested. No evidence of an investigation was presented during the survey. No evidence that the Administrator was informed of an abuse allegation was presented during the survey. The complaint intake form documented the Director of Patient Relations did not contact the patient regarding her grievance until "1/02/12", and the complaint was documented as resolved this same date. No reason for the delay in contacting the complainant was provided. The facility policy stated a written response to complaints/grievances would completed within 7 days. No evidence was presented that this patient received written notification of her allegations, a date of resolution, steps to take if not satisfied with the investigation, or a person to contact if needed. The Director of Patient Relations stated "I didn't take it that way", when asked why Patient # 16's allegation of abuse was not investigated or processed as an allegation of abuse.

Patient # 17's family filed a grievance on 2/20/12 regarding pain control, care, and an allegation of a nurse diverting narcotics prescribed to this patient. These allegations were not investigated. The grievance did not include evidence the allegations were investigated, no written response was sent to the Complainant. Additional evidence was requested of the Director of Patient Relations, but was not presented during the survey.

No Complainant reviewed received a written response to his/her allegations. Patient/family grievances were not investigated, allegations and grievance intake was not documented, and Complainants were not given a written resolution to complaints. The Complainants were not given additional information regarding the nature of the complaint/grievance investigation, the steps taken to investigate their allegations, a hospital contact person, and a date of resolution.

The facility's policy "Patient Concerns and Complaints" stated that within a patient's issue cannot be resolved at the time of receipt, a written response will be provided within 7 days, unless extenuating circumstances prevented completion of this time frame. No extenuating circumstances were documented for any reviewed grievance. The policy stated that with each written response would also include the name of the hospital contract person, steps taken to investigate the grievance, results of the process and a date of completion. No reason for not implementing this policy was provided.

No further information was provided to evidence compliance with the ensuring the grievance process and complaint resolution policy was implemented.
VIOLATION: PATIENT RIGHTS: ACCESS TO MEDICAL RECORD Tag No: A0148
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a complaint investigation, document review, and interview, the facility staff failed to ensure one of 16 patients reviewed received the medical record upon written request, Patient # 1.

Findings:

Patient # 1 made a written request for her medical record on 8/8/2012. Patient # 1 presented in person to the medical records department on 8/8/12 and signed the required form "Authorization to Use and Disclose Protected Health Information," and requested: "Progress notes, emergency room records, discharge summary, history and physical, consultations, lab, pathology report, operative notes, imaging/Xray, entire record." The document also stated "34" pages were released to the patient. This document was (MDS) dated [DATE] at 10:15 a.m. by the Director of Health Information Management. The Director was interviewed at this time and she stated only 34 pages of the patient's record was released to the patient. The Director stated the record was much more than 34 pages. The Director stated she was unsure why the entire chart was not released to the patient, and that it was procedure to release the documents requested by the patient.

No reason was provided during the survey to evidence the facility policy was implemented, or that the patient was provided the medical records requested.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0186
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, document review, and staff interview, the facility staff failed to ensure alternatives or other attempted less restrictive interventions , for one of two patients observed in restraints, Patient # 12.

Findings:

Patient # 12 was observed on 9/25/2012 at 2:50 p.m. inside a Posey enclosed bed. The patient was agitated and hitting himself on top of his head. Patient # 12 was also observed 9/26/2012 at 3:00 p.m. inside the Posey enclosed bed, calm and was in no distress. RN # 8 was interviewed at this time and she stated the Posey enclosed bed was a restraint, and was used for the patient's safety due to "wandering." The patient was admitted on [DATE] and the original order for a physical restraint was dated 8/04/2012.

The patient's clinical record was reviewed and it included physician's orders for the Posey enclosed bed restraint for patient safety. The clinical record did not include interventions or alternate methods used to reduce the use of the restraint. The patient's plan of care stated that the restraint was discontinued on 8/15/2012. The physician's orders and restraint flow sheets evidenced the patient remained in the Posey enclosure bed after that date through 9/26/2012. The RN Unit Manager (RN # 8) stated the restraint was discontinued for a short period of time when the patient was transferred to the ICU unit, but was in continuous use while on Unit 5. The Unit Manager reviewed the restraint and stated the care plan did not include the use of the Posey enclosure bed. The clinical record did not evidence documentation of the patient's release from the restraint, frequent ambulation with staff, activity or alternates attempted to reduce the use of the restraint.

The facility policy (Restraint Seclusion) stated: "...4. All efforts should be made to avoid restraints if patient safety may be maintained with out the use of restraints"...6. Use of restraints shall be added to the patient's plan of care." The policy also stated: "Attempts should be made to evaluate and use interventions/alternatives when possible and in response to the patient's assessed needs:..." The policy listed eleven potential alternatives to attempt to reduce the use of a restraint. The clinical record did not include documentation to evidence these alternatives were attempted. No further documentation was provided during the survey to evidence alternatives or less restrictive interventions to a Posey enclosed bed restraint was attempted.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on record review and interview, the facility's infection control practitioner failed to ensure communicable diseases were reported to the department of health. Communicable diseases were not reported to the health department. The hospital's process for reporting diseases to the infection control practitioner was not implemented.

Findings:

Clinical record review for one patient, Patient # 1 revealed the patient was diagnosed with gonorrhea on 7/11/2012. The clinical record did not evidence the diagnosis was reported to the health department per hospital policy and the Code of Virginia-"Reporting of the following diseases is required by state law (Sections 32.1-3UU6UH and HU32.1-3UU7UH of the Code of Virginia and 12 VAC 5-90-80 and 12 VAC 5-90-90 of the Board of Health Regulations for Disease Reporting and Control - HUhttp://www.vdh.virginia.gov/epidemiology/regulations.htmUH). Gonorrhea was included on this list.(http://www.vdh.virginia.gov/epidemiology/documents/pdf/Reportable_Disease_List.pdf, accessed 10/02/2012 at 10:33 p.m.).

The infection control practitioner (Employee # 29) was interviewed on 9/27/2012 at 8:55 a.m. and evidence this particular disease was reported as required. Employee # 29 stated the disease was supposed to be reported, and she was the employee responsible for reporting to the health department. On 9/27/2012 at 12:40 p.m. Employee # 29 was interviewed and she stated that the diagnosed disease was not reported as she had not received the positive lab reports. Employee # 29 reviewed the positive laboratory reported and stated the positive results should have been reported. Employee # 29 stated she had not received positive gonorrhea results as the "system" did not automatically send the results to her fax/e-mail. The infection control practitioner could not state how long this system did not report these positive results or how many/what positive results had not been reported to her and subsequently to the health department.
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
Based on document review and interview, the agency staff failed to ensure a list of Home Health Agency's available to the patient to each patient identified as requiring post discharge home health services. The hospital did not present a list of available home health agency's to patients that were private pay or charity.

Findings:

A review of discharged patient records failed to evidence that a list of available home health agency's was provided to each patient identified as requiring home health services upon discharge. Patient # 1's discharge planning included the assessed need and physician's order for post-hospital home health services for wound care. The clinical record did not include evidence that the patient was provided a choice of agency's, or that available agencies were presented to the patient.

On 9/27/2012 at 8:50 a.m. a discharge planner/case manager (Employee # 27) was interviewed regarding the hospital's policy regarding home heath agency referrals to patients. Employee # 27 stated that patient's who were not Medicare patients did not receive a list of available home health agencies. Employee # 27 stated if patient's were private pay or charity cases, the patients were automatically referred to/transferred to the services of the hospital's own HHA.

The Director of Social Services (Employee # 28) was interviewed on 9/27/2012 at 9:12 a.m. regarding the hospital policy on HHA referral options. The Director was informed of Employee # 28's statement and actions related to private pay or charity patient's referrals to the hospital's own HHA. The Director stated that each patient should be provided a choice of HHA. The Director stated the hospital's own agency provided these services at a reduced or no fee to these patients.