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.


Based on interview, record review and the hospital policy review, hospital staff failed to follow the hospital Risk Management program related to grievances and incident/event reporting for 1 of 10 patient records reviewed, Patient #1, as evidenced by staff failing to identify an allegation of abuse as a reportable incident and failure to respond timely to a grievance involving Patient #1.

The findings include:

Review of the March 2016 Grievance Log revealed an entry dated 03/02/16 submitted by Patient #1 and signed as received by the therapist on the same date. The grievance addresses an allegation of physical abuse on 02/29/16 made by Patient #1 against the Mental Health Technician (MHT) (Employee #A). Patient #1 is a minor under the age of 18 who was admitted on [DATE] to the psychiatric hospital and is receiving inpatient treatment mandated by the court for illegal drug use. Patient #1 resides on the "Boys Residential Treatment Unit" and his mother is listed as his guardian. Review of the nurses notes, therapy notes and physician progress notes dated 02/29/16, 03/01/16, and 03/02/16 did not reveal any documentation related to the allegation. Patient #1 was discharged from the facility 03/29/2016.

On 05/17/16 at 3:30 PM an interview was conducted with the Risk Manager (RM) and a request was made to review the incident report related to the allegation of abuse by
Patient #1. The RM provided the following information ,"An incident report was not completed by the staff at the time of the incident. I was notified of the incident on 03/04/2016 when the mother of the patient called the facility regarding the allegation of physical abuse. I completed an incident report at that time. The therapist who accepted the written allegation should have notified the family and filled out an incident report."

An interview was conducted with the Patient Advocate on 05/18/16 at approximately 11:30 AM in the presence of the RM. The Patient Advocate, who is a registered nurse (RN) states that she is the person responsible for investigating the facilities' grievances and that the staff submits them directly to her. The Patient Advocate stated that she received the grievance related to Patient #1 on 03/03/16 and began her investigation by interviewing Patient #1 on 03/03/16. She further stated,"The grievance form had limited information on it and I personally spent time and interviewed the patient. After the interview, I asked him to summarize the event in writing. When I reviewed what the patient had written, it was not the same as what he told me during the interview. I discussed the grievance with the management team and the RM on 03/04/2016. "I did not speak directly to the mother of the patient." The patient advocate acknowledged that an incident report should have been completed and neither she or the RM could explain why it it was not. When asked to provide her written documentation of communication or resolution of the grievance, she produced a letter dated 04/08/16 with a Fedex shipping air bill dated 04/11/16. The letter is dated 35 days after the grievance and 10 days after Patient #1 was discharged from the facility and the air bill is dated 38 days after the grievance and 13 days after discharge. The patient advocate stated, "I did not follow up sooner because I was waiting for DCF and the management staff to complete their investigation.". When asked if she communicated this to the patient or the family prior to the letter, she stated, "No".

During an observation tour on 05/18/16 at 2:30 PM, interviews were conducted with the staff working on the Oceanside Unit. The Oceanside Unit is where the adolescents (boys) are housed who are enrolled in the residential treatment program. The interviews were conducted individually for all employees (3) working on the unit. The unit staff consisted of an RN (Employee #F), a MHT (Employee #G) and a therapist (Employee #H). The staff interviews were conducted inquiring what they considered to be a reportable incident. The interviews conducted with the various staff members, all of which did not recite that physical abuse allegations were a reportable incident.

On 5/17/16 at 1:45 PM. the personnel records of all the employees who were interviewed on 5/18/16 were reviewed with the Director of Human Resources in the presence of the Chief Nursing Officer (CNO). All employees had documentation of up to date in-servicing on Risk Management and Incident/Event Reporting. The CNO stated during the review that the clinical staff should be able to articulate what would be a reportable incident.

On 05/18/16 at 4:00 PM, the RM acknowledged that the therapist who received the grievance, and the Nurse Supervisor, RN on duty at that time failed to follow hospital protocol and policy related to the reporting and documenting of a reportable incident. She further stated that the individual staff who witnesses or discovers a event out of the ordinary should fill out an incident report. She stated,"All staff have training in this area, we will reeducate the staff on this issue. If the staff had filled out an incident report, the mother would have been notified at the time of the allegation."

Review of the hospital policy titled, "Occurrence Reporting System", states in part, "Occurrence (Incident Type): That which is not consistent with the routine care of a patient and/or the desired operations of the facility. The results of this event require or could have required unexpected medical intervention, unexpected intensity of care, or had the potential to cause unexpected physical or mental impairment. Any facility employee or staff member who discovers, is directly involved in or is responding to an event/occurrence is to complete or direct the completion of a Healthcare Peer Review (HPR/occurrence) form."

A review was completed of the "Policy Statement" of the facility's Internal Risk Management Program. "The program promotes well being and health of patients, visitors and employees. All employees have a responsibility for safety, health and well being of patients, visitors and fell ow employees. All employees have an affirmative duty to report incidents to the administration , through reporting mechanisms." A review was completed of the facility's policy, "Internal Incident Reporting System", which defines Patient Grievance as any written complaint by a patient relating to patient care or the quality of medical services.

A review was completed of the facilities policy, "Patient/Resident and Family Grievances/The Role of the Patient/Resident Advocate". The following information is documented in the policy, "The Patient /Resident Advocate responding to the grievance shall inform the patient/resident or family the timeframe within which he/she shall expect follow up. This time frame shall not exceed 7 days unless there are extenuating circumstances, at which point the patient/resident shall be notified of the need for an expended time frame and an agreement made as to when follow up will occur. Responsibilities include ensuring appropriate written feedback is provided to the individual presenting the grievance."

An additional review was completed of the policy, "Reporting of Actual or Suspected Abuse or Neglect of a Child, Elder or Handicapped / Disabled Person." The following information was obtained from the policy,"If the patient is a minor or has a guardian, the guardian will be notified." At the time of exit, on 05/18/16 at approximately 4:15 PM, the facility was unable to provide any written documentation of the notification of the guardian of the allegation of abuse made by Patient #1(adolescent). The RM confirmed the findings and stated,"The family should have been notified regarding this event."