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.

WELLSTONE REGIONAL HOSPITAL 2700 VISSING PARK RD JEFFERSONVILLE, IN 47130 Jan. 7, 2016
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on document review and interview, the hospital failed to review, investigate, and resolve each grievance within a reasonable time frame for 3 of 4 patient complaints/grievances between 9/1/15 and 12/31/15 (G1, G3 & G4)

Findings:

1. Review of the policy titled Patient Advocacy Program indicated the following: Department Manager will be responsible for the following: 3.1 Discuss grievance with patient... 3.2 Investigates concerns... 3.3 Documents all investigation information and action taken. 3.4 Forwards all Patient Advocate forms to Patient Advocate Representative within one (1) working day. Patient Advocate and Representative will be responsible for the following: 4.1 Review all concerns/issues, actions taken and pursues further resolution if deemed appropriate. 4.3 In case of successful Grievance Resolution (at any level): a. maintains original patient Advocate Forms in files, and any support documentation for three (3) years. b. Gives written documentation of process to patient, family/guardian. 4.4 In case of Unsuccessful Grievance Resolution at lower level process: a. Schedule internal fair hearing within five (5) working days. e. Assure written documentation procedures as described in this policy (4.3), if problem resolved. 4.6 Will complete the following for patients who have been discharged . a. Will discuss grievance with patient... b. Investigates concerns, takes action, and provides mediation... c. Documents all investigation information and action taken. The policy was last reviewed 11/15.

2. Review of the document titled Patient Handbook Adult Services indicated the following: Complaints/Grievances; ...If you have any concerns, please talk with you physician or social worker. There are patient advocate forms located at the nurses station of each unit (if you do no see any available, please ask a staff member to provide one for you.) Once you have filled out the advocate form, it will be given to the hospital's Patient Advocate. Each complaint/grievance will be addressed in a timely manner. The document was last reviewed 10/15.

3. Review of hospital complaints/grievances between 9/1/15 and 12/31/15 indicated 4 complaints had been voiced with the following noted:
A. Grievance 1 (G1) was documented on a Patient Belongings form dated 9/11/15, and indicated an item was not returned to a patient upon discharge; discharge date not documented. Attached to the document was a sticky note dated 12/30/15 indicating a discussion of a staff member with a patient/representative requesting resolution. G1 lacked documentation of a Patient Advocate form sent to the Patient Advocate, A3, and lacked documentation of investigation or action taken on any date. Documents also lacked documentation of written process documentation given to the patient or family/guardian on any date.
B. Grievance 3 (G3) was documented on email documents dated 10/13/15 at 11:56am and indicated a phone complaint was received by A3, Patient Advocate, from a discharged patient about rude and hateful staff, facility not verifying a home medication upon admission and staff damaging/breaking a personal patient belonging. The complainant indicated he/she had filled out 4 complaint forms without getting a response. Email documentation dated 10/13/15 at 12:36pm indicated A4, Chief Executive Officer, authorized reimbursement to the patient for the item. The email also indicated patient advocate complaints that were filled out are given to the nurse manager first then escalate to the patient advocate if there is no resolution. Review of a document attached to the previous email documentation, indicated that on 10/14/15, S2, Nurse Manager, reimbursed a patient for replacement of an item "broke by staff". G3 lacked documentation of a Patient Advocate form sent to the Patient Advocate, lacked documentation of investigation information related to rude staff and patient not having home medications verified upon admission. Documents also lacked documentation of written process documentation given to the patient or family/guardian on any date.
C. Grievance 4 (G4) was documented by email documentation dated 12/9/15 at 8:38pm and indicated a nurse supervisor emailed A3 to report a family member phoned in with multiple complaints. G4 lacked documentation of a Patient Advocate form sent to the Patient Advocate, lacked documentation of investigation information and action taken and lacked documentation of written process documentation given to the patient or family/guardian on any date.

4. Review of complaint document copies provided by A3 indicated investigation information was documented as follows:
A. The back side of the Patient Belongings form of G1 indicated a nursing supervisor reported no resolution as of 1/4/15 [sic]. The document lacked documentation of written process documentation given to patient, family/guardian on any date or of an internal fair hearing scheduled.
B. G4, hand written documentation on the printed email dated 12/9/15 lacked documentation of written process documentation given to the patient or the family/guardian on any date or of an internal fair hearing scheduled.

5. On 1/7/16 at 4:00pm, A3, Patient Advocate, indicated complaints were not documented on the Patient Advocate form as they had not yet been entered into the system and that he/she did not have written documentation of follow up for 3 complaints between 9/1/15 and 12/31/15. A3 indicated only a verbal satisfaction was provided by nursing supervisors and was uncertain of which ones provided the information, but would look for that information. A3 agreed to bring copies of the complaints and any follow documentation available. At 4:50pm, A3, indicated additional information on the copies provided was documentation of follow-up to the complaints. A3 indicated he/she did not have the information available on paper, but retrieved the information from memory and added it to the documents, G1 and G4, as hand written .

6. On 1/7/16 at 5:00pm, A1, Director of Regulatory Compliance, acknowledged that A3 indicated having no written documentation of complaint investigations or action taken as follow-up and had indicated he/she recorded the dated follow from memory.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and interview, the hospital failed to provide written notice of its decision, name of the hospital contact, steps taken on patient's behalf, the results of the grievance process, and the date of completion for 3 of 4 patient complaints/grievances (G1, G3 and G4) between 9/1/15 and 12/31/15.

Findings:

1. Review of the policy titled Patient Advocacy Program indicated the following: Department Manager will be responsible for the following: 3.1 Discuss grievance with patient... 3.2 Investigates concerns... 3.3 Documents all investigation information and action taken. 3.4 Forwards all Patient Advocate forms to Patient Advocate Representative within one (1) working day. Patient Advocate and Representative will be responsible for the following: 4.1 Review all concerns/issues, actions taken and pursues further resolution if deemed appropriate. 4.3 In case of successful Grievance Resolution (at any level): a. maintains original patient Advocate Forms in files, and any support documentation for three (3) years. b. Gives written documentation of process to patient, family/guardian. 4.4 In case of Unsuccessful Grievance Resolution at lower level process: a. Schedule internal fair hearing within five (5) working days. e. Assure written documentation procedures as described in this policy (4.3), if problem resolved. 4.6 Will complete the following for patients who have been discharged . a. Will discuss grievance with patient... b. Investigates concerns, takes action, and provides mediation... c. Documents all investigation information and action taken. The policy was last reviewed 11/15.

2. Review of hospital complaints/grievances between 9/1/15 and 12/31/15 indicated 4 complaints had been voiced with the following noted:
A. Grievance 1 (G1) was documented on a Patient Belongings form dated 9/11/15, and indicated an item was not returned to a patient upon discharge; discharge date not documented. Attached to the document was a sticky note dated 12/30/15 indicating a discussion of a staff member with a patient/representative requesting resolution. G1 lacked documentation of a Patient Advocate form sent to the Patient Advocate, A3, and lacked documentation of investigation or action taken on any date. Documents also lacked documentation of written process documentation given to the patient or family/guardian on any date.
B. Grievance 3 (G3) was documented on email documents dated 10/13/15 at 11:56am and indicated a phone complaint was received by A3, Patient Advocate, from a discharged patient about rude and hateful staff, facility not verifying a home medication upon admission and staff damaging/breaking a personal patient belonging. The complainant indicated he/she had filled out 4 complaint forms without getting a response. Email documentation dated 10/13/15 at 12:36pm indicated A4, Chief Executive Officer, authorized reimbursement to the patient for the item. The email also indicated patient advocate complaints that were filled out are given to the nurse manager first then escalate to the patient advocate if there is no resolution. Review of a document attached to the previous email documentation, indicated that on 10/14/15, S2, Nurse Manager, reimbursed a patient for replacement of an item "broke by staff". G3 lacked documentation of a Patient Advocate form sent to the Patient Advocate, lacked documentation of investigation information related to rude staff and patient not having home medications verified upon admission. Documents also lacked documentation of written process documentation given to the patient or family/guardian on any date.
C. Grievance 4 (G4) was documented by email documentation dated 12/9/15 at 8:38pm and indicated a nurse supervisor emailed A3 to report a family member phoned in with multiple complaints. G4 lacked documentation of a Patient Advocate form sent to the Patient Advocate, lacked documentation of investigation information and action taken and lacked documentation of written process documentation given to the patient or family/guardian on any date.

3. Review of hospital complaints/grievances between 9/1/15 and 12/31/15 indicated 4 complaints had been voiced. Three complaints lacked indication of written documentation being given to the patient, family or guardian of decision, name of the hospital contact, steps taken on patient's behalf, the results of the grievance process, or the date of completion.

4. On 1/7/16 at 4:00pm, A3, Patient Advocate, indicated the complaints reviewed had not yet been entered into the system and therefore follow-up could not be viewed. A3 indicated he/she did not have documentation of written notice sent to patients or family/guardian for 3 of complaints (G1, G3 and G4).
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the nursing supervisor failed to ensure patient services were provided in accordance with hospital policies and procedures of Patient Belongings for 8 of 8 (P1-P8) discharged patients; Medications Brought from Home for 3 of 3 (P1, P4 & P5) discharged patients with medications brought from home; and Level of Observation and Special Precautions for 1 of 10 patients requesting evaluation (P1).

Findings:

1. Review of the policy titled Patient Belongings indicated the following: Upon discharge the staff member will ensure all items are retrieved... Staff will review the Patient Belongings form with the patient and obtain the patent signature prior to discharge. The completed form is placed in the medical record. The policy was last reviewed 8/14.

2. Review of the policy titled Discharge Process, indicated the following upon discharge: 1.3 Licensed nurse will *Obtain any brought-in medications and valuables stored... *Conduct the method for destroying medications if physician determines... *Assist the patient in gathering up personal belongings and documenting return on the Belongings Checklist. The policy was last reviewed 2/15.

3. Review of 8 (P1-P8) discharged patients medical records (MR) indicated the following:
A. P1 was admitted on [DATE], completed documentation of personal belongings on 3 Patient Belongings forms, 1 of which indicated Brought In Medications, Yes. The patient was discharged on [DATE]. The Patient Belongings forms each had initials in the Staff Initials column titled Upon Return (Patient and Staff initial that items are returned to the patient) beside each item listed. The form lacked patient initials in the Upon Return column and lacked documentation in the section titled Brought In Medications Returned. The MR lacked documentation of a Patient's Personal Medication form and return or destruction of personal medications.
B. P2 was admitted on [DATE] and completed documentation of personal belongings on 2 Patient Belongings forms. The patient was discharged on [DATE]. One of the two (1 of 2) Patient Belongings forms lacked initials in the column titled Upon Return (Patient and Staff initial that items are returned to the patient) beside each item listed. The form lacked patient initials in the Upon Return column beside each item listed and the form lacked signature in the Discharge Staff Signature/Date section.
C. P3 was admitted on [DATE] and completed documentation of personal belongings on 4 Patient Belongings forms. The patient was discharged on [DATE]. The Patient Belongings forms lacked initials in the column titled Upon Return (Patient and Staff initial that items are returned to the patient) beside each item listed. The form lacked patient initials in the Upon Return column beside each item listed and lacked signature in the Discharge Patient Signature/Date section and the Discharge Staff Signature/Date section.
D. P4 was admitted on [DATE] and completed documentation of personal belongings on 2 Patient Belongings forms, the forms lacked documentation of Brought in Medications. The MR indicated, on the form titled Patient's Personal Medications, that 5 medications were brought into the hospital by the patient and were stored in a medication safe. The patient was discharged on [DATE]. The Patient Belongings forms lacked initials in the column titled Upon Return (Patient and Staff initial that items are returned to the patient) beside each item listed. The form lacked patient initials in the Upon Return column beside each item listed and 1 of the 2 lacked signature in the Discharge Patient Signature/Date section and both lacked signature in the Discharge Staff Signature/Date section. The form titled Patient's Personal Medication lacked documentation in the column titled Upon Discharge: Send home/Destroy.
E. P5 was admitted on [DATE] and completed documentation of personal belongings on 6 Patient Belongings forms. The patient was discharged on [DATE]. The Patient Belongings forms lacked initials in the column titled Upon Return (Patient and Staff initial that items are returned to the patient) beside each item listed. The form lacked patient initials in the Upon Return column beside each item listed and lacked signature in the Discharge Patient Signature/Date section and the Discharge Staff Signature/Date section. One of the six (1 of 6) Patient Belonging forms indicated, in the the Brought In Medications section, Yes. The section on this form titled Brought In Medications Returned lacked documentation. The MR lacked documentation of a Patient's Personal Medication form and return or destruction of personal medications.
F. P6 was admitted on [DATE] and completed documentation of personal belongings on 4 Patient Belongings forms. The patient was discharged on [DATE]. The Patient Belongings forms lacked initials in the column titled Upon Return (Patient and Staff initial that items are returned to the patient) beside each item listed. The form lacked patient initials in the Upon Return column beside each item listed and lacked signature in the Discharge Patient Signature/Date section on 3 of 4 forms and in the Discharge Staff Signature/Date section on 4 of 4 forms.
G. P7 was admitted on [DATE] and completed documentation of personal belongings on 8 separate Patient Belongings forms. The patient was discharged on [DATE]. The Patient Belongings forms lacked initials in the column titled Upon Return (Patient and Staff initial that items are returned to the patient) beside each item listed. The form lacked patient initials in the Upon Return column beside each item listed and lacked signature in the Discharge Staff Signature/Date section.
H. P8 was admitted on [DATE] and completed documentation of personal belongings on 4 Patient Belongings forms. The patient was discharged on [DATE]. The Patient Belongings forms lacked initials in the column titled Upon Return (Patient and Staff initial that items are returned to the patient) beside each item listed. The forms lacked patient initials in the Upon Return column beside each item listed and lacked signature in the Discharge Staff Signature/Date section.

4. Review of the policy titled Medications Brought from Home indicated the following: Medications from home to the facility will be removed by nursing staff for identification and storage. The home medications will be listed on the Patient's Personal Medication form by the nurse. When the patient is discharged , medications will be returned to the patient or destroyed per physician order. If home medications, ordered by the physician to be returned, are not returned...attempts will be made to contact the patient. The policy was last reviewed 5/15.

5. Review of 3 (P1, P4 and P5) medical records (MR) for discharged patients who had brought medications from home indicated the following:
A. P1 was admitted on [DATE], completed documentation of personal belongings on 3 Patient Belongings forms, 1 of which indicated Brought In Medications, Yes. The patient was discharged on [DATE]. The form lacked documentation in the section titled Brought In Medications Returned. The MR lacked documentation of a Patient's Personal Medication form and return or destruction of personal medications.
B. P4 was admitted on [DATE] and completed documentation of personal belongings on 2 Patient Belongings forms, the forms lacked documentation of Brought in Medications. The MR indicated, on the form titled Patient's Personal Medications, that 5 medications were brought into the hospital by the patient and were stored in a medication safe. The patient was discharged on [DATE]. The Patient Belongings forms lacked documenation in the section titled Brought In Medications Returned. The form titled Patient's Personal Medication lacked documentation in the column titled Upon Discharge: Send home/Destroy.
E. P5 was admitted on [DATE] and completed documentation of personal belongings on 6 Patient Belongings forms. The patient was discharged on [DATE]. One of the six (1 of 6) Patient Belonging forms indicated, in the the Brought In Medications section, Yes. The section on this form titled Brought In Medications Returned lacked documentation. The MR lacked documentation of a Patient's Personal Medication form and return or destruction of personal medications.

6. On 1/6/16 at 3:15pm, A1, Director of Regulatory Compliance, indicated personal items brought in by patients being returned at discharge should be indicated on the Patient's Belongings form with the initials of both the staff member and the patient beside each item returned, that medications returned should be indicated on that same form by signature and staff initials in the Brought In Medications Returned section and that the MR for P1 did not contain the appropriate documentation. A1 also indicated the MR lacked documentation on any other form of the medication being returned or destroyed.

7. Review of the policy titled Level of Observation and Special Precautions indicated the following: All individuals who request evaluation...are monitored every 15 minutes beginning at their time of arrival. At the time an individual enters the hospital...observation rounds are begun and documented every 15 minutes using a patient observation sheet. The policy was last reviewed 5/15.

8. Review of 8 (P1-P8) discharged patients medical records (MR) and 2 inpatient MRs (P9 and P10) indicated the following: P1 was admitted on [DATE] and was discharged on [DATE]. MR review of the Close Observation Record (Q 15) indicated initial observation began on 9/28/15 at 1630 hrs with the patient in O (other) location, 2 (calm/cooperative). Q 15 observations were indicated to continue as follows: 1645 hrs O2, 1700 hrs ER (Evaluation and Referral), 1715 hrs ER, 1730 hrs ER, 1745 hrs ER, 1800 hrs ER. The time between 1800 hrs and 2300 hrs was marked with an X. Observation was documented again beginning at 2300 hrs as ER and continued at regular intervals with patient noted with various location and behavior codes. The MR lacked documentation of patient location, observation, or behavior between 9/28/15 1800 hrs and 9/28/15 2300 hrs.

9. On 1/7/16 at 5:00pm A1, verified missing initials, signatures and documentation of returned personal belongings and medications as indicated in the MR review for P2-P8. A1 also indicated the MR of P1 lacked documentation of patient location or behavior for 9/28/15 between 1800 hrs and 2300 hrs.

10. On 1/7/15 at 3:30pm, S2, Nurse Manager, indicated that if a patient was first assigned to a different unit, they may have to wait 2-3 hours to get their new room and if wanting to sleep in the mean time may sleep on a sofa with a pillow and blanket provided. S2 indicated being uncertain where a patient may be prior to being admitted to the unit. S2 indicated that information could be determined on the Q 15 Observation sheet due to all patients being observed every 15 minutes, per protocol, from the time they enter the building. S2 also indicated that if patient medications are brought from home, they are returned to the patient or destroyed. He/she indicated that if medications are destroyed, that is handled by the pharmacy and there is a form they use. S2 indicated the Patient Belongings form is not always initialed/completed due to lack of time to fully complete all forms.