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ROGERS MEMORIAL HOSPITAL 34700 VALLEY RD OCONOMOWOC, WI Nov. 8, 2012
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on medical record review, policy and procedures, and staff interview facility failed to ensure complaints of abuse are treated as patient grievances in 2 of 2 Customer Feedback forms reviewed. This can potentially affect all patients treated at this facility.

Findings include:

Review on 11/8/2012 of "Patient Grievance Procedure" last reviewed 3/21/2011 reveals that a "patient grievance is a written or verbal complaint (when the verbal complaint about the patient care is not resolved at the time of the complaint by staff present) by a patient or patient's representative regarding the patient's care, abuse, or neglect issues..."

The "Patient Grievance Procedure", does not reflect a process ensuring all verbal or written complaints of abuse, neglect, or patient harm be considered a "patient grievance" to ensure appropriate documentation, investigation, and follow up is promptly initiated and completed in situations threatening patient safety.

Per interview on 11/8/2012 beginning at 2:05 PM with Dir A, if a patient or patient's representative complaint is resolved at the time of complaint then it does not necessarily have to follow the grievance process; this includes complaints of abuse.

Review on 11/8/12 of 2 "Customer Feedback Forms" both dated 9/23/12 (no time documented) reveals that Pt #1's father reported to staff that "son is being harmed by peers and nothing is being done about it." Review of 2nd "Customer Feedback form" reveals Pt #1's mother complained that Pt #1 told her that a male peer is physically abusive and (Pt #1 stated) "he jumped on me and punched me this morning to wake me up". According to documentation, Pt #1's mother stated that (Pt #1) said peer is always coming in my room when staff is busy.

Per review on 11/8/2012 of the "Customer Feedback" policy and procedure last reviewed on 2/24/12, when a complaint or concern arises regarding services such as billing, communication, environment, food service, or program content, staff will assist the customer with immediate intervention. If the customer is not satisfied , that staff member will immediately initiate the Customer Feedback Form.

Review of the Customer Feedback forms initiated for complaints from Pt #1's mother and father in regards to abuse and harassment, reveals the facility documented complaints of abuse inappropriately on the Customer Feedback form used for facility complaints, instead of following the Patient Grievance Policy and Procedure to ensure appropriate documentation, investigation, and follow up is promptly initiated and completed.

The above finding were confirmed with Dir A and VP B on 11/8/12 beginning at 2:00 PM.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on Policy and Procedure and staff interview the facility failed to ensure that all patient's or patient's representative who file a grievance receive a written response to each grievance. This can potentially affect all patient's receiving treatment at this facility.

Finding include:

Review on 11/8/12 of "Patient Grievance Procedure" last reviewed on 3/21/2011 revealed the "Social Services staff, or designee, provides the patient/guardian/family with a written copy of results of the grievance process, if requested." This process fails to comply with regulatory standards of providing all patient's or patient's representative with a written response. No time frame for a written response is listed on the Patient Grievance Policy and Procedure.

The above findings were confirmed during interview with Dir A and VP B on 11/8/12 beginning at 2:05 PM.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on policy and procedure review, medical record review, and staff interview the facility failed to ensure all patient's receive care in an environment free from all forms of abuse and harrassment in 2 of 10 records reviewed (Pt #1, Pt #2). This can potentially effect all patient's receiving treatment at this facility.

Incident Reporting /risk Management Policy and Procedure last reviewed 3/1/2011:

Purpose: To improve the management of client care and treatment by assuring that appropriate and immediate intervention is taken on the patient's behalf and that there is a subsequent prevention of reoccurrences.

Policy: It is the policy of the hospital to document an occurrence of an incident that deviates from established policy and procedure and causes concern with staff or customers.

Definition: An incident is any occurrence, which is consistent with the routine operation of the organization or routine care of a patient and constitutes some type of risk for patients.
Procedure:

Findings Include:

Review of Pt #1's MR on 11/8/2012 beginning at 11:30 am, reveals that Pt #1 is a 9 year old boy in the 4th grade weighing 98 pounds, and 4 feet 5 inches tall. Pt #1 was admitted on [DATE] with a diagnosis of Post Traumatic Stress Disorder.

Review of Pt #2's MR on 11/8/2012 beginning at 2:20 am, reveals that Pt #2 is a [AGE] year old boy in the 8th grade weighing 164 pounds and 5 feet 4 inches tall. Pt #2 was admitted on [DATE] under emergency detention for threatening to cause injury to family members and threatening to hurt himself. According to Pt #2's Discharge Summary dated 10/16/2012, Pt #2 has a history of physical aggression towards others including legal guardian, 9 year old sibling, and neighbor. Pt #2 was cited by police in past for having physically assaulted a neighbor.

On 9/7/12 at 4:02 PM, SW E documented Pt #2 asking to be placed on the child unit because he wanted to "mess with those kids".

On 9/10/12 at 12:51 PM, RN F documented that Pt #2 began to argue and bicker with female peer and was sent out of group, Pt #2 began pounding walls and making threats to hurt the other peer.

On 9/10/12 at 1:38 PM RN F documented Pt #2 transferred to Child Unit after psych MD and program manager conferenced.

Review of Pt #2's Physician Discharge Summary dated 10/16/2012, revealed the following documentation, "Unfortunately, he had a problem with a female peer with whom he became interested in...she was threatened by his perceived advances..(Pt #2) was placed on peer restriction with her...(Pt #2)continued to have unwelcomed contact with her, becoming frustrated to the point of threatening her well-being." "As such, a decision was made by the nursing supervisor to have him transferred to the Child Unit."

Per interview with MGR C on 11/7/12 beginning at 12:05 PM, children between the ages of 4 to [AGE] years old are assigned to the Child unit, and children ages 13 to [AGE] year old are assigned to the Adolescent unit.

Per MR Review Pt #1(9yrs old) and Pt #2(13 yrs old) were assigned as roommates on the Child Unit on 9/12/2012.

Per interview with Dir A and VP B on 11/8/12 beginning at 2:00 PM, the facility does not utilize any patient assessment tools or behavior criteria in determining roommate assignments to ensure the protection and safety of all children admitted to the units. Per VP B staff receive verbal report over the phone on new admissions and a room assignment is determined at that time. Roommate assignment is normally based on age and gender. Per VP B staff usually like to have roommates similar in age and do not normally consider factors such as aggressive behavior and vulnerability for abuse in determining roommate assignments. This process fails to ensure the facility identifies patients who are vulnerable to abuse to protect these patients from all forms of abuse and harrassment.

On 9/14/2012 At 8:29 PM RN G documented that Pt #1 came out of room and reported argument with roommate, Pt #1 (9 yrs) reported roommate Pt #2 (13 yrs) choked him. Per RN G documentation Pt #2 was moved to a different room on the Child unit; Pt #1 called home and reported incident to father saying "My roommate choked Me!"

On 9/14/2012 at 8:44 PM PT H documented the following in regards to Pt #2 (13 yrs), "Patient does not get along well with roommate, (Pt #2) constantly bullies him and kicks him out of room. (Pt #2) needs multiple redirection to learn that he shares a room and needs to respect his roommates space. (Pt #2) also shows this behavior to other peers on unit."
On 9/14/12 at 9:12 PM, PT H documented on Pt #2's Patient Flowsheet Report under "Safety" assessment that Pt #2 "threatened to drag roommate out of room." No evidence of an incident report initiated to ensure proper documentation, investigation, and follow up of Pt #1's allegation of being choked and bullied by Pt #2.


On 9/15/2012 at 10:03 PM RN I documented the following in Pt #2's progress notes, "(Pt #2) needed to be separated from roommate because he was locking peer in bathroom, pushing peer on the bed, constantly bullying peer, shutting light off when roommate is trying to use bathroom, calling names and poking fun." RN I also documented, "During the gym he was throwing balls at peers face and kicking balls towards peers."

On 9/16/12 at 3:47 PM RN J documented the following in Pt #2's progress notes, "(Pt #2) is disrespectful, instigates reactivity of roommate, (Pt #2) reported that he pushed and 'choked the shit' out of roommate while glorifying aggressive behavior, (Pt #2) encouraged to maintain appropriate boundaries and refrain from harassing roommate." RN J also documented the following, "Door to room to be kept open at all times when both are in room together." Despite Pt #1 reporting being choked by Pt #2 to staff members on 9/14/2012, RN J documented, "Incident was not witnessed by staff nor reported to staff by roommate(Pt#1)." No other interventions documented to protect Pt #1 from ongoing abuse and bullying from Pt #2, despite Pt #2 admitting to assaulting and choking Pt #1.

Per interview with Dir A and VP on 11/8/12 beginning at 2:00 PM, staff unable to provide surveyor with accurate dates and documentation of when Pt #1 and Pt #2 became roommates and when they were officially separated. Per MR documentation Pt #1 and Pt #2 were briefly separated on 9/14/12 after confrontation, however according to documentation on 9/16/12 at 3:47 PM, Pt #1 and Pt #2 were still roommates.

On 9/17/12 at 12:53 PM RN K documented the following in Pt #2's progress notes, "(Pt #2) was made a no roommate due to bullying other patients including ex roommate and other peers on unit, he has not been following directions, at several occasions observed chasing peers around unit, swearing and trying to intimidate both staff and peers, he was warned multiple times that he would not be discharged if he continues with these behaviors...as day progressed (Pt #2) became louder, more defiant and trying to bully others..." Review of Pt #2's MR revealed no documentation by RN on what interventions were put in place to protect the other patients on the unit from Pt #2's aggressive behavior.

On 9/17/12 at 9:13 PM PT L documented the following in Pt #2's progress notes, "As the shift went on (Pt #2) started getting more hype, staring at peers...teasing peers."

The following is documented in progress notes by staff in regards to Pt #2's aggressive behavior:

9/18/12 1:25 PM--"(Pt #2) was redirected for pushing the day room table at a fell ow peer..."

9/19/12 1:13 PM--"during goals group swearing, making threats to staff and peers, refusing to follow directions"

9/21/12 1:20 PM "(Pt #2) refused to sit and was provoking peer, (Pt #2) became physically aggressive with peer and staff had to intervene."

9/21/12 3:34 PM "(Pt #2) Hyper, off task..swearing. Verbal altercations with peers...said he wants to fight...provokes and teases peers."

On 9/23/12 at 3:17 PM RN M documented the following in Pt #2's progress notes, "(Pt #2) had a harsh shift today...he was removed from his usual male peer friend due to the fact this male peer seemed to be stifled by this relationship and when this occurred, (Pt #2) grabbed this peer and said 'no I'm taking you hostage, you can't leave!' as staff tried to lead the rest of the group out of the dayroom when (Pt #2) refused to follow directions...when staff witnessed him bullying younger peers." RN M also documented the following, "Around 3:00 PM (Pt #2) had extreme difficulty, throwing things at staff, giggling, running down the hall...(Pt #2) was negative attention seeking and staff tried to ignore this but he only escalated his behavior, eventually tipping over tables, chairs, and then tried to hit a peer and pull her hair. Staff then called a code due to his unsafety and he ran into peers room and began throwing their belongings down the hall at staff." Per MR review, Pt #2 was calmed down after a few minutes then taken to the comfort room. Pt #2 was then instructed by staff to work on assignments in (Pt #2's) room.
Despite Pt #2's physically aggressive, unpredictable, and impulsive behavior staff continued to have Pt #2 on the Child unit and only monitor Pt #2 every 15 minutes for safety. Pt #2 did not receive increased monitoring to ensure other patients on the Child unit were protected from Pt #2 between 15 minute checks.

Review on 11/8/12 of the Safety Rounds & Suicide Precautions Policy effective 6/13/2012, reveals that "any member of the clinical staff may recommend that a patient is unsafe and institute safety precautions at a level that will provide safety for the patient." Per the policy, a 1 to 1 level of observation (continuous observation) will be used in circumstances when less restrictive methods are ineffective, reasons for this level of observation include but are not limited to: imminent risk of bodily harm to self or others, imminent risk of other types of purposeful or inadvertent injury.

Per review of Pt #1's Customer Feedback form dated 9/23/12 (no time documented), Pt #1's father called staff and complained that Pt #1 "is getting harmed by peers and nothing is being done about it." Per documentation father wants to sign out Pt #1 AMA(against medical advice) in response to Pt #1's complaints. Staff interventions documented on customer feedback form state, staff explained to Pt #1's father that (Pt #1) "will sleep in the comfort room tonight and be closely monitored, separated from peer until allegations are substantiated."
Documentation on Pt #1's Customer Feedback Form dated 9/23/12 reveals on 9/24/12 Pt #2 was moved "to the Adolescent hallway to sleep" as a follow-up intervention documented in response to Pt #1's allegation of abuse on 9/23/12. Pt #2's MR shows no documentation of the exact time Pt #2 was moved back to the Adolescent Unit.

On 9/24/12 1:59 PM, RN J documented that Pt #2 expressed frustration related to room change to the Adolescent hallway and began acting out, threatening and taunting staff. Pt #2 was place in comfort room.
During surveyor tour on the unit on 11/7/12 beginning at 12:00 PM observed the comfort room, which could be accessed from a door on the Adolescent Unit or a door on the Child Unit. These doors are locked from the outside only. Per interview with Dir A and VP B on 11/8/12 beginning at 2:00 PM, on 9/24/12, once in the comfort room Pt #2 was able to run from staff onto the Child Unit and run into Pt #1's room with staff running behind.
Per incident report dated 9/24/12 (no time documented), staff witnessed "(Pt #2) run into (Pt #1's) room and the staff run behind (Pt #2), the staff seen (Pt #2) holding (Pt #1) in a head lock with his arm around (Pt #1's) neck, this staff called out for assistance." Per review of this incident report, as a correction strategy Pt #2 was finally placed in a 1 to 1 observation monitoring and removed again from the Child Unit. Per Pt #2's Discharge Summary, Pt #2 received a disorderly conduct ticket from the police department for assaulting Pt #1.

Per interview with MGR C, Dir A, and VP B on 11/8/12 beginning at approximately 2:00 PM, MGR C was unable to provide surveyor with evidence that a comprehensive investigation was initiated in regards to the events surrounding the above incident report. Per staff the facility does not have a policy and procedure for investigating allegations of patient on patient abuse and/or harrassment. This deficient practice fails to ensure all staff are knowledgeble on how to conduct a proper investigation to ensure all appropriate actions are taken.

The above findings were confirmed with Dir A and VP B on 11/8/12 beginning at 2:00 PM.