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.

HILLCREST MEDICAL CENTER 1120 SOUTH UTICA AVENUE TULSA, OK 74104 June 12, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review and interview the Governing Board failed to:

I . ensure consultative sessions between the Governing Body (Advisory Board), or their designee, and the President of Medical Staff were conducted and correspnding policies were developed.

These failed practices resulted in the lack of action plans being developed regarding the scope and complexity of hospital services, patient populations serviced, the identification of patient safety and quality issues, and had the potential for other issues that required Medical Staff input to go unrecognized, unpursued, and result in missed quality opportunities to improve patient outcomes.(Refer Tag A-0053)


II. protect the physical well-being and security of patients and staff, and to provide a safe environment that was free from hazards especially in regard to securing contraband from patients at risk of harming themselves or others.

These failed practices posed immediate jeopardy to the patients' health and safety when the ED staff took 5 hours and 13 minutes to remove contraband from one patient (Patient #8) out of a sample of five suicidal self-harm patients, who attempted suicide twice by ingesting pills and slit his/her wrist while under the supervision of the Emergency Department staff, and the likelihood of safety risks for all patients with self harm or harm to others and staff and visitors exposed to these risk. (Refer to A-0144)


III. establish clear expectations for the Leadership involved in quality and risk management initiatives, a Quality Program Scope was developed which included the identification and management of all patient grievances according to hospital policies, and establish a Quality Program Scope and developed Program Activities which ensured patient safety events, medical errors and adverse incidents were thoroughly investigated, causes analyzed, preventative action plans implemented, and effectiveness of measured outcomes evaluated.

These failed practices resulted in:

A. deficient incident reporting provided to the Advisory Board for the 894 incidents which occurred from 01/01/18 to 06/11/18, therefore, the Governing Body lacked sufficient information to make informed decision related to the provisions of quality patient care, and resulted in improvement opportunities not to be identified, analyzed for causes, and the implementation of preventative measures to improve patient outcomes. (Refer to Tag A-286)
B. in five (Patient #25, 26, 27, 28 and 29) of 11 grievances not identified, increased the likelihood of other grievances to be unidentified, and for the 172 grievances which occurred from 06/05/17 to 06/05/18 to not be processed through the quality improvement program. (Refer to Tags A-0118, A-0119, and A-0123)
VIOLATION: CONSULTATION WITH MEDICAL STAFF Tag No: A0053
Based on record review and interview, the Governing Body failed to ensure:

a. a policy was implemented that required formal consultations to be conducted with themselves or their designee and the President of the Medical Staff (or staff responsibile for the organization and conduct of the medical staff) with topics including, but not limited to: scope and complexity of hospital services, patient population serviced, identified issues with patient safety and quality that required participation and input of the Medical Staff at minimum biannually.

b. consultative sessions were conducted between themselves or their designee and the President of Medical Staff.

These failed practices resulted in the lack of action plans being developed regarding the scope and complexity of hospital services, patient populations serviced, the identification patient safety and quality issues, and had the potential for other issues that required Medical Staff input to go unrecognized, unpursued, and result in missed quality opportunities to improve patient outcomes.

a. Policy

On 06/12/18 at 11:45 am, the surveyors requested a policy that designated the requirements of formal consultations between the Governing Body and the President of Medical Staff, the topics to include, but not limited to: scope and complexity of hospital services, patient population serviced, and identified issues with patient safety and quality of care that required participation and input of the Medical Staff, and none was provided.

A review of the " Medical Staff By-laws (dated11/14)" showed the duties and responsibilities of the President of the Medical Staff did not include formal consultative sessions with the Governing Body, at minimum, biannually.

On 06/12/18 at 11:45 am, Staff A, (CEO) stated the hospital did not have a policy regarding formal consultations between the Governing Body and the President of Medical Staff.


b. Consultative Sessions

A review of the documents titled, "Advisory Board" for 05/19/18, 01/15/18, 01/26/18, 02/23/18, and 04/27/18 showed no documentation regarding formal consultative sessions between the Board and the President of Medical Staff regarding scope and complexity of hospital services, patient population serviced, and identified issues with patient safety and quality of care that required participation and input of the Medical Staff. the minutes did show the Chief Executive Officer (CEO) was member of the Advisory Board.

On 06/12/18 at 11:45 am, Staff A, (CEO) stated the President of Medical Staff met informally in his/her office regarding quality matters. The surveyors requested the documentation of these informal meetings or evidence of quality initiatives; none was provided.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, interview, and observation, the hospital failed to:

I. ensure grievances were identified, investigated, and written responses that included investigational process and outcome for five (Patient #25, 26, 27, 28, and 29) of nine grievances, and ensure Governing Body provided oversight for the grievance process.

This failed practice resulted in five (Patient #25, 26, 27, 28 and 29) incidents to not be identified as grievances and increased the likelihood to neglect or omit reported incidents pertaining to patient safety and quality of patient care to go unnoticed and reporting inaccurate information to Governing Body. (Refer to Tags A-0118, A-0119 and A-0123)


II. ensure allegations of verbal and/or physical abuse and harassment were investigated and acted upon. This occurred in two (Patient #25 and 26) of five incidents identified as grievances.

This failed practice had the likelihood to increase the risk for abuse to occur for all patients who sought care at the hospital. (Refer to Tag A-0145)


III. Safe Setting

Based on record review and interview the hospital failed to:

A. recognize, monitor, and ensure the safety for one patient (Patient #8) out of a sample of five ED patient medical records reviewed with thoughts of suicide, self-harm and/or harm to others who entered the emergency department (ED).

This failed practice resulted in serious harm to one patient (Patient #8) out of a sample of five suicidal self-harm patients and the likelihood to cause serious harm to patients presenting to the ED with thoughts of self-harm and/or harm to others.


B. protect the physical well-being and security of patients and staff, and to provide a safe environment that was free from hazards in regard to securing contraband from patients at risk of harming themselves or others.

These failed practices posed immediate jeopardy to the patients' health and safety when the ED staff took 5 hours and 13 minutes to remove contraband from one patient (Patient #8) out of a sample of five suicidal self-harm patients, who attempted suicide twice by ingesting pills and slit his/her wrist while under the supervision of the Emergency Department staff, and the likelihood of safety risks for all patients with self harm or harm to others and staff and visitors exposed to these risk.

Refer to Tag A-0144


Summary of Immediate Jeopardy

On 06/05/18, 06/06/18, 06/07/18, 06/08/18, 06/11/18, and 06/12/18, the Oklahoma State Health Department surveyors conducted unannounced complaint surveys (OK 1774 and OK ).

On 06/07/18 at 11:30 am, the surveyors contacted Oklahoma State Department of Health to advise of the Immediate Jeopardy findings for:

482.13 Condition of Participation: Patient Rights, and

482.55 Condition of Participation: Emergency Services


On 06/07/18 at 11:57 am, The Oklahoma State Department of Health notified the CMS Regional Office of the Immediate Jeopardy findings. The Regional Office concurred that Immediate Jeopardy conditions existed.

On 06/07/18 at 12:26 pm, the CEO and members of the hospital leadership team were notified of the Immediate Jeopardy conditions identified in Emergency Department and non-psychiatric in-patient units regarding patients for harming self or others and the searches for contraband.


On 06/11/18 at 11:00 am, the hospital submitted an acceptable written plan of removal consisting of:

* Improved methods for identifying at risk patient populations for harming self or others were implemented in the Emergency department and all in-patient non-psychiatric units.

* Revised policies and practices for patient belonging searches for contraband and for providing sitters for at risk patients upon the patient presentation.

* Conducted clinical (including physicians) and clerical education on all shifts for the Emergency Department and all in-patient units regarding new policies and practices for patient belonging searches for contraband and for providing sitters for at risk patients upon presentation, and planned to continue to education until 100% staff was obtained.

* Implemented increased quality monitoring to include every two hour House Supervisor rounding to evaluate identified at risk patients and ensure new search of patient belongings and sitter policies and practices had been instituted.

* Implemented Rapid Improvement Project that included ensuring patient belonging searches and sitters for at risk patient with measurable indicators, had begun gathering daily data, analyzing the data, and implementing action plans.

* Presented the Rapid Improvement Project to the Governing Board and it was approved for implementation.

* Developed continued reporting processes to Quality and Medical Executive committees and Governing Body.


On 06/11/18 at 11:15 am, the surveyors verified the removal of immediacy by:

* reviewing the list of current in-patients and ED who were identified at risk for harming self or others.

* verified through interview that the House Supervisors would utilize the at risk list, keep-it updated, and use the list to perform the every two hour patient checks.

* reviewing acceptable policies regarding searches and sitters for high risk population for harming self or others.

* reviewing acceptable staff re-education rosters regarding searches and sitters for high risk population for harming self or others and accepted plan for capturing 100% of all staff and ED providers.

* reviewing acceptable quality monitoring measures which assigned House Supervisors surveillance responsibilities to include ensuring at risk patients were searched at arrival to the ED, contraband removed and secured, and ensured the environment and monitoring was appropriate to meet the patient's needs.

* reviewing the initial rounding data from the House Suprvisor's rounding surveillance and verified the information was communicated to leadership.

* interviewed six ED staff regarding their knowledge of policy changes and re-education provided for the management of high risk population for harming self or others.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record review and interview, the hospital failed to ensure grievances were appropriately identified for five (Patient #25, 26, 27, 28 and 29) of nine grievances and adhered to policy and procedures established for grievances.

This failed practice resulted in five (Patient #25, 26, 27, 28 and 29) incidents not identified as grievances and increased the likelihood of incidents affecting patient safety to go unnoticed and processes for improvements not implemented.

Findings:

Review of hospital policy titled "Patient Grievance Guidelines, dated 01/16/17" showed, a grievance was identified as either a written or verbal complaint that "could not be resolved at the time the complaint was made and by staff present".

Review of incident log for adverse events from 01/01/18 to 06/11/18 showed, five (Patient #25, 26, 27, 28 and 29) reported incidents identified by surveyors, contained verbal grievances by patients or patient representatives that were not resolved by the staff present and required referrals and investigations. Per CMS definitions and hospital policy, these incidents should have been considered grievances.


Review of incident report for Patient #25 showed, the patient requested a different foley catheter be placed due to extreme pain in the vaginal area. It was noted the patient was visibly upset. After surgery, the patient had awoken with extreme vaginal pain and felt as if something was "inside her". Patient stated she had pulled an aloe soap container from the vaginal area. Patient threw container in trash can and later reported it to nursing staff. Patient stated being scared and felt she was to blame for it happening. The hospital and the Risk Manager failed to identify the complaint as a grievance, conduct a thorough investigation and provid prompt resolution through written response to the patient.


Review of incident report for Patient #26 showed, laboratory staff entered the patient's room and found the patient visibly upset. Patient reported being mistreated by floor staff and had "begged for help". Patient reported night shift staff were at the nurses' station across from the patient's room "laughing and making a mockery" of the patient. The hospital and Risk Manager failed to identify the complaint as a grievance, conduct a thorough investigation and provid prompt resolution through written response to the patient.


Review of incident report for Patient #27 showed, patient reported "not receiving good care", not receiving his/her heart medications and not receiving adequate pain control. The chart was reviewed and revealed pain medication had been administered. The unit manager met with the patient the day after the complaint was made. The incident report showed, the manager "listened to patient's concerns" and then patient left against medical advice (AMA). The hospital and Risk Manager failed to identify the complaint as a grievance, conduct a thorough investigation and provid prompt resolution through written response to the patient.


Review of incident report for Patient #28 showed, patient and family reported no contact with providers for five days. A message was posted on social media expressing unhappiness with the care being provided to the patient. The family reported concern due to radiology results not being reported for two days and antibiotics not started promptly. Family reported, patient had a pacemaker placed and received no instructions from staff regarding lifting and movements restrictions of the arm until a physical therapist informed them a week later. The hospital and Risk Manager failed to identify the complaint as a grievance, conduct a thorough investigation and provid prompt resolution through written response to the patient.


Review of incident report for Patient #29 showed, patient reported several bruised areas on both arms and counted a total of 12 different sites where sticks were made from repeated unsuccessful peripheral intravenous (IV) line insertions. Patient reported blood in his/her mouth and was informed by staff it was due to a difficult airway insertion during intubation. Patient reported to hospital staff feeling "distressed" due to the multiple IV sticks and airway trauma. The hospital and Risk Manager failed to identify the complaint as a grievance, conduct a thorough investigation and provid prompt resolution through written response to the patient. The incident report showed only that it was "reviewed", no evidence the complaint was investigated and an outcome or resolution was identified.


On 06/11/18 at 12:14 pm, Staff D (Director of Risk Management) stated incidents are entered into the Midas program and reviewed by Staff E (Risk Manager). Staff D stated he/she does not regularly review incidents. Staff D stated the incidents should have been identified as grievances.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record review and interview, the Governing Body failed to maintain oversight of the grievance process resulting in five (Patient #25, 26, 27, 28 and 29) of nine grievances not being identified as grievances.

This failed practice had the likelihood of repeated complaints/grievances on patient safety and patient care to continue without rectifying the issues for improvement; and had the likelihood to neglect or omit submitted complaints/grievances pertaining to patient care and services provided; as well as reporting inaccurate information to the hospital's Governing Body.

Findings:

Review of hospital policy titled "Patient Grievance Guidelines, dated 01/16/17" showed, the hospital's grievance process was designed to be a "coordinated process for receiving, investigating, documenting and trending patient grievances" ... Patient Grievance Committee along with the "Risk Manager" were responsible for grievance trends and referring trends to appropriate directors for performance improvement activities ...Risk Management was appointed by the Advisory Board for resolving patient grievances. Statistical reports were to be provided "regularly" to Quality Management Oversight Council (QMOC) and annually to the Advisory Board. The policy failed to identify the responsibilities of the Director of Risk Management for grievances.

Review of hospital documents titled "Quality Management Oversight Council (QMOC) Meeting Minutes" dated 12/11/17, 02/15/18, and 03/15/18 failed to show evidence of review, discussion or analysis of patient grievances.

On 06/11/18 at 12:14 pm, Staff D stated, grievances were part of the "harm across the board" dashboard that would be reported in QMOC. Staff D stated, he/she was responsible for providing that report in QMOC.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, the hospital failed to provide written responses of the investigational process and outcomes for nine (Patient #21, 22, 23, 24, 25, 26, 27, 28, and 29) of nine grievances reviewed.

This failed practice resulted in four patients (Patient #21, 22, 23, and 24) who did not receive written notice of the investigation and results, five patients (Patient #25, 26, 27, 28, and 29) who received no communication regarding the investigation and results, and the likelihood for all patients who filed grievances to receive no evidence of resolution.

Findings:

Review of hospital policy titled "Patient Grievance Guidelines, dated 01/16/17" showed, a resolution letter should be mailed to the patient or patient representative(s) within 7 days. The policy failed to identify the elements for resolution of grievance required in the written response to the patient or patient representative(s).

Review of incident log for adverse events from 01/01/18 to 06/11/18 showed five (Patient #25, 26, 27, 28, and 29) reported incidents identified by surveyors, contained verbal complaints by patients or patient representative(s) that could not be resolved by the staff present and required referral and investigation. Per CMS definitions and hospital policy these incidents should have been considered grievances.

Review of a sample of four (Patients #21, 22, 23, and 24) of nine grievances showed, the hospital's written response had no evidence of the steps taken by the hospital to investigate the patient's grievance, results from the investigation and the completion date.

On 06/11/18 at 12:14 pm, Staff D (Director of Risk Management) stated, incidents were entered into the Midas program and reviewed by Staff E (Risk Manager). Staff D stated, he/she did not regularly review incidents. Staff D stated, the incidents should have been identified as grievances. Staff D stated, he/she did not include the steps taken in the investigation in the patient's response letter because the investigation often included internal processes such as peer review which were confidential.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to:

I. recognize, monitor, and ensure the safety for one patient (Patient #8) out of a sample of five patients who presented to the ED with thoughts of suicide, self-harm and/or harm to others.

II. protect the physical well-being and security of patients and staff, and to provide a safe environment that was free from hazards especially in regard to securing contraband from patients at risk of harming themselves or others.

These failed practices posed immediate jeopardy to the patients' health and safety when the ED staff took 5 hours and 13 minutes to remove contraband from one patient (Patient #8) out of a sample of five suicidal self-harm patients, who attempted suicide twice by ingesting pills and slit his/her wrist while under the supervision of the Emergency Department staff, and the likelihood of safety risks for all patients with self harm or harm to others and staff and visitors exposed to these risk.

Findings:

I. Assessment and Monitoring


Review of hospital policy titled "Suicidal Screening, dated 02/16/17" showed, screening criteria included depression and thoughts of suicide or harming themselves ...the patient's immediate safety needs should be considered ...initiate frequent 15 minute observation and documentation.


Review of hospital policy titled "Management of Behavioral Health, dated 12/13/17" showed, behavioral health patients who presented to the ED would be placed in a behavioral designated room (if available) and when a Third Party Statement (TPS) was obtained the patient would be monitored via constant video monitoring.


Review of document titled "Suicide Assessment Five-Step Evaluation and Triage, dated 2009" from the Suicide Prevention Resource Center showed, assessment of suicide should be performed when patient first presented and when there were any subsequent suicidal behaviors ...risk factors for suicide included but were not limited to: prior attempts, psychiatric disorders, alcohol and key symptoms included command hallucinations ...high suicide risk included "psychiatric disorders with severe symptoms or an acute precipitating event" and "potentially lethal suicide attempt, persistent ideation or suicide rehearsal."


Review of hospital policy titled "Behavioral Patient Property Inventory Process, dated 04/25/17" showed, nursing staff were to notify security when a behavioral patient had been checked into the ED. Security were responsible for assisting ED staff during the search of a patient's belongings for weapons, medications, illegal drugs and/or drug paraphernalia ...security staff were responsible for documenting items on the Behavioral Patient Property Inventory form.


Review of incident report dated 01/11/18 entered by Staff MM (ED Charge Nurse) for Patient #8 showed, at around 8:00 pm, the patient "called out" from his/her room and reported he/she had cut self with a razor from his/her belongings. Patient reported "security did not remove all belonging earlier and had razor in backpack". An empty Vodka bottle was found during search of linen bag.


Patient #8 was a [AGE] year old patient who arrived in the ED on 01/11/18 at 3:30 pm, via EMS. EMS staff reported, the patient had jumped into oncoming traffic but was not injured due to the vehicle being able to stop before impact. Primary assessment reported by EMS was suicidal ideations.


Patient arrived in the ED at 3:30 pm, and was triaged approximately 20 minutes later by Staff U (ED RN). Staff U noted, patient was down in the street, motorist stopped their car and notified EMS. Staff U documented, the patient reported visual/auditory hallucinations of "people telling him/her to jump into traffic" and identified a chief complaint of hallucinations.


Staff GG (ED resident) performed an initial assessment at 4:33 pm, noted, the patient reported visual hallucinations ...hearing his/her uncle telling him/her to step into traffic and kill self. Staff GG noted "patient denied wanting to kill self but was afraid he/she may do so." Staff HH (attending ED physician) saw patient in conjunction with ED Resident and noted the patient had hallucinations telling him/her to jump into traffic ...stated did not want to kill self. Staff GG's primary clinical impression was auditory hallucinations.


ED staff failed to recognize and monitor Patient #8 for suicidal ideation and/or self-harm to ensure the patient's safety as evidenced by:

* Staff U performed a suicide risk assessment at 3:50 pm, and noted the patient had not had thoughts of killing himself/herself in the past two weeks and had not attempted to kill self. Based on findings of the suicide risk assessment patient was determined not to be at risk for suicide and there was no evidence of initiation of suicide precautions including frequent monitoring and search of the patient's personal belongings for potential items that could be used to self-harm or harm others.

* Staff U failed to recognize the overt act of jumping into oncoming traffic was a suicide attempt and should have warranted suicide precautions including search of the patient's personal belongings and frequent monitoring.

* Staff GG and Staff HH failed to recognize the patient was at high risk for suicide or self-harm secondary to a suicide attempt just prior to admission related to voices which directed him/her to jump into oncoming traffic.

*At 6:15 pm, the medical record showed, Patient #8 retrieved sleeping pills from his personal belongings and took an unidentified number of pills in an attempt to overdose and "stop the voices". Patient #8 notified Staff U of the suicide attempt by overdose. Staff U completed a TPS (Third Party Statement) for an Emergency Order of Detention (EOD) but did not remove the sleeping pills or search the patient's belongings for additional items that could be used to harm him/herself or others.

*At approximately 8:00 pm, the patient attempted a second suicide by obtaining a razor blade from his/her belongings and slitting his/her left wrist creating a two inch laceration. Patient #8 notified staff of the second attempt. A search of patient's personal belongings which included a bag of razors, "bottles of drugs" (description including number of bottles, pills and drug names were not identified), and a knife was not completed until approximately 40 minutes later at 8:43 pm.

*The hospital did not place the patient on suicide precautions and perform frequent monitoring to ensure patient safety during the patient's admission in the ED from 01/11/18 at 3:30 pm until discharge 01/12/18 at 8:39 am.

*Medical and nursing staff failed to perform reassessments following the suicide attempts and treatment for the left wrist laceration to ensure the continued stability of the patient and prior to discharge.



On 06/06/18 at 1:54 pm, Staff G stated, eight ED room were designated as behavioral health rooms and have video monitoring capabilities. Staff G stated, the room has no ligature features and if the patient has a TPS and deemed suicidal their personal belongings would be searched and checked into security and video turned on for monitoring purposes. Staff G stated, Staff MM (ED Medical Director) reviews all incidents involving the ED and decide if they need to peer review for further review. Staff G stated the review determined medical care was based on patient's presenting symptoms of hallucinations and there was no need for further review.


On 06/07/18 at 2:07 pm, Staff U stated, he/she would receive a report from EMS that would include the reason for patient's presentation to the ED. Staff U stated, he/she would discuss with EMS their assessment and findings. Staff U stated, it would take more assessment to determine if a person who was hallucinating was actually suicidal or at risk for self-harm. Staff U stated, he/she would not search patient belongings unless they had had an EOD because they "would get all defensive and agitated" and he/she felt would be taking items for his/her own curiosity.


II. Safe Setting

A review of the policy titled, "Risk Management and Patient Safety Plan (date 05/17) documented the purpose of the Risk Management program was to protect patients, visitors, and employees...".

A review of the policy titled, "Management of Behavioral Health Patients- ED (dated 12/17)" documented:

* patients who present with behavioral health complaints or such behavior was noted during the visit, staff would place patient in designated behavioral rooms (6-8 and 14-16) if available. If the room was not available, the patient would will be placed in a treatment room with direct view of clinical staff.

* when it was determined patients met the criteria for a Third Party Statement (TPS) [under emergency order of detention], staff would follow the behavioral patient property inventory process policy.

* patient who had a TPS would be monitored via constant video monitoring and/or one-on-one sitters.

The policy failed to clearly address the management of patients with no TPS, and who exhibited behaviors of harming self and/or others.


A review of the policy titled, " Behavioral Patient Property Inventory Process (dated 04/17)" documented, the policy applied to all patient units including the ED. The policy documented, the security department would be notified by the admitting nurse that a behavioral patient had checked in, and security would assist staff with the search of the patient's belongings and/or valuables for items that could be used by the patient to harm themselves or staff, such as weapons, home medication, or illegal drugs or drug paraphernalia. The policy showed the security staff would properly secure all the patients' belongings with the exception of home medication which would be confiscated by the nursing staff and taken to the pharmacy for proper storage.


A review of the medical record showed, Patient #8 arrived at 3:30 pm in accompanyment of EMSA having a recent history of suicidal ideation with attempt of suicide, and showed no evidence of being searched or belongings searched for contraband.

At 6:15 pm, the medical record showed, Patient #8 retrieved sleeping pills from his personal belongings and took an unidentified number of pills in an attempt to overdose and "stop the voices," and then notified staff. Staff U completed a TPS for an Emergency Order of Detention (EOD) but did not remove the sleeping pills or search the patient's belongings for additional items that could be used to harm him/herself.

At approximately 8:00 pm, the patient attempted a second suicide by obtaining a razor blade from his/her belongings and slitting his/her left wrist creating a two inch laceration. Patient #8 notified staff of the second attempt. Five hours and 13 minutes after arrival to the ED, at 8:43 pm, Patient# 8's belongings were searched and staff removed of a bag of razors, "bottles of drugs" (description including number of bottles, pills and drug names were not identified), and a knife.

On 06/07/18 at 1:31 pm, Staff H stated, he/she had established a task force two years prior, whose goal was to improve security, but the initiative had "dropped off". Staff H said, he/she had recently been trying to implement increased security measures, especially in the ED. Staff H stated ,the entrances to the ED had no metal detectors.

On 06/07/18 at 1:31 pm, Staff G stated, Patient # 8's suicide attempts had occurred at the height of flu season, when the patient census had increased and staffing was a challenge.

06/07/18 at 2:49 pm, Staff G stated, behavioral health patients in the ED were defined as flight risks, those under emergency order of detention by the physician, and those patients with a higher degree of safety concerns. Staff G stated, Patient #8 was a repeat patient.

On 06/07/18 at 2:01 pm (via telephone). Staff U stated, only ED patients who were under EOD had their belongings searched for contraband. Staff U stated, unless a patients is EOD, "out of respect" to the patient, their belongings were not searched. Staff U stated, he/she did not know the hospital's policy for searching patients for contraband. Staff U stated, he/she did not remember Patient# 8.

06/07/18 at 8:12 am, Staff NN stated, the ED's behavioral health rooms were room 6, 7, 8, 12, 14, 15, and 16.

On 06/17/18 at 8:50 am, Staff V stated, staff tried to bring behavioral health patients to the designated ED behavioral health exam if possible. Staff V stated, security was contacted for violent patients. Staff V stated, if patients' had suicidal ideation with a plan, the patient's belongings would be searched, and the patient would be placed in EOD. Staff V stated, the hospital policy said that only EOD patients would be searched. Staff V stated, if a patient was voluntary and cooperative with no suicidal or homicidal plan, despite a past history of the diagnoses, the patient would not be searched. Staff V stated, if the patient was hallucinating, and not under EOD, the staff would not search patient and their belongings without a specific physician directive.

On 06/17/18 at 9:14 am, Staff LL stated, if an ED patient was under EOD, the patient would change into a gown, and the patient and their belongings would be searched. Staff LL stated, security would be contacted. Staff LL stated, if a patient was not under EOD, the staff was "not allowed" to take patients' belongings. Staff LL stated, if a patient was hallucinating or not in their "right mind", he/she would not think it was appropriate to take the patient's belongings.

On 06/07/18 at 9:34am, Staff R stated, all patients, including ED patients, being admitted to the Behavioral Health Unit were searched and their belongings were searched. Staff R stated, the staff did not perform cavity searches.

06/07/18 at 1:31 pm, Staff H showed surveyors a display of contraband acquired from the patient population from the past year. The patient population included ED patients with suicide or homicidal ideation, some of whom were in EOD. The display included two guns, 12 knives, two brace knuckles (one of which had pointed edges).
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview, the hospital failed to ensure allegations of verbal and/or physical abuse and harassment were investigated and acted upon. This occurred in two (Patient #25 and 26) of five incidents identified as grievances. This failed practice had the likelihood to increase the risk for abuse to occur to all patients who sought care at the hospital.

Findings:

Review of hospital policy titled "Patient Rights and Responsibilities, dated 01/16/17" showed, patients had the right to be free from harassment and/or abuse including but not limited to: verbal, physical, emotional, and/or psychological abuse or harassment. Patients would be protected from real or perceived abuse from anyone by the hospital "to the best of its ability".

Review of hospital document titled "Patient Rights and Responsibilities, dated 07/17" showed, patients had the right to receive considerate care, quality and continuity of care that was respectful, the right to personal dignity and freedom from all forms of harassment or abuse.

Review of hospital policy titled "Suspected Abuse - Neglect Guidelines - Reporting, dated 02/16/17" showed, patients had the right to be free from all forms of abuse or harassment ...abuse or harassment was prohibited by the hospital ...staff were required to report suspected abuse as soon as staff were made aware of the event ...the hospital would investigate suspected cases of abuse ...staff should identify and report clinical signs and behaviors of potential abuse including but not limited to: verbalized incidences of abuse, acts frightened or anxious, and other behaviors that reasonable judgment would indicate possible abuse.


Review of incident log for adverse events from 01/01/18 to 06/11/18 showed two incidents (Patient #25 and 26) identified by surveyors contained allegations of abuse that were not investigated and acted upon.


Review of incident report for Patient #25 showed, the patient requested a different foley catheter be placed for reports of extreme pain in the vaginal area. It was noted the patient was visibly upset. After surgery, the patient had awoken with extreme vaginal pain and felt as if something was "inside her". Patient stated she pulled an aloe soap container from the vaginal area. Patient threw container in trash can and later reported it to nursing staff. Patient stated being scared and felt to blame for it happening. No evidence the incident was identified as an allegation of abuse, investigated and/or acted upon.


Review of incident for Patient #26 showed, the patient was crying when a lab tech entered the patient's room to draw blood. Patient #26 reported being mistreated by floor staff and had "begged for help" from the lab tech. Patient reported night shift staff were at the nurses' station across from his/her room "laughing and making a mockery" of the patient. It was noted in the report lab tech had witnessed staff behavior including staff speaking "derogatory about patient" and patient needs were not taken seriously. No evidence incident was identified as an allegation of abuse, investigated and/or acted upon. Risk Manager (in role for one month) forwarded incident to manager, who apologized to patient for "her perception" and spoke to staff.


On 06/11/18 at 12:14 pm, Staff D (Director of Risk Management) stated, incidents were entered into the Midas program and reviewed by Staff E (Risk Manager). Staff D stated, he/she did not regularly review incidents. Staff D stated he/she was not aware of these incidents.
VIOLATION: QAPI Tag No: A0263
Based on record review and interview, the hospital failed to:

I. ensure Governing Body (Advisory Board) established clear expectations for the Leadership involved in quality and risk management initiatives including, but not limited to defining role responsibilities, developing policies, processes, and reporting methods relating to grievances and patient safety, medical errors and adverse events.

These failed practices resulted in deficient incident reporting provided to the Advisory Board for the 894 incidents which occurred from 01/01/18 to 06/11/18, therefore, the Governing Body lacked sufficient information to make informed decision related to the provisions of quality patient care. (Refer to Tag A-0286)


II. establish a Quality Program Scope which included the identification and management of all patient grievances according to hospital policies.
This failed practices resulted in five (Patient #25, 26, 27, 28 and 29) grievances to be identified, increased the likelihood of other grievances to be unidentified, and for the 172 grievances which occurred from 06/05/17 to 06/05/18 to not be managed through the quality improvement process. (Refer to below and Tags A-0118, A-0119, A-0123, and A-0286)


III. establish a Quality Program Scope and developed Program Activities which ensured patient safety, and medical errors and adverse incidents were thoroughly investigated, causes analyzed, preventative action plans implemented, and effectiveness of measured outcomes evaluated.

These failed practices had the likelihood of 894 incidents from 01/01/18 to 06/11/18 to have improvement opportunities not to be identified, analyzed for causes, and the implementation of preventative measures to improve patient outcomes. (Refer to Tag A-0286)
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to:

I. ensure Governing Body (Advisory Board) established clear expectations for the Leadership involved in quality and risk management initiatives to include, but not limited to defining role responsibilities, developing policies, processes, and reporting methods relating to grievances, patient safety, medical errors and adverse events.

These failed practices resulted in deficient incident reporting provided to the Advisory Board for the 894 incidents which occurred from 01/01/18 to 06/11/18, therefore, the Governing Body lacked sufficient information to make informed decision related to the provisions of quality patient care.


II. establish a Quality Program Scope which included the identification and management of all patient grievances according to hospital policies.


These failed practices resulted in five incidents (Patient #25, 26, 27, 28, and 29) not identified as grievance, increased the likelihood of other grievances to be unidentified, and for the 172 grievances which occurred from 06/05/17 to 06/05/18 to not be managed through the quality improvement process. (Refer to below and Tags A-0118, A-0119, and A-0123)


III. establish a Quality Program Scope and developed Program Activities which ensured patient safety events, medical errors and adverse incidents were thoroughly investigated, causes analyzed, preventative action plans implemented, and effectiveness of measured outcomes evaluated.

These failed practices resulted in the likelihood for improvement opportunities to be unidentified, causes not analyzed, and preventative measures to not be implemented to improve patient outcomes for the 894 incidents from 01/01/18 to 06/11/18


Findings:

I. Governing Body and Leadership Responsibilities with Quality Initiatives

A. Roles

A review of the policy titled, "Quality Assurance and Performance Improvement Plan (dated 04/18)" showed, the leadership team was the CEO, COO, CNO, and the Director of Quality, and their responsibilities included improving patient safety and evaluating responses to sentinel events, and unexpected and/or usual occurrences. The plan documented the Quality Management Review Team included Risk staff amongst other members.

A review of the policy titled, "Risk Management and Patient Safety Plan (date 05/17)" showed, the "Risk Manager" was responsible for the implementation and coordination of the risk program and worked in cooperation with the Director of Quality Management. The risk plan failed to address the role of the Director of Risk Management.


On 06/11/18 at 12:09 pm, Staff B stated, the "Risk Management and Patient Safety Plan (date 05/17)" was developed by the Corporate System, approved by the Advisory Board (Governing Body), but failed to address the role and responsibilities of the Director of Risk Management. Staff B identified three primary staff responsible for quality and risk activities: Staff C, Director of Quality; Staff D, Director of Risk management; and Staff E, Risk Manager.

A review of the job description for the Director of Quality showed the position to include organizing and coordinating operational support for the Quality, Risk, and Medical staff departments.

On 06/11/18 at 1:00 pm, surveyors requested the job description for the Director of Risk management, and none was provided.

A review of the job description for the Risk Manager included position responsibilities which included assisting the design, measurement, monitoring, and implementation of the program, and to improve patient care was measured by improved clinical outcomes.

On 06/11/18 at 12:09 pm, Staff D stated, in the six years of his/her employment, there had been much turnover in Leadership: 2-3 Chief Executive Officers, approximately five Chief Nursing Officers, and three to four Quality Directors, which reflected a large turnover.

On 06/11/18 at 12:09 pm, Staff D, Director of Risk Management, stated, he/she and Staff E, Risk Manager, fulfilled the responsibilities for the Risk Management Program, and stated Staff C, Quality Director, managed matters regarding peer review. Staff D stated, Staff E was responsible for reviewing and routing all incidents events and grievances to other staff, such as Department Managers. Staff D stated, incidents and grievances were routed to Staff C for issues possibly requiring peer review evaluations. Staff D stated, criteria for routing was not well-defined.

On 06/11/18 at 12:09 pm, Staff D stated, when an event occurred, staff or leadership entered incident or grievance information into the Midas reporting system (computer program for incident reporting).

On 06/11/18 at 2:15 pm, Staff D stated, the hospital did not have a written evaluation of the effectiveness for the 2017-2018 Risk Plan. Staff D stated the annual Risk Plan was not developed at the hospital level, but was developed by corporate staff and was not reviewed at the hospital level.


B. Reporting

A review of the policy titled, "Quality Assurance and Performance Improvement Plan (dated 04/18" documented reports of findings, conclusions, recommendations, and actions should be reported at Quality Management Oversight Council (QMOC), Medical Executive Committee (MEC), and Advisory Board.

A review of the policy titled, "Risk Management and Patient Safety Plan (date 05/17)" documented, the Advisory Board should receive reports on the findings, actions, and results of the risk management program activities, and approved the actions taken and recommended further action and/or follow-up.

A review of hospital policy titled "Patient Grievance Guidelines, dated 01/16/17" showed, statistical reports were to be provided "regularly" to Quality Management Oversight Council (QMOC) and annually to the Advisory Board.

A review of the documents titled, "Advisory Board" [meeting minutes] for 05/19/18, 01/15/18, 01/26/18, 02/23/18, and 04/27/18 showed no evidence of information and oversight over the grievance and incident reporting, consistent review of statistical reports, and showed no evidence events were consistently incorporated in the quality assessment and improvement (QAPI) program.

A review of the documents titled, "Medical Executive Committee" for 01/16/18, 02/20/18, 03/27/18, 04/27/18, and 05/15/18 showed no evidence of information and oversight over the grievance and incidents, patient safety, medical errors, adverse events reporting and showed no evidence events were consistently incorporated in the quality assessment and improvement (QAPI) program.

A review of the documents titled, "Quality Management Oversight Council" for 02/15/18, 03/15/18, 04/26/18, and 05/21/18 contained no patient grievance reporting, minimal comparative data, no quality initiatives for many of the high risk patient care issues reflected in the incident log from 01/01/18 to 06/11/18.

On 06/12/18 at 10:40 am, the surveyors requested the Grievance Committee minutes for 2018, and none were provided. Staff D stated stated the 03/18 meeting was cancelled due to an accreditation survey, the next meeting was scheduled for 07/18, and there had been no significant issues identified which would warrant an ad hoc meeting.

On 06/11/18 at 12:23 pm, when asked if he/she provided the Advisory Board with aggregate data and quality action plans, Staff D stated he/she did not take such information to the Board. Staff D stated he/she recently noticed that the dashboard may or may not be included with the Quality Management Oversight Council (QMOC) Meeting Minutes.

A review of hospital policy titled "Critical Event Analysis" showed a critical event had the potential to cause serious harm or death this included but was not limited to ...attempted suicide of any patient ...critical event should be reported to the Director of Quality Management (DQM). DQM should notify the Risk Manager of the event and the need to initiate a critical event analysis. A report should be provided to Chief of Staff, Risk Management and the Clinical Quality Improvement Council (CQIC). CQIC was responsible for making recommendations for improvement actions. A results report by CQIC should be provided to the Advisory Board.

On 06/11/18 at 12:23 pm, Staff D stated, Patient #8's two suicide attempts of ingesting pills and slitting his/her wrist while under the supervision of the Emergency Department staff were not communicated to the Advisory Board.

On 06/11/18 at 12:23 pm, Staff D stated, two (Patient #25 and 26) of five incidents identified as grievances with allegations of verbal and/or physical abuse and harassment were not communicated to the Advisory Board.

On 06/08/18 at 8:15am, Staff B stated, the Advisory Minutes were not "robust" will quality improvement information and did not reflect the full content of discussions which had occurred during the meetings.


II. Program Scope- Grievances

A review of hospital policy titled, "Patient Grievance Guidelines, dated 01/16/17" showed, the Patient Grievance Committee in cooperation with the "Risk Manager" were responsible for grievance trends and referring trends to appropriate directors for performance improvement activities ...Risk Management was appointed by the Advisory Board for resolving patient grievances.

The surveyors reviewed the documents titled, "Incident Report Log" from 01/01/18 to 06/11/18 and they identified five (Patient #25, 26, 27, 28, and 29) which met the CMS definition of abuse of 894 total incidents. The patients' allegations were not documented as grievances, and the hospital did not adhere to policies and procedures established for grievances in managing these allegations. (Refer to Tag A-0119)

A review of the documents identified as the grievance log from 06/05/17 to 06/05/18 showed 172 grievances. The log showed the lack of investigation, analyzation of causes, implementation of preventative action plans, and measurement of outcomes for effectiveness.

On 06/12/18 at 10:40 am, Staff D stated the Grievance log reflected the hospital's response to the patients' grievance.


II. Program Scope and Activities- Patient Safety, Medical Errors, and Adverse Events

A review of the policy titled, "Quality Assurance and Performance Improvement Plan (dated 04/18)" documented plan objectives which included, but was not limited to the following: providing a culture where patient safety was first priority, ensuring care was delivered in a safe environment and the quality of care was measured, monitored, and continuously improved.

A review of the policy titled, "Risk Management and Patient Safety Plan (date 05/17)" documented the plan objectives which included, but was not limited to the following: to reduce patient, visitor, and employee injury to its lowest possible, to enhance quality process and outcomes of provided, to promote patient rights, and to provide a safe for patients, visitors, and employees.

A review of hospital policy titled, "Patient Grievance Guidelines, dated 01/16/17" showed the hospital's grievance process was designed to be a "coordinated process for receiving, investigating, documenting and trending patient grievances.

A review of the documents identified as the incident report log from 01/01/18 to 06/11/18 defined 894 incidents showed the significance-severity of incidents ranging from categories A-I:

A= Capacity to cause harm
B= No harm- variance did not reach patient
C=No harm- variance reached patient
D=No harm- monitoring
E=Temporary harm-treatment
F=Temporary harm- Increased length of stay
G= Harm- near death
H=Permanent harm
I= Death


A review of the document titled, "Consolidated Benchmark Report (dated 12/17) showed the annual significance-severity for the A-I categories and documented the percentage of events per category for 2017. On 06/12/18 at 10:40 am, Staff D stated the document, which was compiled by corporate was the hospital's annual evaluation of the Risk Management Program and was provided to the Advisory Board. No evidence was provided that the data was used to evaluate safety and quality of care and the effectiveness of the program.

A review of the documents identified as the incident report log from 01/01/18 to 06/11/18 showed 168 incidents of the 894 total incidents had no assignment of the significance-severity for the A-I categories, which may result in under-reporting on the annual report.

The log had a column for "comments" included desciptions of the incident and various degrees of follow- up actions from the managers or others staff. The log failed to show consistent detailed descriptions of the event, which staff were involved, what actions taken, lessons learned, and resolutions. The log failed to show which incidents were routed to peer review.

Examples of the "comment" section of the log included some of the following: "reviewed", "sent for review dated 2/18", "noted", and "follow-up completed".

A review of the documents titled, "Incident Report Log" from 01/01/18 to 06/11/18 showed multiple high risk patient care incidents which were categories A-F and not reviewed by the Director of Risk Management, and the documentation showed minimal evidence of specific responses and evaluations for improvement opportunities. Examples of documented incidents were as follows:

On 01/11/18, Patient #8 (Category E: Temporary Harm-Treatment) was admitted to the ED after a suicide attempt and called out to staff stating that he had cut himself with a razor blade from persomnal belongings. An approximately two inch laceration was noted on the patient's forearm, which required suturing. Security did not remove his belongings, which included a backpack with the a bag of razors and a bottle of drugs. An empty bottle of vodka was in his linens. Patient #8's medical record also documented the patient had reported to the staff that he/she had taken sleeping pills while under the ED staff's supervision, which was not contained in the incident report. The final comment on the incident report documented "reviewed with staff" with no evidence of investigation for causes and lessons learned.

On 05/11/18, Patient # 30 (not assigned incident category A-I) was agitated walked out of room with sitter following, because he/she stated a desire to go to home. Patient # 30 said they felt like he/she was was being held hostage, and security was called. The attending physician (Staff FF) talked to patient, but the patient wanted to leave. The APRN allowed the patient to leave AMA. Patient # 30's discharge diagnosis was accidental cocaine poisoning and there was no documentation indicating why a sitter was ordered.

On 05/11/18, Patient # 32 (Category I: Death) was in isolation for Methicillin Resistant Staph Auresus (MRSA- a resistent strain of bacteria) in his/her sputum. Patient # 32 left the hospital with a left internal jugular triple lumen catheter (IV in the patients's neck) and peripheral IV still in place without notifying staff. Staff called security to detain the patient, but the patient refused to stop at security. There was no documentation as to any follow up to determine the outcome of patient.

On 03/13/18, Patient # 32 (not assigned incident category A-I) was admitted with telemetry ordered, but the patient was never placed on telemetry, because the order never got submitted. Patient # 32 expired on ,d+[DATE]. The log showed the incident was reviewed and concluded that in EPIC (the hospital's electronic medical record) the physician ordering telemetry could do so in many ways. No evidence was documented that the investigation included the evaluation of the role telemetry played in providing early detection for change of condition to possibly prevent patient death, or other lessons learned.

On 01/03/18, Patient # 33 (Category E: Temp Harm-Treatment Required) was placed on an air mattress (fluidized bed) used for patients which had skin breakdown. The mattress, which had been turned off deflated, and caused the patient to lie on the hard frame, which resulted the development of "at least 30% purple ischemia area". The documented action included an inservice given by the bed vendor, and failed to show who was trained or if lack of training resulted in the event. The action did not include a surveillance system to prevent the event from reoccurring.

On 02/01/18, Patient, 34, (Category A: Capacity to cause harm) was admitted to the Emergency Department with suicide ideation and had swallowed razor blades before admission. The patient was not in emergency order of detention custody and wanted to leave against medical advice. Staff EE was notified and the log documented the provider "was not concerned about the patient leaving", and patient education was done as to possible outcomes. The final log evaluation was the patient had ingested the razor blades "BEFORE" presenting to the hospital.

On 06/11/18 at 12:23 pm, Staff D stated Staff E, who had been in the role of Risk Manager for one month, reviewed all incidents initially and assigned a "significance" (A_I) to each event in the Midas system.

On 06/11/18 at 12:23 pm, Staff D stated Staff E only routed him/her the incidents assigned the significance categorized as "G, H and I", and incidents categorized A-F were not reviewed at his/her level.

On 06/07/18 at 4:49 pm, Staff G stated after Patient 8's suicide attempt in the ED, he/she spoke to specific staff and the ED Medical Director. Staff G stated the events were compared to hospital policy. Staff G stated Patient #8's incident occurred during the height of flu season, and he/she was rendering direct patient care, which distracted from her leadership responsibilities and impacted the investigation of the event and resulted in no root cause analysis being performed.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on record review and interview, the hospital failed to:

I. ensure Governing Body (Advisory Board) established clear expectations for the Leadership involved in quality and risk management initiatives to include, but not limited to the defining role responsibilities, developing policies, processes, and reporting methods relating to grievances and patient safety, medical errors and adverse events.

These failed practices resulted in inadequate incident reporting provided to the Advisory Board for the 894 incidents which occurred from 01/01/18 to 06/11/18 so that the Governing Body had enough information to ensure the hospital was providing quality patient care.

Findings:

A. Roles
A review of the policy titled, "Quality Assurance and Performance Improvement Plan (dated 04/18)" showed the leadership team was the CEO, COO, CNO, and the Director of Quality and their responsibilities included improving patient safety and evaluating responses to sentinel events, and unexpected and/or usual occurrences. The plan documented the Quality Management Review Team included Risk staff amongst other members.

A review of the policy titled, "Risk Management and Patient Safety Plan (date 05/17)" showed the "Risk Manager" was responsible for the implementation and coordination of the risk program and worked in cooperation with the Director of Quality Management. The risk plan failed to address the role of the Director of Risk Management.

On 06/11/18 at 12:09 pm, Staff B stated the "Risk Management and Patient Safety Plan (date 05/17)" was developed by the Corporate System, approved by the Advisory Board (Governing Body), but failed to address the role and responsibilities of the Director of Risk Management. Staff B identified three primary staff responsible for quality and risk activities: Staff C, Director of Quality; Staff D, Director of Risk management; and Staff E, Risk Manager.

A review of the job description for the Director of Quality showed the position to include organizing and coordinating operational support for the Quality, Risk, and Medical staff departments.

On 06/11/18 at 1:00 pm, surveyors requested the job description for the Director of Risk management, and none was provided.

A review of the job description for the Risk Manager included position responsibilities which included assisting the design, measurement, monitoring, and implementation of the program, and to improve patient care was measured by improved clinical outcomes.

On 06/11/18 at 12:09 pm, Staff D stated in the six years of his/her employment, there had been much turnover in Leadership: 2-3 Chief Executive Officers, approximately five Chief Nursing Officers, and three to four Quality Directors, which reflected a large turnover.

On 06/11/18 at 12:09 pm, Staff D, Director of Risk Management, stated he/she and Staff E, Risk Manager, fulfilled the responsibilities for the Risk Management Program, and stated Staff C, Quality Director, managed matters regarding peer review. Staff D stated Staff E was responsible for reviewing and routing all incidents events and grievances to other staff, such as Department Managers. Staff D stated incidents and grievances were routed to Staff C for issues possibly requiring peer review evaluations. Staff D stated criteria for routing was not well-defined.

On 06/11/18 at 12:09 pm, Staff D stated when an event occurred, staff or leadership entered incident or grievance information into the Midas reporting system (computer program for incident reporting).

On 06/11/18 at 2:15 pm, Staff D stated the hospital did not have a written evaluation of the effectiveness for the 2017-2018 Risk Plan. Staff D stated the annual Risk Plan was not developed at the hospital level, but was developed by corporate staff and was not reviewed at the hospital level.

B. Reporting
A review of the policy titled, "Quality Assurance and Performance Improvement Plan (dated 04/18" documented reports of findings, conclusions, recommendations and actions should be reported at Quality Management Oversight Council (QMOC), Medical Executive Committee (MEC), and Advisory Board.

A review of the policy titled, "Risk Management and Patient Safety Plan (date 05/17)" documented the Advisory Board should receive reports on the findings, actions, and results of the risk management program activities, and approved the actions taken and recommended further action and/or follow-up.

A review of hospital policy titled "Patient Grievance Guidelines, dated 01/16/17" showed statistical reports were to be provided "regularly" to Quality Management Oversight Council (QMOC) and annually to the Advisory Board.

A review of the documents titled, "Advisory Board" [meeting minutes] for 05/19/18, 01/15/18, 01/26/18, 02/23/18, and 04/27/18 showed no evidence of information and oversight over the grievance and incident reporting, consistent review of statistical reports, and showed no evidence events were consistently incorporated in the quality assessment and improvement (QAPI) program.

A review of the documents titled, "Medical Executive Committee" for 01/16/18, 02/20/18, 03/27/18, 04/27/18, and 05/15/18 showed no evidence of information and oversight over the grievance and incidents, patient safety, medical errors, adverse events reporting and showed no evidence events were consistently incorporated in the quality assessment and improvement (QAPI) program.

A review of the documents titled, "Quality Management Oversight Council" for 02/15/18, 03/15/18, 04/26/18, and 05/21/18 contained no patient grievance reporting, minimal comparative data, no quality initiatives for many of the high risk patient care issues reflected in the incident log from 01/01/18 to 06/11/18.

On 06/12/18 at 10:40 am, the surveyors requested the Grievance Committee minutes for 2018, and none were provided. Staff D stated stated the 03/18 meeting was cancelled due to an accreditation survey, the next meeting was scheduled for 07/18, and there had been no significant issues identified which would warrant an ad hoc meeting.

On 06/11/18 at 12:23 pm, when asked if he/she provided the Advisory Board with aggregate data and quality action plans, Staff D stated he/she did not take such information to the Board. Staff D stated he/she recently noticed that the dashboard may or may not be included with the Quality Management Oversight Council (QMOC) Meeting Minutes.

A review of hospital policy titled "Critical Event Analysis" showed a critical event had the potential to cause serious harm or death this included but was not limited to ...attempted suicide of any patient ...critical event should be reported to the Director of Quality Management (DQM). DQM should notify the Risk Manager of the event and the need to initiate a critical event analysis. A report should be provided to Chief of Staff, Risk Management and the Clinical Quality Improvement Council (CQIC). CQIC was responsible for making recommendations for improvement actions. A results report by CQIC should be provided to the Advisory Board.

On 06/11/18 at 12:23 pm, Staff D stated Patient #8's two suicide attempts of ingesting pills and slitting his/her wrist while under the supervision of the Emergency Department staff were not communicated to the Advisory Board.

On 06/11/18 at 12:23 pm, Staff D stated two (Patient #25 and 26) of five incidents identified as grievances with allegations of verbal and/or physical abuse and harassment were not communicated to the Advisory Board.

On 06/08/18 at 8:15am, Staff B stated the Advisory Minutes were not "robust" will quality improvement information and did not reflect the full content of discussions which had occurred during the meetings.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on record review and interview the hospital failed to ensure the medical staff were accountable to the Governing Body for the quality of care provided to one patient (Patient #8) of a total sample of 20 patient medical records reviewed. This failed practice resulted in a suicide attempt while in the ED for one patient (Patient #8) and the likelihood for increased risk to patient safety for all patients seeking care in the ED for self-harm and/or harm to others.

Findings:

Review of hospital policy titled "Patient Rights and Responsibilities, dated 01/16/17" showed patients had the right "to expect reasonable safety within the facility and environment".

Review of hospital document titled "Patient Rights and Responsibilities, dated 07/17" showed patients had the right to receive considerate care, quality and continuity of care and the receipt of care in a setting that was determined to be safe.

Review of hospital document titled "Medical Staff Bylaws, dated 11/21/14" showed care should be provided "at an acceptable level of quality" ..."provide or arrange for continuous appropriate care" ..."responsible for maintaining current knowledge of clinical practice guidelines and practice parameters concerning patient care" ..."retain responsibility for the continuous care and supervision of each patient".

Patient #8 was a [AGE] year old patient who arrived in the ED on 01/11/18 at 3:30 pm, via EMS who reported the patient had jumped into oncoming traffic but was not injured due to the vehicle being able to stop before impact. Staff GG (ED resident) performed an initial assessment at 4:33 pm, and noted the patient reported visual hallucinations and hearing his/her uncle telling him/her to step into traffic and kill self. Staff GG noted "patient denied wanting to kill self but was afraid he/she may do so." Staff HH (attending ED physician) saw patient in conjunction with ED resident at 4:33 pm, and noted the patient had hallucinations telling him/her to jump into traffic ...stated did not want to kill self. Staff GG's primary clinical impression was auditory hallucinations. ED Medical Staff failed to recognize the following:
*On admission the patient had attempted suicide by jumping into traffic. There was no evidence the patient was placed on suicide precautions and monitored for suicidal ideations and/or self-harm.
*At 6:15 pm, the patient attempted suicide by taking sleeping pills from his personal possessions. Medical Staff took no action to initiate orders for suicidal precautions or removal of patient belongings. Medical Staff did not reassess the patient following this attempt to ensure the stability of the patient or need for additional treatment.
*At approximately 8:00 pm, the patient attempted a second suicide by obtaining a razor blade from his/her belongings and slitting his/her left wrist creating a two inch laceration. Medical Staff took no action to initiate orders for suicidal precautions or removal of patient belongings. Medical Staff did not reassess the patient following this attempt to ensure the stability of the patient or need for additional treatment. There was no evidence treatment was provided for the laceration to the left wrist.
*Approximately 40 minutes later security and clinical staff searched and removed the patient's belongings. During the search the following items were found: bag of razors, bottles of drugs, and a knife.

On 06/06/18 at 1:54 pm, Staff G stated Staff MM (ED Medical Director) reviewed all incidents involving the ED and decided if they need to peer review for further review. Staff G stated the review determined medical care was based on patient's presenting symptoms of hallucinations and there was no need for further review.

On 06/07/18 at 12:44 pm, Staff G stated he/she discussed the incident (Patient #8) with staff and it was determined not to be a quality of care issue so it was not taken to physician peer review.

On 06/11/18 at 11:53 am, Staff C (Director of Quality/Peer Review) stated risk management was responsible for follow up of adverse events and/or incidents with department managers. Staff C stated he/she was responsible for taking events or incidents to peer review. Staff C stated cases would be initially reviewed by a physician with similar credentials and then the case would be taken to the peer review committee for review and determination would be made and entered into Midas. Staff C stated the incident involving Patient #8 was not taken to peer review and he/she was not aware of the incident.
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on record review and interview the hospital failed to ensure the patient's electronic medical record included complete and accurate patient care information. This failed practice resulted in the unavailability of pertinent medical information for one patient (Patient #8) who was transferred to a psychiatric facility for treatment, and the likelihood of increased risk to all patients due to the unavailability of pertinent information to make timely medical and nursing decisions.

Findings:

Review of hospital policy titled "Electronic Clinical Documentation, dated 06/15/17" showed the medical record should reflect an accurate description of the treatments provided, changes in condition and patient's responses.

Review of hospital policy titled "ED Standards of Care and Documentation, dated 04/11/17" showed assessments in the ED were problem-focused which included the primary body system of the chief complaint and any associated body systems ...a suicidal risk assessment should be performed for all patients who presented with complaints of suicidal and/or homicidal ideation. The policy failed to identify the requirements for the completion of forms and consents in the ED, including but not limited to the Third Party Statement for behavioral health patients.

Review of hospital policy titled "Management of Behavioral Health Patients - ED, dated 12/13/17" failed to include who was responsible for the completion of the Third Party Statement and the minimum standards for completion of the legal form which included but was not limited to: inclusion of the patient's name in legal citation, relationship to patient, address and completion of all blanks on the form.

Review of hospital policy titled "Behavioral Patient Property Inventory Process, dated 04/25/17" showed nursing staff were to notify security when a behavioral patient had been checked into the ED. Security were responsible for assisting ED staff during the search of a patient's belongings for weapons, home medications, illegal drugs and/or drug paraphernalia ...nursing staff were to confiscate home medications and take them to pharmacy for storage ...security staff were responsible for documenting items on the Behavioral Patient Property Inventory form and both security staff and clinical staff were to initial the form in the identified locations for where property was taken. For weapons, the policy failed to identify the documentation requirements for weapons receipt, including but not limited to, the visitor/patient signature and witness signature.

Review of Patient #8's medical record showed the following:
*Staff U (ED RN) had not filled in all the blanks of the Third Party Statement including but not limited: printing his/her name and identifying the relationship to the patient in order to clearly identify who had completed the legal form that would be used for emergency order of detention.
*Staff GG (ED Resident) performed an assessment at 4:33 pm, the "medical decision making" section included reference to TPS completed by RN and laceration to left wrist with razor. There was no documentation in the electronic medical record (EMR) regarding when these events occurred or the decision making that lead to the initiation of the TPS (which occurred prior to the second suicide attempt involving the razor), treatment of the laceration to the left wrist, response to treatment, and the initial suicide attempt involving the ingestion of sleeping pills.
*Staff HH (attending physician) saw patient at 4:33 pm, (in conjunction with ED Resident) and the "medical decision making" section included reference to the laceration of the left wrist with the razor. There was no documentation in the EMR regarding when this event occurred, treatment of the laceration to the left wrist, response to treatment and the initial suicide attempt involving the ingestion of sleeping pills.
*At 6:10 pm, a Visitor/Patient Firearms Receipt was issued for a "fleding (sic) knife" for Patient #8. Officer's signature was not legible. There was no documentation the officer tried to obtain the patient's signature or if patient refused to sign receipt. If patient unable or refused to sign receipt hospital policy required a witness signature, and there was no documentation of a witness signature.
*At 8:43 pm, an inventory of property was completed by security and ED clinical staff. A bag of razors, "bottles of drugs", and knife were found during a search and inventory of patient's belongings. Staff signatures were not legible, initials for security staff were numerical and nurse initials were not legible. The item listed as "bottles of drugs" failed to identify the following: number of pill bottles, name of drug for each bottle, dosage, and number of pills in each pill bottle.

06/07/18 at 2:07pm, Staff U stated ED staff would notify security staff once a patient was placed on EOD status, and security staff would search and inventory the patient's belongings on a form that was signed by security and nursing staff. Staff U stated the form would be scanned in the patient's chart.

On 06/07/18 at 9:07 am, Staff W stated once a patient was placed on EOD status security staff would come and inventory their personal belongings and write them down on a form and then the nurse would sign the form acknowledging that it was correct.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure the ED:

I. protected the physical well-being and security of patients and staff, and provided a safe environment that was free from hazards especially in regard to securing contraband from patients at risk of harming themselves or others.

These failed practices posed immediate jeopardy to the patients' health and safety when the ED staff took 5 hours and 13 minutes to remove contraband from one patient (Patient #8) out of a sample of five suicidal self-harm patients, who attempted suicide twice by ingesting pills and slit his/her wrist while under the supervision of the Emergency Department staff, and the likelihood of safety risks for all patients with self harm or harm to others and staff and visitors exposed to these risk.


II. provided services and interventions according to standards of practice for one patient (Patient #8) out of sample of five patients who presented to the ED with complaints of harm to self or others from to arrival to admission, transfer or discharge.

This failed practice resulted in serious harm to one patient (Patient #8) out of a sample of five suicidal self-harm patients and the likelihood to cause serious harm to patients presenting to the ED with thoughts of self-harm and/or harm to others.


Patient #8 was a [AGE] year old patient who arrived in the ED on 01/11/18 at 3:30 pm, via EMS. EMS staff reported, the patient had jumped into oncoming traffic but was not injured due to the vehicle being able to stop before impact. Primary
assessment reported by EMS was suicidal ideations.

Patient arrived in the ED at 3:30 pm, and was triaged approximately 20 minutes later by Staff U (ED RN). Staff U noted, patient was down in the street, motorist stopped their car and notified EMS. Staff U documented, the patient reported visual/auditory hallucinations of "people telling him/her to jump into traffic" and identified a chief complaint of hallucinations.

Staff GG (ED resident) performed an initial assessment at 4:33 pm, noted, the patient reported visual hallucinations ...hearing his/her uncle telling him/her to step into traffic and killself. Staff GG noted "patient denied wanting to kill self but was afraid he/she may do so." Staff HH (attending ED physician) saw patient in conjunction with ED Resident and noted the patient had hallucinations telling him/her to jump into traffic ...stated did not want to kill self. Staff GG's primary clinical impression was auditory hallucinations.

ED staff failed to recognize and monitor Patient #8 for suicidal ideation and/or self-harm to ensure the patient's safety


Immediate Jeopardy Summary
On 06/05/18, 06/06/18, 06/07/18, 06/08/18, 06/11/18 and 06/12/18, the Oklahoma State Health Department surveyors conducted unannounced complaint surveys (OK 1774 and OK ).

On 06/07/18 at 11:30 am, the surveyors contacted Oklahoma State Department of Health to advise of the Immediate Jeopardy findings for:

482.13 Condition of Participation: Patient Rights, and

482.55 Condition of Participation: Emergency Services


On 06/07/18 at 11:57 am, The Oklahoma State Department of Health notified the CMS Regional Office of the Immediate Jeopardy findings. The Regional Office concurred that Immediate Jeopardy conditions existed.

On 06/07/18 at 12:26 pm, the CEO and members of the hospital leadership team were notified of the Immediate Jeopardy conditions identified in Emergency Department and non-psychiatric in-patient units regarding patients for harming self or others and the searches for contraband.


On 06/11/18 at 11:00 am, the hospital submitted an acceptable written plan of removal consisting of:

* Improved methods for identifying at risk patient populations for harming self or others were implemented in the Emergency department and all in-patient non-psychiatric units.

* Revised policies and practices for patient belonging searches for contraband and for providing sitters for at risk patients upon the patient presentation.

* Conducted clinical (including physicians) and clerical education on all shifts for the Emergency Department and all in-patient units regarding new policies and practices for patient belonging searches for contraband and for providing sitters for at risk patients upon presentation, and planned to continue to education until 100% staff was obtained.

* Implemented increased quality monitoring to include every two hour House Supervisor rounding to evaluate identified at risk patients and ensure new search of patient belongings and sitter policies and practices had been instituted.

* Implemented Rapid Improvement Project that included ensuring patient belonging searches and sitters for at risk patient with measurable indicators, had begun gathering daily data, analyzing the data, and implementing action plans.

* Presented the Rapid Improvement Project to the Governing Board and it was approved for implementation.

* Developed continued reporting processes to Quality and Medical Executive committees and Governing Body.


On 06/11/18 at 11:15 am, the surveyors verified the removal of immediacy by:

* reviewing the list of current in-patients and ED who were identified at risk for harming self or others.

* verified through interview that the House Supervisors would utilize the at risk list, keep-it updated, and use the list to perform the every two hour patient checks.

* reviewing acceptable policies regarding searches and sitters for high risk population for harming self or others.

* reviewing acceptable staff re-education rosters regarding searches and sitters for high risk population for harming self or others and accepted plan for capturing 100% of all staff and ED providers.

* reviewing acceptable quality monitoring measures which assigned House Supervisors surveillance responsibilities to include ensuring at risk patients were searched at arrival to the ED, contraband removed and secured, and ensured the environment and monitoring was appropriate to meet the patient's needs.

* reviewing the initial rounding data from the House Suprvisor's rounding surveillance and verified the information was communicated to leadership.

* interviewed six ED staff regarding their knowledge of policy changes and re-education provided for the management of high risk population for harming self or others.