The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

WELLSTONE REGIONAL HOSPITAL 2700 VISSING PARK RD JEFFERSONVILLE, IN 47130 June 19, 2018
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on document review and interview, the hospital failed to ensure verbal orders were promptly authenticated according to facility policy in 1 instance.

Findings include:

1. Review of the policy titled Authenticating Telephone Orders, Review/Revision Date 2/18, indicated the following: It is the policy of the hospital to ensure a complete Medical Record, that all telephone orders shall be authenticated within 48 hours.

2. Review of the MR of P1 indicated a verbal order to "Block" the patients room was entered on 6/10/18 at 17:00 hours. The order lacked documentation of the practitioner's authentication.

3. On 6/19/18 at approximately 2:30pm, A2, Director of Nursing, verified that on 6/10/18 a physician's verbal order to block the room of patient P1 was documented, but was not signed/authenticated by the physician.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and interview, the hospital failed to provide patient (P2) with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion in 1 instance.

Findings include:

1. Review of the hospital policy titled Patient Advocacy Program, Review/Revision Date 6/16, indicated the following:
A. Policy: It is the policy of (the hospital) to provide a means whereby patient, families/guardians, and other concerned individuals can identify a problem or complaint and be assured it will be heard and acted upon in a non-biased manner to problem resolution for all parties.
B. 3.0 Department Manager will be responsible for the following: 3.1 Discuss grievance with patient, family/guardians, and other as deemed appropriate. 3.2 Investigate concerns, takes actions, and provides mediation toward problem resolution. 3.3 Documents all investigation information and action taken.
C. 4.0 Patient Advocate and Representative will be responsible for the following: 4.1 Review all concerns/issues, actions taken and pursues further resolution if deemed appropriate. 4.2 Assist patient and other concerned individuals to pursue process through all levels until problem resolution. 4.3 In case of successful Grievance Resolutions (at any level): b. Gives written documentation of process to patient, family/guardian. 4.4 In case of Unsuccessful Grievance Resolution at lower level process: a. Schedule internal fair hearing within five (5) days. b. Assist in compiling panel for fair hearing to include: 1. Chief Executive Officer. 2. Chief Nursing Officer. 3. Hospital Medical Director. c. Assist patient in presenting grievance. d. Works with all towards problem resolution. e. Assure written documentation procedures as described in this policy (4.3), if problem resolved. 4.6 Will complete the following for patients who have been discharged . a. Will discuss grievance with patient, family/guardian, and other as deemed appropriate. b. Investigate concerns, takes action, and provides mediation toward problems resolution. c. Documents all investigation information and action taken.

2. Review of hospital complaints and grievances indicated a follow-up letter, dated 6/11/18, was sent to P2. The letter lacked documentation of the hospital's decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the prievance process and the date of completion.

3. On 6/19/18 between approximately 11:20am and 11:50am, A1, Director of Regulatory Compliance, verified that following the complaint reported by P2 on 6/8/18, P2 was the only person interviewed. She, nor other facility staff, investigated the reported incident by interview of the RN on duty, the MHT (mental health technician) who reportedly had knowledge of the event, nor the accused perpetrator. A1 indicated that the person signing the follow-up letter, A9, Patient Advocate, would be the contact person, but verified that that was not indicated in the letter and that the letter lacked documentation of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. A1 further indicated that although the complaint was marked as complete with resolution and patient satisfaction on 6/8/18, the patient (P2) left the hospital AMA and threatened lawsuit. A1 then indicated the investigation was actually "ongoing".
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the hospital failed to investigate reports of sexual assault per hospital policy in 1 instance.

Findings include:

1. Review of hospital policies indicated the following:
A. The policy titled Incident Reporting, Review/Revision 8/17, indicated the following: Policy:
i. Any occurrence or incident that is not consistent with the routine delivery of care or operation of hospital or expected outcomes of patient or employment shall be promptly, accurately and factually reported by the employee witnessing or having knowledge of the occurrence. Employee will enter the incident into MIDAS RDE (the electronic incident reporting system) and report it to the supervisor before leaving his/her shift.
ii. Procedure: Who Does What. Reporting Level 1 or 2 incidents: All Staff (who witnessed incident or has knowledge) 1. Any employee who witnessed the incident or has knowledge will document the incident using MIDAS RDE... Nurse on Unit:. Notifies the physician of the incident and documents notification. 5. Documents assessment, intervention, and outcome in the medical record (MR). House Supervisor and/or Nurse Manager: 9. Conducts a preliminary investigation and verifies completion of incident report by employee. 10. Documents immediate steps taken following the incident to include: e. Witnesses to the event.

2. Review of medical records (MR) indicated the following:
A. The MR of P1 indicated the patient was admitted to the hospital 6/5/18 and discharged [DATE]. The Interdisciplinary Master Treatment Plan (IDMTP), indicated the following "Psychiatric Problems" were identified: On 6/5/18: 1. Potential for agitation. 2. Altered thoughts. On 6/8/18 3. SAO (sexually acting out).
B. The MR of P2 indicated the patient was admitted to the hospital 6/6/18 at 1431 hours, was transferred to an outside hospital for emergency services on 6/6/18 at 2140 hours, returned to (Facility #1) on 6/7/18 at 1930 hours and was discharged AMA (Against Medical Advice) on 6/8/18 at 1620 hours. CPE documentation, dictated 6/8/18, and the physician's Short Stay Summary, dictated 6/8/18, indicated the following: Plan of Treatment: I discussed in detail with the patient and with the therapist, S1. Patient signed AMA. Patient said that he/she has an incidence in the late night or early morning today that 1 of the patients who has dementia came close to him/her and touched his/her private parts, which made him/her very upset. He/she does not want to stay here and said he/she does not feel safe here and wants to leave today. After reviewing all the circumstances, discussing with the treatment team, social worker, risk management, I have no criteria to hold him/her against his/her will as he/she is competent to make his/her own decision... Social Services Individual Session note dated 6/8/18 at 1710 hours indicated the following: Writer spoke with P2 around 9:30am. He/she requested to see me. He/she said that last night his/her roommate was fondling him/her as he/she slept. He/she woke up to see the roommate standing over him/her and the roommate's hand was in P2's pants. He/she said that he/she became very angry and wanted to hurt the roommate but did not and instead called for help. The staff came in and separated the roommate from P2. The MR lacked documentation of the unit nurse having notified the physician of the incident and lacked documentation of assessment, intervention and outcome.

3. Review of facility administrative documents indicated the following:
A. Incident report (IR) dated 6/8/18, indicated it was entered in to the the MIDAS RDE system by S3, unit RN. The IR indicated the following: Patient reported that he/she woke up with his roommate touching him/her and work him/her up. He/she reports that he/she yelled at him/her to get away from him/her and came out of his/her room. When he/she came down the hall, he/she stated "I'm not going back in that room." This nurse spoke to the supervisor and the patient was moved to another unit, another room immediately. The patient was agitated and still would not go lay down in his/her new room, sat in the dayroom for the rest of the shift. Patient reported that no injury happened. Refused medications to help with anxiety or agitation. Patient refused medications and vitals since returning from being sent out to hospital the day before. Patient was very focused on being discharged since he/she came into the hospital on the 7th of June, did not want to go AMA (against medical advice). The IR lacked documentation of a thorough, objective investigation. The MIDAS RDE report(s) lacked documentation of an entry by S2, MHT (mental health technician) indicated to have knowledge of the event.
B. Complaints/grievance documentation indicated the following: Patient P2 had written a complaint dated 6/8/18 with the following concern: Sexual assault on me (P2) on 6/8/18 at 2:00am by a man/woman named (P1). "I want out of here." "Not safe at this facility." The document indicated the following action was taken: A1, Director of Regulatory Compliance, and A9, Patient Advocate, met with patient and listened to concerns. S1, social worker, has also spoke to P2. MD1 was called by A9 to inform him/her of AMA (against medical advice) request and concerns. The document indicated the patient refused to sign.

4. Review of the document titled Nursing Supervisor Report: Date: Thursday; 6-7/2018, lacked documentation of witnesses to the event.

5. A. On 6/18/19 at approximately 11:00am A1, Director of Regulatory Compliance, indicated that if the facility had an allegation of abuse, it would be considered an incident and the hospital would follow their policy for Incident Reporting. At approximately 3:10pm, A1 indicated that he/she felt the "roommate" (P1) probably did touch P2. A1 indicated P2 yelled for help, staff came in and the roommate was reportedly standing over, but not touching P2. A1 indicated that the staff who reportedly came in to the room was MHT S2 and that the unit nurse was S3.
B. On 6/19/18 at approximately 10:25am, A1 indicated the MHT with knowledge of the above incident, did not document the observation in the MR, nor did the unit RN on duty document notification of the event. A1 further indicated that while patient (P2) was moved to another unit following the incident, that documentation was not recorded in the MR by the unit RN, nor was notification to the supervisor or the physician, or assessment, intervention and outcome.
C. On 6/19/18 between approximately 11:20am and 11:50am, A1 indicated that documentation of investigation of the above complaint and incident were combined and notes of actions taken were what were in the complaint folder. A1 verified that following the complaint reported by P2 on 6/8/18 and the related incident on 6/8/18, P2 was the only person interviewed. She, nor other facility staff, investigated the reported incident by interview of the RN on duty, the MHT, nor the accused perpetrator.