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.

SAINT LUKE'S CUSHING HOSPITAL 711 MARSHALL STREET LEAVENWORTH, KS 66048 Sept. 2, 2020
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interviews, medical record reviews, document reviews, and review of facility policies, the facility failed to promote all patients' rights by failing to respond to grievances in a timely fashion, failing to protect a patient from intimidation, failing to provide an order for physical restraints, and failing to ensure patients are examined for injuries following release of restraints. The cumulative effects of these failures have the potential to infringe on the rights of all patients presenting for care to this facility, with possible negative outcomes, both physical and psychosocial.

Findings include:

1. Review of the facility's policy titled, "Customer Grievance/Concern Resolution," last revised 06/30/20, showed, Grievances will be handled as follows: Within seven days the customer will receive a telephone call or a written response acknowledging receipt or resolution of the complaint. An investigation of the complaint will be initiated, and the appropriate staff contacted. Within 30 days the customer will be provided written notice of action taken regarding the grievance. Should the investigation take longer than 30 days, the customer or their representative/guardian will be notified in writing.

Review of two grievance files showed the responses to these grievances did not meet hospital policy for timeliness. During an interview with Staff C, Emergency Department (ED) Nurse Manager on 09/01/20 at 11:10 AM, Staff C reported having the responsibility to investigate and respond to complaints and grievances for the facility. Staff C agreed the initial and final responses to both grievances reviewed did not meet the time frames established by facility policy.

(Refer to A0122)

2. Review of the facility's policy titled, "Patient Rights and Responsibilities," last revised 07/26/16, showed, The patient has the right to be free from all forms of abuse, bullying or harassment, including physical, mental, sexual and verbal abuse, neglect and exploitation and corporal punishment.

Review of video recordings of activities in the ED hallway, and body-cam audio and video recording of Staff G, Security Officer called to assist in the ED following release of a patient from a physical hold showed the following. The audio and video recording showed Staff D, the ED physician, verbalizing warnings to the patient, a minor, and the patient's mother, of the possible use of mechanical restraints due to the patient's yelling and refusal to get on a bed.

During a joint interview with Staff C, ED Nurse Manager, Staff N, Director of Nursing, and Staff I, Quality Analyst on 09/02/20 at 10:39 AM, all the above agreed it was never acceptable to threaten a patient with restraints or any other threat. When asked if a patient yelling, or not cooperating in getting on a bed was considered a reason for applying restraints of any kind, Staff N and Staff C stated that it was not a valid reason. When asked if it would be considered a threat to announce to Patient 1, a minor patient, and F1" ...he will be tied up," after a physical hold had been released and Patient 1 was no longer actively aggressive or dangerous, Staff N and Staff C agreed that Staff D's statement was threatening, was a form of intimidation, and did not adhere to facility policy for Patient Rights.

(Refer to A0145)

3. Review of the facility's "Rules and Regulations," for Medical Staff, approved by the Governing Body 11/24/15, showed, Use of Restraints and Seclusion: Medical Staff and Allied Health Professionals will comply with the Hospital's policies, procedures and patient care guidelines on the use and management of restraints ...and will be implemented in accordance with safe and appropriate restraint techniques as determined by Hospital policy ... Restraints may only be used upon the order of a Physician Member who is responsible for the care of the patient when less restrictive interventions have been determined to be ineffective to protect the patient, staff or others from harm.

Review of the facility's policy titled, "Restraint and Seclusion Management - Violent Behavior/Self-Destructive Behavior," last revised 10/19/17, showed, Restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his/her arms, legs, body or head freely, and, Physical Hold: Physically holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraints. The policy also showed, Guideline: Discontinuing the restraint or seclusion: Assess for patient injury related to the restraint or seclusion, and Documentation: Any patient injuries sustained while restrained and/or secluded, and Guideline: Ordered by a physician ...order includes: Type of restraint or seclusion to be used; Reason for restraint or seclusion; Criteria for release or removal; Date, time, signature.

Review of Patient 1's electronic medical record showed the patient was placed in a physical hold during the ED encounter on 08/21/20. Further review of Patient 1's record showed no physician's order for the restraint was obtained and no physical assessment was conducted following release of the restraint. Review of Patient 9's electronic medical record showed the patient was in mechanical restraints for a portion of the ED encounter on 06/21/20, but no documentation was found of a physical assessment following release from the restraints.

(Refer to A0167 and A0168)
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on staff interview, review of documents, and review of facility policy, the facility failed to follow facility policy to ensure a timely response to grievances for two of two complaint patient records reviewed (Patient 10 and Patient 11). Failure to provide a timely response to grievances infringes on the rights of all patients or their representatives to have their grievances investigated and addressed and hinders the facility's opportunity to discover and address systemic problems.

Findings include:

Review of the facility's policy titled, "Customer Grievance/Concern Resolution," last revised 06/30/20, showed, Grievances will be handled as follows: Within seven days the customer will receive a telephone call or a written response acknowledging receipt or resolution of the complaint. An investigation of the complaint will be initiated, and the appropriate staff contacted. Within 30 days the customer will be provided written notice of action taken regarding the grievance. Should the investigation take longer than 30 days, the customer or their representative/guardian will be notified in writing.

Review of the facility's "Grievances" log dated 03/01/20 - 08/28/20 showed two grievances filed during that time, one by Patient 10 and one by Patient 11.

Review of Patient 10's grievance file showed a written grievance was filed on 03/05/20. Review of the initial letter sent to Patient 10 in response was dated 03/19/20, or 14 days following receipt of the complaint. The facility was unable to provide a copy of a letter informing the complainant of the investigation results, action taken, or a final resolution of the grievance.

Review of Patient 11's grievance file showed an initial response letter was sent to the patient's representative (the complainant) on 06/17/20. The contents of the letter showed the entry, "I am writing in follow up to the concerns that you shared with me by phone on June 5th, 2020 ...," showing that the initial response was sent twelve days after receipt of the grievance. The final letter addressing the investigation results was dated 08/31/20, or 87 days following receipt of the grievance.

During an interview with Staff C, Emergency Department Nurse Manager (ED Mgr.) on 09/01/20 at 11:10 AM, Staff C reported having the responsibility to investigate and respond to complaints and grievances for the facility. Staff C agreed the initial response to Patient 10's grievance was not sent within the seven days dictated by facility policy and acknowledged having no documentation of a final letter of response to Patient 10. Staff C agreed the initial response and final response letters sent to Patient 11's representative were not sent within the time frames established by facility policy.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on family and staff interviews, medical record reviews, and review of facility policy, the facility failed to ensure one of eleven patients sampled was protected from threats and intimidation by staff members (Patient 1). This failure can infringe on the rights of all patients to be free from verbal abuse or harassment, with possible psychosocial harm.

Findings include:

Review of the facility's policy titled, "Patient Rights and Responsibilities," last revised 07/26/16, showed the patient has the right to be free from all forms of abuse, bullying or harassment, including physical, mental, sexual, and verbal abuse, neglect and exploitation and corporal punishment.

Review of Patient 1's electronic medical record showed a visit to the facility's Emergency Department (ED) on 08/21/20 related to behavioral changes observed by Family (F) 1, Patient 1's mother. Review of the entry, "ED Notes," by Staff J (ED RN1) dated 08/21/20, timed at 5:18 PM showed, "Pt refusing blood draw. Mother of pt present. Pt became verbally aggressive and grabs his mother forcefully on her left arm. Pt refusing to let go of his mother and kicks this RN and attempts to punch other staff. Pt lowered to a position of safety on the floor with RN to protect this RN from the punches and kicks thrown by pt. Pt continued to try and strike his head against this RN. As staff approached to assist pt kicked (Staff D) in groin and attempted to kick other staff. Pt eventually made verbal agreed to not strike pt and pt sat on floor to continue to deescalate. Pt threw his shoe at (Staff D). Pt screaming constantly on floor of room ..." Review of the entry, "ED Provider Notes," dated 08/21/20 at 7:10 PM, showed, a diagnosis of Psychiatric disorder, and the entry, " ...patient became violent with the staff to the point they had to restrain him physically ..."

During a telephone interview with F 1, Patient 1's mother, on 08/31/20 at 1:42 PM, F1 confirmed that Patient 1, F1's [AGE] year old son, had been placed in a physical hold by staff at the above-named facility during the ED visit on 08/21/20. During the interview, F1 made multiple allegations of remarks made to Patient 1 by Staff D, the ED physician during and after the physical hold, including, "I'm going to show you how it feels to hit other people," and, "You're acting like a baby," and, "You've got 10 minutes to get up on the bed - if you don't, we'll restrain you." When asked if F1 believed Patient 1 had sustained psychological harm from the experience, F1 stated that Patient 1 has since stated that Patient 1 does not ever want to go back to (name of facility). F1 stated concern because F1 anticipates Patient 1 will need more behavioral health care in the future and fears Patient 1 will be unwilling to seek treatment in the future.

Review of a Security Office video-only recording of the activities in the ED hallway on 08/21/20 in the presence of Staff E, Risk Management and Staff H, Security Officer 2 showed the video displayed the exact time of events, and Staff E confirmed Patient 1 was treated in ED Room 3 directly across from the nurse's desk. Staff J, RN1, primary nurse for Patient 1 and the RN who documented the physical hold of Patient 1 noted above, exited the room with the a wheeled supply tray at 5:15 PM, indicating that the physical hold had been discontinued at this time. Staff E identified Staff G, Security Officer 1 as arriving to Room 3 at 5:19 PM.

During a telephone interview with Staff G on 09/01/2020 at 12:30 PM, Staff G stated that when Staff G was called to ED Room 3 on 8/21/20, Patient 1 was sitting on the floor crying and F1 was sitting in a chair, both Patient 1 and F1 were alone in the room.

Review of both audio and video recording from the "body-cam" of Staff G was reviewed in the presence of Staff E, Risk Management, and audio was confirmed with Staff E during the review.
Staff G arrived at Room 3 at 5:19 PM, after the physical hold had ended due to Patient 1 ceasing aggressive activity. Patient 1 was heard to be loudly yelling, and Staff D, standing near the doorway to the room was heard to state to Staff G, "He's old enough to know better." Staff G was heard to state, "I don't know, do we need to restrain him?" and Staff D, still in the doorway, stated, "I don't know. If he won't stop yelling, we might have to. If he hits somebody or throws anything, he will be put in four-point restraints for his and the staff's safety, Mom." Staff D was then heard to say, "Let's move that out, this is going to be a fiasco, he's old enough to know better." Later in the video, while Staff G and Staff J were at nurse's station, Staff D was heard to state, "Mom, I've got a message for you just to let you know, they're about ready to put him in four-point restraints. However, I'm intervening. I'm going to let you talk with him for a moment. He just needs to lay on the bed. We're not going to be doing labs or anything else. We just need him to calm down. If he can't do that, if he's still a danger to the staff or himself or you, he will be tied up in four-point restraints. You know where I'm going with this?" A female voice was then heard to say, "I sure do." Staff G left the area at 5:22 PM, ending the review of the video recording.

During a joint interview with Staff C, ED Nurse Manager, Staff N, Director of Nursing, and Staff I, Quality Analyst on 09/02/20 at 10:39 AM, all the above agreed it was never acceptable to threaten a patient with restraints or any other threat. When asked if a patient yelling, or not cooperating in getting on a bed was considered a reason for applying restraints of any kind, Staff N and Staff C stated that it was not a valid reason. When asked if it would be considered a threat to announce to Patient 1, a minor patient, and F1" ...he will be tied up," after a physical hold had been released and Patient 1 was no longer actively aggressive or dangerous, Staff N and Staff C agreed that Staff D's statement was threatening, was a form of intimidation, and did not adhere to facility policy for Patient Rights.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff and family interviews, review of medical records, and review of facility policy, the facility did not follow their policy for safe use of restraints when they failed to examine patients for possible injuries following removal of restraints for two of two restraint records reviewed (Patient 1 and Patient 9). Failure to perform a physical assessment on patients following an episode of physical or mechanical restraints could result in undetected patient injuries, with possible negative outcomes.

Findings include:

Review of the facility's "Rules and Regulations," for Medical Staff, approved by the Governing Body 11/24/15, showed, Use of Restraints and Seclusion: Medical Staff and Allied Health Professionals will comply with the Hospital's policies, procedures and patient care guidelines on the use and management of restraints ...and will be implemented in accordance with safe and appropriate restraint techniques as determined by Hospital policy.

Review of the facility's policy titled, "Restraint and Seclusion Management - Violent Behavior/Self-Destructive Behavior," last revised 10/19/17, showed, Restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his/her arms, legs, body or head freely, and Guideline: Discontinuing the restraint or seclusion: Assess for patient injury related to the restraint or seclusion, and Documentation: Any patient injuries sustained while restrained and/or secluded.

1. Review of Patient 1's electronic medical record showed a visit to the facility's Emergency Department (ED) on 08/21/20 related to behavioral changes. Review of the entry, "ED Notes," by Staff J (ED RN1) dated 08/21/20, timed at 5:18 PM showed, "Pt refusing blood draw. Mother of patient present," Family (F)1. Pt became verbally aggressive and grabs his mother forcefully on her left arm. Pt refusing to let go of his mother and kicks this RN and attempts to punch other staff. Pt lowered to a position of safety on the floor with RN to protect this RN from the punches and kicks thrown by pt. Pt continued to try and strike his head against this RN. As staff approached to assist pt kicked (Staff D) in groin and attempted to kick other staff. Pt eventually made verbal agreed to not strike pt and pt sat on floor to continue to deescalate. Pt threw his shoe at (Staff D). Pt screaming constantly on floor of room ..." Review of the entry, "ED Provider Notes," dated 08/21/20 at 7:10 PM, showed, a diagnosis of Psychiatric disorder, and the entry, " ...patient became violent with the staff to the point they had to restrain him physically ..." Review of the remainder of the record showed no documentation of an assessment of Patient 1 after the release of the hold for possible injuries.

During a telephone interview with Staff D, ED Physician on 09/01/20 at 1:00 PM, Staff D recalled Patient 1 and the events of 08/21/20 and declined to review the electronic medical record prior to the interview. Staff D stated that nursing staff and Staff D did employ a physical hold on Patient 1 when Patient 1 suddenly became physically aggressive. When asked if Staff D had conducted a physical assessment of Patient 1 following release from the physical hold, Staff D stated, "I did re-examine him. He said he was okay." When asked if Staff D had documented this reassessment, Staff D could not recall.

During an interview with Staff J, Registered Nurse (RN) 1 on 09/01/20 at 9:30 AM, Staff J reported being Patient 1's primary nurse during the ED visit of 08/21/20. Staff J reported there was a physical hold of Patient 1 during an incident of physical aggression by Patient 1 toward staff, as Staff J documented in the medical record. When Staff J was asked if Staff J or anyone else conducted an examination of Patient 1 for possible injuries following the release of the physical hold, Staff J replied, "I don't know."

During a telephone interview with F1, Patient 1's mother, on 08/31/20 at 1:42 PM, F1 confirmed that Patient 1, F1's [AGE] year old son, had been placed in a physical hold by staff at the above-named facility during the ED visit on 08/21/20, a Friday. F1 stated that Patient 1 was transferred to a psychiatric facility later that evening. F1 stated that during a telephone call with Patient 1 the following day, Saturday, Patient 1 reported neck and leg pain because, "They held me too hard." F1 stated that Patient 1 returned home on the following Wednesday and F1 observed bruising on Patient 1's neck and back and a scratch on Patient 1's leg.

2. Review of Patient 9's electronic medical record "ED Provider Notes" showed Patient 9 arrived at the ED on 06/21/20 at 2:32 AM via EMS, in restraints, with a diagnosis of acute alcohol intoxication and aggressive behavior. Documented orders showed continued restraints for continued aggressive behavior. Physician Orders showed the restraints were discontinued on 06/21/20 at 8:20 AM. No documentation was found of a physical assessment of Patient 9 following removal of the restraints, and Patient 9 was discharged on [DATE] at 11:50 AM.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on staff interview, review of medical records, and review of facility policy, the facility failed to ensure application of restraints with a physician's order for one of two restraint records reviewed (Patient 1). The failure to obtain a written order for a restraint infringes on the rights of patients to be restrained only by a licensed practitioner responsible for the care of that patient.

Findings include:

Review of the facility's "Rules and Regulations" for Medical Staff, approved by the Governing Body 11/24/15, showed, "Medical Staff Members and Allied Health Professionals will comply with the Hospital's policies, procedures and patient care guidelines on the use and management of restraints. Restraints may only be used upon the order of a Physician Member who is responsible for the care of the patient when less restrictive interventions have been determined to be ineffective to protect the patient, staff or others from harm."

Review of the facility's policy titled, "Restraint and Seclusion Management - Violent Behavior/Self-Destructive Behavior," last revised 10/19/17, showed, Physical Hold: Physically holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraints. The policy also showed, Guideline: Ordered by a physician ...order includes: Type of restraint or seclusion to be used; Reason for restraint or seclusion; Criteria for release or removal; Date, time, signature.

Review of Patient 1's electronic medical record showed a visit to the facility's Emergency Department (ED) on 08/21/20 related to behavioral changes. Review of the entry, "ED Notes," by Staff J (ED RN1) dated 08/21/20, timed at 5:18 PM showed, "Pt refusing blood draw. Mother of pt present, [Family (F)1]. Pt became verbally aggressive and grabs his mother forcefully on her left arm. Pt refusing to let go of his mother and kicks this RN and attempts to punch other staff. Pt lowered to a position of safety on the floor with RN to protect this RN from the punches and kicks thrown by pt. Pt continued to try and strike his head against this RN. As staff approached to assist pt kicked (Staff D) in groin and attempted to kick other staff. Pt eventually made verbal agreed to not strike pt and pt sat on floor to continue to deescalate. Pt threw his shoe at (Staff D). Pt screaming constantly on floor of room ..." Review of the entry, "ED Provider Notes," dated 08/21/20 at 7:10 PM, showed, a diagnosis of Psychiatric disorder, and the entry, " ...patient became violent with the staff to the point they had to restrain him physically ..." Review of "Laboratory Orders," and "Other Orders," showed no documented order for restraints.

During a telephone interview with Staff D, ED Physician on 09/01/20 at 1:00 PM, Staff D recalled Patient 1 and the events of 08/21/20 and declined to review the electronic medical record prior to the interview. Staff D stated that nursing staff and Staff D did employ a physical hold on Patient 1 when Patient 1 suddenly became physically aggressive. Staff D denied writing an order for the physical restraint after the event, stating, "It was just a few minutes."

During an interview with Staff J, Registered Nurse (RN) 1 on 09/01/20 at 9:30 AM, Staff J reported being Patient 1's primary nurse during the ED visit of 08/21/20. Staff J reported there was a physical hold of Patient 1 during an incident of physical aggression by Patient 1 toward staff. Staff J reported four staff members (three RN's and the physician) had hands on Patient 1 by the end of the incident. Staff J reported using the physical hold as an emergency measure but stated there was no written order for the restraint."

During a telephone interview with Staff K (RN2) on 09/01/20 at 8:45 AM, Staff K stated that Staff K did participate in the physical hold of Patient 1 on 08/21/20. Staff K recalled the physical hold lasted, "less than five minutes." Staff K stated there was no order for the restraint."

During an interview with Staff L (RN3) on 09/01/20 at 2:00 PM, Staff L stated that Staff L did participate in the physical hold of Patient 1 on 08/21/20. Staff L was unable to report that there was an order for the restraint.

During a joint interview with Staff C, ED Nurse Manager, Staff N, Director of Nursing, and Staff I, QA Analyst on 09/02/20 at 10:39 AM, all three staff members agreed the physical hold documented in Patient 1's medical record and reported by the physician and nurses interviewed constituted a restraint. Staff N added any restraint requires a physician's order either before or immediately following an emergency restraint.