HospitalInspections.org

The Hospital failed to provide resolution to grievances submitted by Patient #2's family and by Patient #5. The Hospital failed to provide care in a safe setting by preventing Patient #3 from attempting to elope which resulted in a fractured arm and the Hospital failed to ensure that Patient #5's care was free of abuse by a care provider.

Refer to tags:
A-0123
A-0144
A-145

The Hospital failed for 5 of 11 patient records reviewed to implement performance improvement activities, track medical errors and adverse patient events, analyze their causes, and implement preventive actions throughout the hospital.

Refer to Tag: A-0286

The Hospital's infection prevention and control program failed to employ methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings.

Refer to tag A-747

Based on interviews and records reviewed, the Hospital failed to provide resolution to grievances in 2 (Patient #2 and Patient #5) of 11 patient records reviewed.

Findings include:

Review of the Hospital's Grievance Policy, dated 12/2018 indicated that the Hospital will establish a process for prompt and effective resolution of patient's, families' and visitors' complaints and grievances.

A verbal or written complaint regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purposes of these requirements.

Complaints:
a. The hospital will review, investigate and resolve each patient's complaint within 24 hours.
b. The hospital will remove the patient immediately from any situation that may endanger the patient.
c. Once the complaint is resolved the appropriate hospital personnel will communicate the resolution to the patient and confirm that the complaint is no longer valid.
d. If the complaint cannot be resolved in 24 hours or to the patient's satisfaction, the complaint will become a grievance and a grievance form must be completed.

Grievances:
a. The grievance will be investigated by hospital leadership.
b. Every effort will be made to respond to grievances within 7 days. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, an update will be given to the patient or the patient's representative informing them that the Hospital is continuing to resolve and investigate the grievance and that the Hospital will follow up with a written response within a stated number of days in accordance with the hospital's grievance policy.
c. Upon resolution of the issue, the CEO will provide to the patient or patient representative, written communication containing: Facility Contact Person, The steps taken on behalf of the patient to investigate the grievance, the findings and determination, the date of completion, this written communication will be sent to the patient within 7 days of the resolution.

1. Patient #2 was admitted on 3/3/20 and readmitted 3/27/20 with a diagnosis of endocarditis with a past medical history that included intravenous drug use.

On 4/8/20 at 10:00 A.M., Patient #2 was found unresponsive in his/her bed and a Code Blue was initiated. At 10:20 A.M. Patient #2 was pronounced dead. It was reported that the Hospital failed to communicate this to the Patient's family for 4 hours. The family filed a grievance with the Chief Executive officer.

Record review indicated that Patient #2's family sent an email to the CEO on 4/13/20 to inform him that they wanted an answer as to why the family wasn't notified in a timely manner that their son passed away. The CEO sent a response on 4/14/20 which indicated that the matter will be looked into and that the Hospital will look for opportunities to learn and improve from the incident.

During an interview with the Chief Executive Officer (CEO) on 6/25/20 at 12:30 P.M., the CEO said that he did respond to the family member's email on 4/14/20. There was no further correspondence to the family regarding resolution or corrective actions to be taken.
There was no further correspondence to the family which identified an investigation took place. The family did not receive a letter or any follow-up information from the CEO.

2. Record review of an internal grievance indicated that on 4/24/20 Patient #5 told the Wound Care Nurse that the night before, Nurse #2 was viciously and toxically rough with him/her while providing care.

In an interview with the Wound Care Nurse on 6/25/20 at 11:30 A.M. the Wound Care Nurse said that she responded to Patient #5's call light and Patient #5 told her that Nurse #2 was very rough with him/her and had a temper problem. Patient #5 told the Wound Care Nurse that Nurse #2 treated him/her with violence while repositioning him/her causing him/her fear and Nurse #2 refused to use skin prep when helping with his/her colostomy bag. Patient #5 told the Wound Care Nurse that due to Nurse #2's temper, he/she was afraid to ask for help and had to lay flat on his/her back for the night. The Wound Care Nurse said that due to the absence of both the Nurse Manager and the Chief Quality Officer, she informed the CEO of the complaint. She said that she felt this was emotional, mental and physical abuse and wanted to make sure it was investigated. The Wound Care Nurse said that the CEO requested the complaint in writing so she went back and got it in writing and co-signed the complaint with Patient #5. She then gave the complaint to the CEO.

During an interview with the Chief Quality Officer on 6/23/20 at 12:00 P.M. the CQO said he/she was not working during the allegation. He further said that Patient #5 was discharged days after the allegation and that there was no follow-up provided to the patient by the Hospital regarding the complaint.

During an interview with the Nurse Manager on 6/25/20 at 11:00 A.M., she said that she was out on a leave of absence during this complaint and that when she returned from a leave of absence, she found the typed complaint letter in a pile of papers on her desk and wasn't sure what came of the complaint investigation. The Nurse Manager said that Nurse #2 was an agency nurse and is no longer working at the Hospital due to scheduling issues.

During an interview with the CEO on 6/25/20 at 12:30 P.M., the CEO said that he didn't know the outcome of the complaint of abuse by Patient #5.

No further information was provided by the facility regarding the complaint and its resolution.

Based on interviews and records reviewed, the hospital failed to provide care in a safe setting for 2 (Patient #3 and Patient #6) of 11 patient's records reviewed.

Findings include:

1. Patient #3 was admitted to the Hospital on 11/13/18 with a diagnoses of traumatic brain injury, depression and anxiety.
It was reported that during an attempt to elope from the locked Neurological Rehabilitation Unit, Patient #3 fell and broke the right humerus.

Record review indicated that on 5/20/20 Patient #3 and Patient #6 were able to get out of the locked Neurological Rehabilitation Unit in an attempt to go outside to smoke a cigarette.

Review of a Nurses Note, dated 5/20/20 indicated that Patient #3 pushed the (locked) main door and got out to the elevator.

The Incident Report dated 5/20/20, indicated that Patient #3 fell, landed on the floor in the prone position with his/her right arm hyperextended while resisting staff while attempting to leave the unit. The investigation comments indicated that there was no apparent injury at the time of the incident, but 3 days later, Patient #3's right upper arm/shoulder was bruised and Patient #3 had limited movement to the right arm.

Review of the Incident Report indicated that an investigation is underway.

During an interview with Physician #1 on 6/23/20 at 11:30 A.M., Physician #1 said that Patient #3 was able to manipulate the door. The door beeped and staff were alerted that the Patient had eloped. Physician #1 said that she was informed of the incident 2-3 days after it occurred.

During an interview with the Nurse #1 on 6/24/20 at 11:50 A.M., Nurse #1 said that she was not present at the time of Patient #3's elopement and fall. She said that the door is on a timer. If you hit the door, after ten seconds you can push it.

During an interview with the Director of Maintenance on 6/24/20 at 10:45 A.M., the Director of Maintenance said that he was informed that the door was broken on Sunday, June 21, 2020, 31 days after the elopement. He said that he looked at it the next day and then had an outside security company come in 6/23/20.

The outside security company sent an email to the Director of Maintenance on 6/25/20 informing him that their technician was able to secure the door 6/23/20, 33 days after Patient #3 and Patient #6 were able to elope.

No further information was provided by the Hospital to identify how the facility was keeping patients safe on a locked unit if the locked door was broken and patients were able to elope.

Based on interviews and records reviewed the Hospital failed to protect 1 (Patient #5) of 11 Patient records reviewed from abuse while admitted to the Hospital.

Findings include:

Review of the Hospitals Abuse/Neglect Policy, dated 2/2020 indicated that:
1. The Hospital supports the patient's right to receive care in a safe setting and will act to protect vulnerable patients, including protection of the patient's emotional and physical health and safety.
2. The Hospital maintains a strict policy to prevent or respond to allegations of abuse, neglect or mistreatment, including prompt reporting of any alleged abuse incident to hospital leaders and applicable state agencies.
3. Failure to report immediately, a suspected abuse incident or co-operate in the appropriate investigation can result in corrective action.
4. The hospital investigates and reports allegations of abuse promptly in accordance with state law.

Patient #5 was admitted to the Hospital on 1/23/20 with a diagnosis of end stage renal disease and was receiving dialysis and wound care.

Record review indicated that on 4/24/20 Patient #5 told the Wound Care Nurse that the night before, Nurse #2 was viscously and toxically rough with him/her while providing care.

During an interview with the Wound Care Nurse on 6/25/20 at 11:30 A.M. the Wound Care Nurse said that she responded to Patient #5's call light and Patient #5 told her that Nurse #2 was very rough with him/her and had a temper problem. Patient #5 told the Wound Care Nurse that Nurse #2 treated him/her with violence while repositioning him/her causing him/her fear and Nurse #2 refused to use skin prep when helping with his/her colostomy bag. Patient #5 told the Wound Care Nurse that due to Nurse #2's temper, he/she was afraid to ask for help and had to lay flat on his/her back for the night. The Wound Care Nurse said that due to the absence of both the Nurse Manager and the Chief Quality Officer, she informed the CEO of the complaint. She said that this was emotional, mental and physical abuse and wanted to make sure it was investigated. The Wound Care Nurse said that the CEO requested the complaint be put in writing, so she went back and got it in writing and co-signed the complaint with Patient #5. She then gave the complaint to the CEO.

During an interview with the Chief Quality Officer on 6/23/20 at 12:00 P.M. the CQO said he/she was not working during the allegation. He further said that Patient #5 was discharged days after the allegation and that there was no investigation into the allegation of abuse.

During an interview with the Nurse Manager on 6/25/20 at 11:00 A.M., she said that she was out on a leave of absence during this complaint and that when she returned from a leave of absence, she found the typed complaint letter in a pile of papers on her desk and wasn't sure what came of the complaint investigation. The Nurse Manager said that Nurse #2 was an agency nurse and is no longer working at the Hospital due to other reasons.

During an interview with the CEO on 6/25/20 at 12:30 P.M., the CEO said that he didn't know the outcome of the complaint of abuse by Patient #5.

No further information was provided by the facility regarding the complaint of abuse.

The Hospital failed for 5 (Patient #2, Patient #3, Patient #4, Patient #5 and Patient #6) of 11 patient records reviewed to implement performance improvement activities, track medical errors and adverse patient events, analyze their causes, and implement preventive actions throughout the hospital.

The Hospital document titled "Incident Report", dated 3/2018, indicated that all incidents must be acted upon within 24 hours of occurrence. Incident reports will be routed to the Chief Quality Officer (CQO). The CQO will investigate and complete the incident summary sheet.

1. Patient #2 was admitted on 3/3/20 with a diagnosis of endocarditis with a past medical history that included intravenous drug use. On 3/17/20, at 4:20 A.M., Patient #2 was found lying supine on the floor of his/her room with a bag containing syringes next to him/her. Patient #2 was helped back into bed and began to wheeze and became unresponsive. A rapid response was called to Patient #2's room. During the rapid response Narcan (an opioid antagonist used for the complete or partial reversal of opioid overdose, including respiratory depression) was administered. Patient #2 became more responsive and alert. Patient #2 was transported to an outside hospital for possible drug overdose.

On 3/27/20, Patient #2 was re-admitted to the Hospital. On 4/7/20, Nurse #1 found Patient #2's Peripherally inserted central catheter (PICC) without a cap. Nurse #1 documented this in the nurse's notes. No interventions were documented. On 4/8/20, at 10:00 A.M., Patient #2 was found unresponsive in his/her bed and a rapid response was initiated. Patient #2's PICC line was noted to be missing the cap. At 10:20 A.M. the Code was stopped, and Patient #2 was pronounced dead.

During an interview on 6/24/20, at 11:00 A.M., the Chief Quality Officer (CQO) was interviewed. The CQO said that Patient #2's first incident (3/17/20) was still being investigated and there were no actions implemented or findings as of 6/24/20. The CQO said that there was no investigation as to where Patient #2 obtained a bag of syringes or where they were from. The CQO said that there was no investigation of Patient #2's second event on 4/8/20. The CQO was unaware that Patient #2's PICC was missing a cap on 4/7/20, and on 4/8/20 during the code.

2. Patient #3 was admitted to the Hospital on 11/13/18 with a diagnoses of traumatic brain injury, depression and anxiety.

Patient #3 had 3 documented falls, one with a fractured arm and only one of the falls had an incident report submitted to the Chief Quality Officer.

Review of Patient #3's nursing notes indicated that on 5/9/20 Patient #3 told the nurse that he/she fell in the bathroom and now has pain to his/her left arm. The Nurse's note further indicated that there was no swelling, no bruising and no open areas, an ice pack was applied and Tylenol given with mild effect.

There was no documented incident report, investigation or preventative actions involving this fall provided by the Hospital.

Review of Patient #3's Nursing Notes indicated that on 5/20/20, Patient #3 attempted to elope and when outside of the locked Neurological Rehabilitation Unit, Patient #3 fell in the elevator and landed on his/her right arm and it was hyperextended, resulting in a fractured right humerus.

During an interview with Physician #1 on 6/23/20 at 11:30 A.M., Physician #1 said that Patient #3 was able to manipulate the door. The door beeped and staff were alerted that the Patient had eloped. Physician #1 said that she was informed of the incident 2-3 days after it occurred.

During an interview with the Psychiatrist on 6/24/20 at 10:00 A.M., the Psychiatrist said that there was no investigation that took place regarding this elopement, fall and fracture.

During an interview with Behavioral Technician #1 on 6/24/20 at 11:55 A.M., He said there was no follow-up or education regarding this incident/accident. He further said that he was not a witness to the fall.

During an interview with Behavioral Technician #2 on 6/25/20 at 11:15 A.M., Behavioral Technician #2 said that someone had to investigate this incident and figure out what happened.

There was no investigation or preventative actions involving this elopement, fall and fracture provided by the Hospital.
Review of Patient #3's Nursing Notes indicated that on 5/21/20, Patient #3 was found on the floor by his/her bed. Patient #3 told the nurse that he/she went to the bathroom alone and fell when trying to get back to bed.

There was no documented incident report, investigation or preventative actions involving this fall provided by the Hospital.

3. Patient #4 was admitted to the hospital on 6/15/20 testing positive for COVID-19 and was placed in a single room with precaution notices on the outside door.

On 6/21/20 at 8:45 P.M., Patient #4 was found on the floor. Patient #4 complained of left side pain and abdominal pain. The Nurse Practitioner was notified, and a neurological assessment was completed. Patient #4 was placed back into bed and was monitored for the rest of the shift.

During an interview on 6/25/20, at 11:00 A.M., the Chief Quality Officer (CQO) was interviewed. The CQO said that he was unaware that Patient #4 had fallen, and it was never reported to him. An incident report was placed in Patient #4's chart but was never submitted to the CQO.

4. Patient #5 was admitted to the Hospital on 1/23/2020 with a diagnosis of end stage renal disease and was receiving hemodialysis and wound care.

Record review indicated that on 4/24/20 Patient #5 told the Wound Care Nurse that the night before, Nurse #2 was viscously and toxically rough with him/her while providing care.

During an interview with the Wound Care Nurse on 6/25/20 at 11:30 A.M. the Wound Care Nurse said that due to the absence of both the Nurse Manager and the Chief Quality Officer, she informed the CEO of the complaint. She said that she felt this was emotional, mental and physical abuse and wanted to make sure it was investigated. The Wound Care Nurse said that the CEO requested the complaint in writing so she went back and got it in writing and co-signed the complaint with Patient #5. She then gave the complaint to the CEO.

During an interview with the Chief Quality Officer on 6/23/20 at 12:00 P.M. the CQO said he was not working during the allegation. He said that Patient #5 was discharged days after the allegation and that there was no follow-up provided by the Hospital regarding the complaint.

During an interview with the Nurse Manager on 6/25/20 at 11:00 A.M., she said that she was out on a leave of absence during this complaint and that when she returned from a leave of absence, she found the typed complaint letter in a pile of papers and wasn't sure what came of the complaint investigation. She said that Nurse # was an agency nurse and is no longer working at this hospital due to scheduling issues.

During an interview with the CEO on 6/25/20 at 12:30 P.M., the CEO said that he didn't know the outcome of the complaint of abuse by Patient #5.

There is no documented incident report, investigation or preventative actions that took place as a result of this allegation of patient abuse.

5. Patient #6 was admitted to the Hospital on 1/2/2007 with a diagnosis of traumatic brain injury.

Record review revealed that Patient #6 was able to elope from the locked Neurological Rehabilitation Unit on 5/20/20.
In an interview with the Psychiatrist on 6/24/20 at 10:00 A.M., the Psychiatrist said that there was no investigation that took place regarding this elopement.

During an interview with Behavioral Technician #1 on 6/24/20 at 11:55 A.M., He said there was no follow-up or education regarding this incident.

There was no documented incident report, investigation or preventative actions involving this fall provided by the Hospital.

During an interview with the Chief Quality Officer (CQO) on 6/25/20 at 12:00 P.M., the CQO was not able to say why these incidents were not investigated, why all but one was missing an incident report or why no preventative actions were taken as a result of these incidents.

Based on records reviewed, observations and interviews the Hospital's infection prevention and control program failed to employ methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings.

Findings include:

The Hospital document titled "Identification Placement Notification of Patients with Covid-19", dated 3/2020, indicated that staff at all access to care points should be trained on identifying potentially at risk patients at the time contact is established.

The Hospital document titled "Infection Control Plan", dated 10/2019, indicated that education of contracted staff will occur based on identified needs of the hospital.

Patient #4 was admitted to the hospital on 6/15/20 testing positive for COVID-19 and was placed in a single room with precaution notices on the outside door.

On 6/25/20, at 11:20 A.M., the contracted radiology technician was observed entering Patient #4's room, which had signage in place to wear an N-95 mask when entering room, with a portable x-ray machine. The radiology technician donned a gown, gloves, and pulled up a mask which he was already wearing around his neck, while in the room. The radiology technician obtained the x-ray and removed the gown and gloves then pulled his mask down and left it attached around his neck. The Radiology Technician then sanitized his hands and exited the room with the portable x-ray machine while wearing the mask around his neck. The radiology technician never sanitized the portable x-ray machine or changed his mask. The radiology technician then pushed the portable x-ray machine to the other end of the unit and began to enter another patient's room with the x-ray machine. The radiology technician was stopped by the surveyor as he was about to enter the patient's room. The radiology technician acknowledged that the x-ray machine was not sanitized. The radiology technician said that he sometimes sanitized his machine in the patient's rooms and sometimes in the hall. The radiology technician was wearing the same mask as he wore with the previous patient and the mask was not an N-95. When asked about how he uses personal protective equipment and his sanitation practice with COVID-19 positive patients, the radiology technician responded that he did not know the previous patient was COVID-19 positive.

During an interview on 6/25/20, at 11:45 A.M., the Nurse Manager said that she provides infection control training to all staff and contracted staff. The Nurse Manger said that she expects all medical devices including portable x-ray machines to be cleaned before it is removed from the patient's room. The Nurse Manager said that anyone who enters a COVID-19 positive patient's room is required to wear an N-95 face mask.