HospitalInspections.org

Based on staff interview, and document review, it was determined the facility did not protect patients' rights by failing to appropriately review and investigate grievances related to alleged patient abuse, failed to maintain appropriate oversight over the grievance review process, and failed to follow proper grievance resolution procedures (see Tag A 119), and failed to provide written notice of grievance resolution (see Tag A 123). This failure puts an immediate risk of serious harm or death to any patient filing a grievance or reporting abuse, by the hospital failing to respond immediately. Immediate action is needed to ensure patient safety. Immediate Jeopardy (IJ) was identified, and the facility was notified on 01/19/23 at 4:35 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency on 01/19/23 at 5:55 p.m.

The following interventions were implemented to resolve the IJ: A change to the facility's policy titled "Handling Patient Complaints and Grievances." Grievances will be retrieved seven (7) days a week. The hospital staff will be responsible for retrieving and reviewing all grievances. All treatment team members will be educated prior to their next scheduled shift. All grievance resolutions and processes will be monitored monthly by the Grievance Committee, monthly to the Quality Safety Committee, and quarterly to the Governing Board, for a minimum of twelve (12) months.

Based on document review, and staff interview, it was determined that the facility failed to appropriately review and investigate grievances related to alleged patient abuse, failed to maintain appropriate oversight over the grievance review process, and failed to follow proper grievance resolution procedures.

Findings include:

A review of a patient grievance form for patient #7 revealed on 10/09/22 the patient filed a grievance that claimed Licensed Practical Nurse (LPN) #1 raped them and now they are pregnant. A review of the grievance was conducted by Behavior Health Advocate (BHA) #3. Documentation states in part: "Met with [states patient's name]. They said they were put in a hold and got a shot. Myself and [states patient's name] met with [states LPN #1's name]. [States patient's name] said they got a shot for physical aggression. [States patient's name] was smiling and in distress when we met. They said they were sorry that they lied. They were just mad at [states LPN #1's name]. Date resolved: 10/12/22. The CEO [Chief Executive Officer] signed the grievance was acknowledged."

A review was conducted of policy titled "Handling of Patient Complaint/Grievances," last revised 1/6/23. The policy states in part: "Policy: The patient shall have the ability to file a grievance as part of the patient rights process. It is the policy of the hospital to address all patient complaints and grievances in a timely and appropriate manner ... Procedure ... 4. Complaints alleging abuse, neglect, endangerment or misappropriation of property are given top priority, are reviewed immediately by the Legal Aid Patient Advocate with immediate interventions taken as necessary to safeguard the patient, and the matter referred at once to Administration or further management."

A review was conducted of the grievance log reviewed by the grievance committee monthly from October 2022. The grievance for patient #7 was listed on the log.

An interview was conducted with BHA #1 (who is not a hospital employee) on 1/17/23 at 10:20 a.m. Regarding patient grievances, BHA #1 states, "If the grievance has to do with patient-to-patient assault we will do a video review. We will see if at any time the patients could have been together or if we see any video evidence. We would contact the staff if there's a possibility that it happened to have them file an APS [Adult Protective Services]. We do not file an APS unless staff neglect is involved. Either way, it would still go on the grievance log. We follow up with patient-to-patient APS reports by notating it in our file, and letting Administration know. We do not investigate patient-to-patient abuse because we feel we are advocates for both patients involved. Even if we say that we saw something on video, the hospital still does their own investigation. On other APS investigations, we do our investigation and turn our report in and it becomes property of the hospital." When asked about APS complaints for suspected staff abuse, BHA #1 states, "Administration notifies us as soon as an APS is filed. If we do an APS, we give that immediately to the nursing clinical coordinator [NCC]. We receive the paperwork from APS filed by staff, but not always on the same day. We do not investigate APS for patient-to-patient, again, we just do a memo and let them know if we suspect staff neglect is involved, and then we would do an APS in that case."

An interview was conducted with BHA #2 (who is not a hospital employee) on 01/18/23 at 8:16 a.m. When asked about grievances for patient-to-patient abuse, BHA #2 states, "We make sure there is no staff involved; if we feel there is neglect or abuse on the part of the staff, we would file an APS. We will fight to get the patient separated if there's an issue. The hospital will have to look into all patient-to-patient incidents, as we feel we are advocates for both patients. I will file an APS if I feel there's staff neglect or abuse."

An interview was conducted with BHA #3 (who is not a hospital employee) on 01/18/23 at 9:11 a.m. Regarding patient grievances, BHA #3 states, "If there is an allegation of abuse, we meet with the treatment team right away. We do have some fictitious reporters, which this would be documented in their treatment plan. If it is blatantly obvious that it's fictitious reporting, then no APS would be filed. If we have any suspicion there is, we would file an APS. We do an investigation either way. If an APS is filed and then given to us, there's a packet that the NCC gets. It goes to CEO [Chief Executive Officer] and [CEO's] secretary gives us the whole packet. We have a box in the [CEO's] office where we get our packets. I will meet with the patient and get more information. I can file an APS myself if I need to, but staff usually will. This is due to staff being able to document in the chart and we are not able to document anything in the patient's medical record. We would follow up to make sure the staff did file an APS. If the grievance is patient-to-patient, I cannot talk to one (1) patient about another patient's treatment. I would meet with a Nurse Manager and the treatment team. Staff will intervene if needed. For patient-to-patient APS, we don't investigate or substantiate against patients, but we do ensure no staff neglect or abuse is involved, by video review and interviews. Some patient-to-patient abuse will get an APS filed, but there is no clear definition on which patient-to-patient abuse gets filed with APS."

An interview was conducted with the CEO on 01/18/23 at 12:28 p.m. The CEO concurred that the grievance process "leans on the Patient Advocates, which rely on hospital staff members to come to a resolution." They further explained that they did not know that the allegation was against a staff member; they thought it was patient-to-patient.

An interview was conducted with the Chief Nursing Officer on 01/19/23 at 1:40 p.m. There was no knowledge of the grievance with patient #7.

An interview was conducted with the Survey Coordinator on 01/19/23 at 2:00 p.m. The Survey Coordinator confirmed there was no video review done to investigate the incident with patient #7 and LPN #1.

An interview was conducted with BHA #3 on 01/19/23 at 2:03 p.m. Regarding the grievance with patient #7, BHA #3 states, "The grievance was in the box. I went to [lead RN on the unit]. [Patient #7] was upset because [patient #7] was having a behavior on the unit and had to get a shot. [Patient #7] was laughing and smiling. [Patient #7] said [patient #7] got upset when [patient #7] had to get a shot and lied and said [LPN #1] raped [patient #7]. [Patient #7] then apologized to [LPN #1]." BHA #3 explained they did not review any video to ensure the staff and patient weren't alone.

Based on document review, and staff interview, it was determined the facility failed to provide a written resolution of grievances, to the person filing the grievance, in all grievances received by the facility. This failure has the potential to negatively impact all patients and anyone filing a grievance at the facility.

Findings include:

Seven (7) random grievance forms were selected for review. The grievances were resolved by the Behavior Health Advocate (BHA) and signed acknowledged by the Chief Executive Officer (CEO) or Assistant CEO, and reported to the monthly grievance committee for review. There is no documentation the patient who filed the grievance received a resolution in writing.

An interview was conducted with BHA #1 (who is not a hospital employee) on 1/17/23 at 10:20 a.m. Regarding patient grievances, BHA #1 states, "If the patients' grievances take more than seven (7) days to resolve, we don't send them a letter, we just go and talk to them and then write it on the grievance form that we discussed with them that it was taking longer. When the grievance is resolved, we don't send a letter, we just talk to the patient and write it on the grievance form."

An interview was conducted with the CEO on 01/18/23 at 12:28 p.m. The CEO confirmed the patients do not receive a copy of the resolved grievance.

Based on document review, and staff interview, it was determined the facility failed to ensure care in a safe setting by failing to report all patient-to-patient abuse to Adult Protective Services (APS), as per the state law. This failure has the potential to cause great harm or death for all patients at the facility.

Findings include:

A review was conducted of a document titled "Incident Log" for patient-to-patient abuse for the past three (3) months. Eight (8) incidents were reviewed. APS was notified in one (1) out of eight (8) incidents of patient-to-patient abuse.

A review was conducted of policy titled "Reporting and Investigating Verbal Abuse, Physical Abuse, Neglect, and Sexual Harassment of Patient," last revised 8/2022. The policy states in part: "Procedures ... B. Mandatory Reporting of Neglect, Physical Abuse, Verbal Abuse, and Sexual Harassment ... 2. Allegations of patient-to-patient Verbal Abuse, Physical Abuse, or Sexual Harassment shall be reviewed by the Administrator on Call (AOC) or NCC [Nurse Clinical Coordinator] prior to contacting DHHR [Department of Health and Human Resources] Centralized Intake Unit."

A review was conducted of State Code §9-6-11. "Reporting procedures." The code states: "(a) A report of neglect, abuse, or financial exploitation of a vulnerable adult or facility resident, or of an emergency situation involving such an adult, shall be made immediately, and not more than [forty-eight] 48 hours after suspecting abuse, neglect, or financial exploitation, to the department's adult protective services agency by a method established by the department. The department shall, upon receiving any such report, take such action as may be appropriate and shall maintain a record thereof. The department shall receive reports on its [twenty-four] 24-hour, seven [7] day-a-week, toll-free number established to receive calls reporting cases of suspected or known adult abuse or neglect.

(b) A copy of any report of abuse, neglect, financial exploitation, or emergency situation shall be immediately filed with the following agencies:

(1) The Department of Health and Human Resources;
(2) The appropriate law-enforcement agency and the prosecuting attorney, if necessary; or
(3) In case of a death, to the appropriate medical examiner or coroner's office.

(c) If the person who is alleged to be abused, neglected, or financially exploited is a resident of a nursing home or other residential facility, a copy of the report shall also be filed with the state or regional long-term care ombudsman and the administrator of the nursing home or facility.

(d) Reports of known or suspected institutional abuse, neglect, or financial exploitation of a vulnerable adult or facility resident, or the existence of an emergency situation in an institution, nursing home, or other residential facility shall be made, received, and investigated in the same manner as other reports provided for in this article. In the case of a report regarding an institution, nursing home, or residential facility, the department shall immediately cause an investigation to be conducted."

An interview was conducted with the Chief Executive Officer (CEO) on 1/17/23 at 12:51 p.m. Regarding reporting patient-to-patient abuse to APS, the CEO states, "APS are filed on patient-to-patient abuse only if staff neglect or suspected staff neglect resulted in or was involved in the patient-to-patient abuse."

A. Based on medical record review, document review, and staff interview, it was determined nursing failed to follow their policy on self-harm in one (1) of five (5) patients (patient #1) who self-harmed. This failure has the potential for all patients who self-harm to not receive necessary medical care.

Findings include:

Review of the medical record for patient #1 revealed the patient was admitted on 10/21/22 at 1:13 p.m. on probable cause with a diagnosis of amphetamine abuse, stimulant abuse, and threatening suicide, with a discharge estimated on 11/20/22.

A nurse practitioner note on 10/25/22 at 2:55 p.m. states in part: "While attempting to see another patient, [states patient's name] pushed into the conference room. When asked to leave, they refused and required the prompting of the support team before exit. Following [their] exit, they struck a wall. Some swelling noted. No wincing or verbalizing pain with palpation. Patient verbalizing going to the hospital so that [they] can escape. Placed on Elopement precautions."

A consultation note on 10/27/22 at 9:51 a.m. by the medical doctor states in part: "Patient struck a wall Tuesday with right hand. Minimal swelling and probable boxing fracture. Due to the patient's risk of elopement and their parent waiting in the area to help with elopement we will splint which is normal treatment. Patient does not complain of pain on palpation and has minimal edema. Good range of motion, distally digits is neurovascularly intact with good sensation and good capillary refill. HCS [Healthcare Surrogate] notified of patient's injury."

Review of the patient's treatment plan revealed the patient is at high risk for elopement and at the time of admission lacked capacity. [States which parent] and partner are not to visit due to trying to help patient elope and at the request of the HCS.

A review was conducted of the incident log for "Intentional Self-Injury" for the past six (6) months. The injury with patient #1 was not on the log.

A review of the policy titled "Incident Reporting and Review," last effective 03/30/21, states in part: "Employees who witness or are aware of an incident are responsible for completing and signing an incident report form at the time they become aware of the incident. Reporting must be completed and submitted prior to the end of the current shift or within [eight] 8 hours of the incident, whichever is earlier. Incident Reports must be completed when there is potential for injury ... self-injurious behavior."

A review of the policy titled "Elopement," last effective 04/01/20, revealed it does not provide any guidance on high risk elopement patients on receiving medical care off campus.

An interview was conducted with Nurse Manager #1 on 01/18/23 at 11:40 a.m. When asked to explain why medical care for their hand was delayed after self-harm, they stated in part, "Well, they had just got admitted and we don't know that patient yet to know if they are at risk for elopement, etc. The patient was heard telling someone on the phone to come and get them [states the local hospital] and they would be leaving with them and not coming back. When they hit the wall, the nurse practitioner immediately came and saw the patient and knew they were a risk for elopement, and because the patient did not complain of pain and had minimal edema and could move their hand, the decision was made to monitor them, and a medical consult was put in place. The patient continued to threaten to leave, and they needed to go to [states the local hospital] because their parent [states which parent] is meeting them there to take them home. We explained they were here on probable cause, and they can't go home. They did not want to hear it. [Patient #1] had a medical consult, and the decision was made to put a splint on the patient due to the risk of elopement. The patient was calm when the decision was made." It should be noted the Nurse Manager was the patient's nurse on the date of the incident and concurred they did not file an incident on the self-harm.

An interview was conducted with Physician #1 on 01/18/23 at 1:25 p.m. When asked why patient #1 was not taken to the hospital for X-rays, they stated in part, "Well, they were heard on the phone telling their parent they were going to hurt themselves to get to go to the hospital so they [the parent] could help them escape the hospital. We did a medical consult and the physician felt they had a boxer's fracture, that the treatment is a splint. A splint was applied to the hand. The risk of sending them out to the hospital and risking elopement for a hand that was moving, minimal edema, and good capillary refill was not worth the risk."

An interview was conducted on 01/19/23 at 11:50 a.m. with the Patient Safety Specialist. They concurred the patient caused self-injury and no incident was filed.




32177

B. Based on document review and staff interview it was determined the Director of Nursing failed to ensure that nursing followed their policies and procedures in one (1) of two (2) allegations of rape (patient #1). This failure has the potential to not ensure the safety of any patient who may be a victim of sexual abuse.

Findings include:

A review of the medical record for patient #1 revealed the patient was admitted to the hospital for probable cause on 10/06/22 with a diagnosis of intermittent explosive disorder, Attention-deficit/hyperactivity disorder (ADHD), and High functioning Intellectually Developmental Disability (IDD). The patient attends all group and individual therapy and on 02/02/23 had graduated to integral community training (the program allows patients off hospital grounds with staff to learn how to become a part of the community). On 02/02/23, the patient had a meeting with the group home they will be discharged to. A review of fifteen (15) minute safety checks revealed all checks were conducted. On 02/05/23 at 7:29 p.m., Health Service Worker (HSW) #1 was doing vital signs and safety checks. Patient #1 was not in their room. HSW #1 went into patient #2's room and they were in the shower. HSW #1 went to get Registered Nurse (RN) #1. RN #1 went into patient #2's room and opened the shower curtain and patient #1's pants and underwear were below their knees, and they were pulling up their pants. Patient #1 was taken to their room and both patients were placed on a Close Constant Observation (CCO). Physician Assistant-Certified (PA-C) was notified, an attempt was made to contact the guardian, and law enforcement was notified.

An interview was conducted on 02/21/23 at 9:00 a.m. with PA-C #1. When asked to explain the alleged rape of patient #1, they stated in part, "Well, the patient is a high functioning IDD patient. They lack capacity to make their own decisions. I was called to the unit because they were caught in [states patient #2's name] room and [states patient #1's name] pants and underwear were below their knees. I got on the unit and [states patient #1's name] was on the phone with their [relative] and their [relative] was yelling at them for having sex. [States patient #1's name] got off the phone so that I could assess them. [States patient #1's name] said, '[relative] is throwing the bible to me for having sex'. When I asked them to explain what happened, they said, 'Well, we had sex. I'm so embarrassed because I'm going to lose my community integration'. I explained they could earn that back. Then I asked if they wanted to have sex and they said 'Yes'. I asked if they wanted to go to the hospital and they asked why would they want to go. So, I explained and they said 'No'." When asked how the staff knew what room to immediately look in, they stated in part, "The staff had seen them together talking for the last few days. So, when they couldn't find [states patient #1's name] they checked [states patient #2's room]. They immediately placed them both on CCO. I examined and interviewed both of them. When I couldn't get ahold of their DHHR [Department of Health and Human Resources] guardian, I contacted my boss because [states patient #1's name] is IDD and they said to send for a SANE [Sexual Assaulted Nurse Examiner] test. We couldn't get one done until the next morning because there wasn't one (1) on call in all of the hospitals we called." When asked if either were hypersexual, they stated in part, "[States patient #1's name] likes to lift [their] clothes and show [their] boobs and [states patient #2's name] masturbates in their room all of the time. That is why when they told me they didn't ejaculate, I believed them." When asked if they were made aware by unit staff of the two (2) patients hanging out for the past few days, they stated, "No, not until I got to the unit."

An attempt was made to contact HSW #1 via phone on 02/21/23 at 1:30 p.m., 02/21/23 at 3:00 p.m., and 02/22/23 at 8:30 a.m. Left a message on answering machine requesting them to call back. No phone call was received back prior to exit. It should be noted the HSW is between contracts at present and is off for three (3) weeks.

An attempt was made to contact the Nurse Clinical Coordinator (NCC) via phone on 02/21/23 at 1:35 p.m., 02/21/23 at 2:40 p.m., and 02/22/23 at 8:45 a.m. Left a message on answering machine requesting them to call back. No phone call was received back prior to exit.

An attempt was made to contact RN #1 via phone on 02/21/23 at 2:00 p.m., 02/21/23 at 3:45 p.m., and 02/22/23 at 9:15 a.m. Left a message on answering machine requesting them to call back. No phone call was received back prior to exit. It should be noted RN #1 is between contracts at present and is off for month.

An interview was conducted on 02/22/23 at 7:25 a.m. with RN #2. When asked to explain the events the night of the alleged rape between patient #1 and patient #2, they stated in part, "I just got out of report and came onto the unit. [States HSW #1's name] came to me and asked me to come with them to [states patient #2's name] room. We began walking down the hall and [states HSW #1's name] said, 'I think [states patient #1's name] is in [states patient #2's name] room. They were acting funny when I went in to take their temperature and would only put their head out of the door'. So, I go in the room open the shower curtain and there they were [states patient #2's name] was fully clothed but [states patient #1's name] had their pants and underwear below their knees. I told them to get out of the shower. [States patient #1's name] pulled up their pants and left the room with me and I immediately placed them on CCO. I asked [states patient #1's name] what they were doing, and they stated, 'We did it'. I then called the on-call physician, the NCC, filed APS and because they have IDD, we knew we had to follow the rape policy." When asked if they had noticed any behaviors with the two (2) leading up to the alleged rape, they stated in part, "Well, I just got out of report, and I hadn't seen them yet, but for the last few days they have been hanging out." When asked if either have sexual behaviors, they stated in part, "[States patient #1's name] likes to expose themselves and [states patient #2's name] masturbates in their room all day long." When asked if they notified the physician of the two (2) patients "hanging" out, they stated, "No."

A review of a document titled "Functionable Job Description Registered Nurse #3" states in part: "Essential duties and Responsibilities": Observes assigned patients on a daily basis to identify, interpret, and documentation of physical and emotional status and/or patterns such as assaultive or suicidal behavior ... Responsible for the supervision and evaluation of subordinate nursing employees ... Functions as charge nurse on duty when required."

A review of policy titled "Non-Suicidal Levels of Observation," last revised 01/23, states in part: "All patients are placed on an observation level based on clinical assessment of the patient's needs, risk conditions and behavior. Patients will be documented at a minimum of 15 [fifteen] minute intervals, during the patient location activity checks. To provide staff guidelines related to levels of observation patient behaviors such as, but not limited to non-suicidal self-harm, aggression, homicidal ideation, sexually inappropriate behavior, fall risk, elopement risk, and any acute medical concerns.

1. Close Constant Observation (CCO) within view with no barriers ...

A. Require a provider's order that includes the indication for the CCO.

B. A nurse may initiate a CCO, for any patient behavior that requires an increase in observation for safety, such as to non-suicidal self-harm, aggression, homicidal ideation, sexually inappropriate behavior, fall risk, elopement risk, and any acute medical concerns.

C. Documentation of the behavior must be made at least every fifteen [15] minutes on the observation documentation sheet unless otherwise specified by an order based on the patient's clinical needs. The RN will make the first and last entry on observation documentation sheet."

During the above noted interview on 02/22/23 at 7:25 a.m., RN #2 concurred with the findings.

A telephone interview was conducted with the Chief Executive Officer on 02/23/23 at 6:00 p.m. When asked if the nursing staff failed to follow the policy for Non-Suicidal Levels of Observation, they stated in part, "Yes."