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Based on record review and interview, the Governing Body failed to ensure policies were approved for the specific services and functions provided by the hospital for five of five policies reviewed.

This failed practice had the likelihood for the staff not to implement the practice expectations of the Governing Body for the services the hospital provided.

Findings:

On 09/17/18 at 9:38 am, surveyors requested the policies and procedures for the hosptial, Staff B provided multiple policies thoughout the course of the survey.

A review of the policies had the corporate LLC name, and failed to clearly specify how those policies applied to the hospital being surveyed. Other facilities were listed in the body of policies. The following of these policies included, but were not limited to the following:

* "Abuse and Neglect Internal and External (01/18)" documented "each facility will comply with the reporting requirements for each state for state may differ...".

* Suicide Risk Assessment and Precautions (12/17)" documented the scope applied "to all Post Acute Medical Hospitals".

* Nursing Documentation (04/17)" showed a narrative note would include patient functional status in Rehab Hospitals.

* "Fall Prevention (01/18)" showed the policy of "Post Acute Medical LLC (PAM)..."


A review of policy titled "Admission/ Discharge Critieria (no date)" had no corporate or hospital identifier, and showed it was for "Clinical Service Departments".


On 09/17/18 at 1:35 pm, Staff B stated the hospital did not have a specific policy for vital signs or assessments, and used corporate policies.

Based on record review and interview, the hospital failed to recognize a grievance and provide a written response that included the investigation process and outcomes for two (Patient # 12 and 16) of ten grievances reviewed from 01/18- 09/18.

This failed practice increased the likelihood for grievances to go unrecognized and no written response provided by the hospital.

Findings:

A review of policy titled, "Grievance Resolution (07/17)" showed, if complaint cannot be resolved at the time by staff present, refer to other staff for resolution, required investigation and/or further actions for resolution then the complaint would be considered a grievance. Grievances are any "written or verbal complaints related to patient care not resolved at the time, abuse or neglect ...AMA." The policy showed a patient would be provided with a written response within seven calendar days on average, but on-going, no later that 30 days.

A review of the document titled, "Against Medical Advice (AMA) Document" signed by Patient # 12 on 07/25/18 at 2:45 am, showed, patient noted "I am leving (sic) BC (sic) I was fiz (sic) abused by a nurse". Staff T (RN) who discharged the patient AMA and witnessed the AMA document failed to recognize the patient's complaint as a grievance. The hospital failed to recognize the AMA discharge and the patient's statement as a grievance. The patient was not provided written notice containing decisions made, hospital contact information, steps of the investigation, results of the process, or date completed.

A review of the incident report for Patient # 16 dated 07/02/18 showed the following:

-Initially patient complained he/she had not been turned during the 7:00 am to 7:00 pm shift. Nurse noted his pad was soaked and stuck to his buttocks.

-On 07/09/18 at 2:00 pm, Staff D (Director of Quality Management) spoke with patient and patient stated, he/she did not remember making complaint. During meeting patient stated he/she believed "there was an issue with his pain medication last night and he/she did not get his pain medications". Patient stated "I think she pocketed my medications."

-Pharmacy was notified, medications records were pulled. Pharmacy "ran report for nurse in quest for last week and several instance of irregularities identified".

-Nurse Manager and Chief Nursing Officer notified.

-Human Resources (HR) following up for action.

-Nursing, Pharmacy, and HR will handle the medication diversion per policy.

-The hospital failed to recognize the complaint was a grievance. The patient was not provided written notice containing decisions made, hospital contact information, steps of the investigation, results of the process, or date completed.


On 09/19/18 at 9:30 am, Staff Y stated, if an issue was determined to be a grievance, it would be entered into the computer for a follow-up note, and the grievance would be logged in. Staff Y stated, he/she did not consider either (Patient #12 or 16) a grievance so a written response was not sent. Staff Y stated, "I see now how these (Patient #12 and 16) could be considered grievances".

Based on record review and interview, the RN failed to perform an admission self-harm risk assessment, evaluated the environment of care, and monitored the patient to decrease the risk for self-harm according to hospital policy.

This failed practice increased the risk of self harm for two (Patient # 12 and 13) of three patients who presented with diagnoses which included behavioral health related complaints from 05/18 to 09/18.

Findings:

A review of policy, titled "Suicide Risk Assessment and Precautions (12/17)" documented all patients admitted to the hospital presenting with a behavioral health related complaints or showed signs / symptoms of being a self-harm risk would be screened using the question; "do you have thoughts of harming yourself?" The policy showed, a positive answer would require further assessment by a physician or qualified staff. The policy documented, the nurse would place the patient under one to one precautions at all times, until the further assessment was performed to determine level of risk. The policy showed, until patient received his/her in-depth assessment, the nurse would complete the activities listed on the "Environment Patient Safety Checklist".

A review of the document titled, "Initial Nursing Assessment (07/16)" showed, the question "Does the patient have thoughts of harming self or others? Yes/No (If yes, notify MD [physician] , SS [social services ] consult).

A review of the medical record for Patient # 12, who had a behavioral complaint (history of alcohol and subtance abuse), showed no evidence the patient was screened on admission for self-harm risk.

A review of the medical record for Patient # 13 showed, he/she was admitted at 09/12/18 at 3:00 pm, had a behavioral health issue (depression and anxiety), and answered positively to the suicide risk screening question. There was no evidence the physician or social service were contacted regarding the patient's stating he/she had thoughts for self harm or harm to others. The medical record showed no evidence the "Environment Patient Safety Checklist" was completed or the patient was monitored one to one. The record documented hourly rounds were performed beginning at 7:00 pm. The physician's history and physical was completed on 09/13/18 at 9:11 am, and listed "psychosis" under the Impression.

On 09/20/18 at 9:42 am, Staff Z stated, when patients came in and stated they were having thoughts of harming themselves, the initial assessment would be performed, the Charge Nurse and the physician would be notified, and the patient would be further assessed. Staff Z stated he/she did not know if there was a specific policy for self-harm assessments.