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Based on observation, interview, record review and policy review the facility failed to:
-Protect one patient from abuse or neglect when the staff did not implement immediate measures to remove a staff member from patient care after allegations of neglect were reported;
-Provide patients and/or their representative with consistent and complete contact information in order to file a grievance with the Department of Health And Senior Services;
-Recognize an ongoing verbal complaint as a grievance and did not follow the facility policy to resolve the grievance;
-Respond to grievances by letter.
-Ensure the Staff Educator was qualified by education, training and experience in techniques used to educate staff in first aid training related to restraints; and
-Provide education or training on first aid techniques for patients placed in restraints.

The facility census was 25.

These deficient practices and systemic failures had the potential to place all patients at continued risk.

The cumulative result of these findings resulted in noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

Based on interview and record review the facility failed to provide patients and/or their representative with correct contact information to file a complaint/grievance with the Department of Health and Senior Services. The facility also failed to recognize an ongoing verbal complaint as a grievance for one patient (#12) of three patients reviewed and failed to follow facility policy and procedure for complaint/grievances processes. This had the potential to affect all patients in the facility. The facility census was 25.

Findings included:

1. Record review of the facility's undated document titled, "Patient Rights, Responsibilities and Advance Directives", showed the following: The Board of Managers, the Medical Staff and the employees of [facility]
jointly affirm and recognize the following rights and responsibilities of patients. Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment or service.

Record review of the facility's policy titled, "Complaint/Grievance" reviewed 11/12, showed the following:
- Upon admission to the Hospital, patients and/or patient representatives receive information regarding the grievance process that is available if an issue cannot be resolved promptly by staff.
- The information is provided to them in the notification of patient rights, in the Patient Rights brochure, and as corridor signage.
- The information also provides patients and/or patient representatives with contact information for the state agency that has licensure survey responsibility for the hospital including the telephone number and mailing address.

2. Observation on 05/21/13 at 8:47 AM showed the following: Signage posted on the walls inside the patient care areas gave the incorrect telephone number for the Department of Health and Senior Services in very small type (approximately half the size of the rest of the document type) in the bottom right hand corner. Under "How to file a Grievance" in the body of the document were the names of the facility Case Manager and two Social Workers.

3. Review on 05/21/13 at 10:15 AM of the Patient Bill of Rights from the patient admission packet, showed an incorrect telephone number for the Department of Health and Senior Services in very small type. Also in the admission packet was an undated brochure titled, "Speak Up, Know Your Rights", which showed the following:
-How do you file a complaint? First, call the hospital or health system so that they can correct the problem.
-Next, if you still have concerns, complaints can be sent to the licensing authority or to The Joint Commission. (The Department of Health and Senior Services is the licensing authority for the facility, however the name, address or telephone numbers were not provided to the patient or their representative in the brochure.)
-"[Facility] and Medical Staff's Joint Notice of Privacy Practices" dated 11/26/12, stated, "For More Information or to Report a Problem: If you believe your privacy rights have been violated, you can file a complaint with the Corporate Compliance Officer at (573) 331-8425 or visit our website at www.facilityname.com".

No alternative information to file a complaint was provided to patients or their representatives.

4. During an interview on 05/22/13 at 9:42 AM, Staff M, Social Worker, stated he used the Department of Health and Senior Services hot line telephone number but was unable to verbalize what that number was or produce the telephone number during the interview.

5. During an interview on 05/22/13 at 2:45 PM, Staff C, Quality Management Director, stated that they use the Patient Rights information given to them by the corporate office and it hadn't been reviewed for accuracy.

6. Record review of the facility's policy titled, "Complaint/Grievance" reviewed 11/12, showed the following:
- To define a process for addressing patient grievances.
- Definitions: Complaint: A minor request, usually not considered a "grievance," resolved by staff present at the time of the request.
- Grievance: A formal written or verbal grievance filed (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient or the patient's representative regarding care of the patient, abuse or neglect, issue . . .
- Patient complaints that are considered grievances also include situations where a patient or patient's representative telephones the hospital with a complaint regarding the patient's care.
- The hospital maintains documentation of its efforts and demonstrates compliance with CMS (Centers of Medicare and Medicaid Services) requirements.
- The hospital provides a general explanation of action the hospital has taken to investigate the grievance, resolve the grievance, or other actions taken by the hospital.
- The hospital will maintain a listing of complaints/grievances.
- Investigation: The Director of Quality Management coordinates the investigation, and involves appropriate administration and/or department leadership when indicated.
- Response: Within 7 [seven] days after first receiving the grievance, the Director of Quality Management contacts the complainant and responds in writing to the complainant.
- If the process has not yet been completed, the Director of Quality Management notifies the complainant of the status of the process and sends the response within the next 10 days.

7. Record review of Patient #12's medical record showed she was admitted to the facility on 01/04/13 and discharged 02/04/13. The admitting diagnosis was respiratory failure (affects breathing function or the lungs themselves and can result in failure of the lungs to function properly) and the patient was placed on a ventilator (a machine that keeps air moving in and out of the lungs of a patient who cannot breathe).

8. Record review of Patient #12's 24 Hour Flowsheet (a form used by nurses to document patient status and interventions during their care of the patient) dated 01/23/13 showed the patient had requested to speak with Staff A, Chief Executive Officer (CEO), regarding her discharge plan.

9. During an interview on 05/22/13 at 1:40 PM, Staff A, stated that he had talked with Patient #12 and she did not want to be discharged to a nursing home. The patient's husband wanted her to be discharged to home and called almost every day while she was an inpatient at the facility. Staff A stated that he had the husband's cell phone number and sometimes would talk with him more than once a day. He stated that the husband had many concerns about his wife's care. Staff A stated that he did not document any of the conversations and did not acknowledge the husband's concerns as complaints or grievances.

10. During an interview on 05/22/13 at 9:42 AM, Staff M, Social Worker, stated that it had been difficult to communicate with Patient #12 before her trach (tracheostomy tube, a tube placed through an opening in the windpipe to provide an airway and to remove secretions from the lungs) was removed. Staff M stated that the patient and her husband were concerned about her living situation when she was discharged. Staff M stated he did not document any of this information in the patient's record but indicated that all the medical staff were aware of the constant complaints.

11. During an interview on 05/23/13 at 8:47 AM, Staff AAA, Registered Nurse (RN), stated that she was the nurse assigned to Patient #12 on 01/23/13. She stated she remembered the patient and her husband, "very well". She stated that she didn't believe that the patient or her husband understood the level of care she needed upon discharge and the husband would become very frustrated and consequently verbally abusive to staff on the telephone. She stated that he was disabled and did not have transportation to the hospital and therefore all of his communication was by telephone.

12. Record review of the facility's log for complaints and grievances for the past four months showed three separate patient grievances. Patient #12 or her representative (husband) was not one of the patients logged on the complaint list.

Based on interview and record review the facility failed to respond by letter per their policy for two patients (#28,#29) of three patients who filed grievances. The facility census was 25.



Findings included:

1. Record review of the facility policy titled, "Complaint/Grievance" revised 12/12, showed the following:
-The hospital maintains documentation of its efforts and demonstrates compliance with CMS [Centers for Medicare and Medicaid Services] requirements;
-The hospital provides a general explanation of action the hospital has taken to investigate the grievance, resolve the grievance, or other actions taken by the hospital;
-Response: Within 7 [seven] days after first receiving the grievance, the Director of Quality Management contacts the complainant and responds in writing to the complainant.
-The response notifies the complainant of the steps taken on behalf of the patient to investigate the grievance; the results of the grievance process; the date of completion of the process; and the Hospital employee to contact with questions.

2. Record review of the Administrative Complaint/Grievance Log since January 20, 2013 showed no responses sent by the facility for two patient (#28 #29) grievances.

3. Record review of a complaint submitted on 04/09/13 for Patient #29 showed no follow up letter was sent to the patient by the facility.

4. Record review of a complaint submitted on 04/22/13 for Patient #28 showed no follow up letter was sent to the patient by the facility.

5. During an interview on 05/23/13 at 12:47 PM Staff C, Quality Management Director, stated that Staff A, Chief Executive Officer (CEO), was responsible for sending the letters to the complainants.

Record review of the facility policy showed that the Director of Quality should contact the complainant and respond in writing to the complainant.

6. During an interview on 05/23/13 at 4:17 PM Staff A, CEO stated he took the responsibility for the letter not being sent. He stated that he could not give a reason why the letters were not sent.

Based on interview, record review, and policy review, the facility failed to protect one patient (#27) of four patients reviewed for abuse or neglect. The facility staff failed to implement immediate measures to remove a staff member from patient care after allegations of neglect were reported. This had the potential to affect all patients in the facility.The facility census was 25.
Findings included:
1. Record review of the facility's policy titled, "Abuse and Neglect: Suspected" revised 08/12, showed that upon witnessing or receiving an allegation of abuse or neglect, facility staff should:
-Ensure immediate patient safety by removing any suspected caregiver from caring for the patient;
-Notify Risk Manager, Chief Clinical Officer and Manager immediately; and
-Place the staff member on paid administrative leave pending the outcome of the investigation.

2. Record review of an email dated 02/04/13 at 8:33 AM, from Staff HH, Respiratory Therapist, to Staff B, Director of Nursing, alleged that on 02/02/13, Staff HH found Patient #27's condom catheter (tubing connected to a condom, used to collect urine) had come off of the patient and that the patient's gown and draw sheet (sheet used to assist in moving the patient) were "soaked with urine and the chair was sitting in a large puddle of urine". Staff HH alleged that he informed Staff GG, Licensed Practical Nurse (LPN), who was caring for the patient on that day, of what he found, when Staff GG stated that he "wasn't going to deal with it at that time because the patient had already turned is [his] call light on 30 times that day". Staff HH further alleged that 45 minutes later, the patient was still sitting in the urine soaked gown and draw sheet, so he cleaned the patient and informed Staff F, Charge Nurse, of the incident.
3. During a telephone interview on 05/30/13 at 11:43 AM, Staff HH stated that he notified Staff GG that Patient #27 was sitting in urine. Staff GG was sitting down and charting at the nurses station, then left the area and went to lunch without cleaning the patient up. Staff HH stated that he notified Staff F of the incident, when Staff F requested that Staff HH report it to Staff B, Director of Nursing, which he did on the following Monday, 02/04/13.
4. Record review of a documented interview dated 02/05/13 at approximately 4:00 PM, showed that Staff B, spoke to Staff JJ, Monitor Technician (staff member who monitors multiple patient's heart acitivity on an electronic monitor), about the incident involving Staff GG and Patient #27. The document alleged that Staff JJ confirmed the documented email from Staff HH and stated that when she entered the patient's room, "there was so much urine on the floor it looked like a lake". The document alleged that Staff JJ notified Staff GG, after she assisted in cleaning the patient of the urine, that the patient needed his condom catheter replaced, when Staff GG replied, "That's your job ...I shouldn't have to grab the guys dick".
5. Record review of an email dated 02/06/13 from Staff F, Charge Nurse, to Staff B showed that the charge nurse was made aware of the allegations on 02/02/13.
6. During a phone interview on 05/29/13 at 7:41 AM, Staff F stated that he became aware of the allegations against Staff GG on 02/02/13, the day of the incident. Staff F stated that he couldn't remember if he contacted Staff B regarding the incident on the day it occurred because "I have to be careful about what I contact the administrators about when they are off". Staff F stated that he did tell her about the allegation on the following day, 02/03/13. Staff F stated that he did not remove Staff GG from caring for the patient involved after the allegation was reported to him.

7. Record review of Staff GG's timecard showed that he continued to work on 02/02/13 until 7:32 PM, after the allegation was reported to the charge nurse and again on 02/04/13 from 6:53 PM until 7:29 AM, after the allegations were reported to the Director of Nursing. The timecard also showed that Staff GG was placed on paid suspension on 02/06/13 and 02/07/13.

8. During an interview on 05/23/13 at 10:35 AM, Staff B stated that she became aware of the allegation against Staff GG on 02/04/13 and investigated the allegation through 02/06/13 before placing Staff GG on suspension. Staff B couldn't explain why Staff GG continued to work during the investigation.
9. During an interview on 05/22/13 at 4:30 PM, Staff C, Quality Management Director, stated that the allegation was investigated by hospital administration and found to be substantiated (sufficient evidence indicating the incident did occur) for neglect of the patient and Staff GG was terminated.
10. Record review of a list of terminated employees showed that Staff GG was terminated on 02/07/13.

Based on observation, interview and record review the facility failed to provide education or training and require demonstrated knowledge to staff on first aid techniques for patients placed in restraints for 10 of 10 staff training records reviewed. Patients in restraints are placed at a higher risk for injuries or death. This had the potential to affect all patients placed in restraints.The facility census was 25.

Findings included:

1. Observation on 05/21/13 showed that one patient (#25) of 25 patients was currently in restraints during the survey.

2. Record review of the staff members' personnel, training and/or credentialing files showed no documentation that they received first aid education or training for patients placed in restraints. Although these employees may not directly apply restraints to patients they could potentially provide care or alert other medical staff to provide care.

3. Record review of educational records for staff included:
- Staff CC, Registered Nurse (RN);
- Staff DD, RN;
- Staff E, RN, Dialysis Nurse;
- Staff F, RN, Charge Nurse/House Supervisor;
- Staff EE, RN;
- Staff V, RN;
- Staff XX, RN;
- Staff Z, RN, Staff Educator;
- Staff BB, PCT (Patient Care Technician);
- Staff FF, RT/MT (Respiratory Technician/Monitor Technician)

4. During an interview on 05/22/13 at 9:35 AM, Staff Z, RN, Staff Educator, stated she was responsible for training all staff for competencies (focused practice and education in their area of interest) in their current positions. She stated she was not aware that all employees should receive first aid training related to restraints. She stated that no one had ever audited her work and there are no facility policies or procedures for staff training.

Based on interview and record review the facility failed to ensure that the Staff Educator was qualified by education, training and experience in techniques used to educate medical staff in first aid training related to restraints. This had the potential to affect all patients in restraints.
The facility census was 25.

Findings included:

1. Record review of personnel training files and/or credentialing files for 10 staff showed the employees had not received first aid training related to restraints.

2. During an interview on 05/22/13 at 10:10 AM, Staff B, Registered Nurse (RN), Director of Nursing (DON), stated that she supervised Staff Z, Staff Educator. She stated that she had not reviewed, monitored or performed any quality assurance (QA) of Staff B's performance, qualifications or staff training records.

3. During an interview on 05/22/13 at 1:40 PM, Staff Z, RN, Staff Educator, stated that she worked as Staff Educator 10 hours per week and was responsible for all of the employee training records. She stated that she had no experience in staff education or training beyond the RN degree she completed on 07/24/03. She stated she had been in this position approximately three months and had never read the State or Federal regulations regarding her qualifications or requirements for staff education and there were no facility policies and procedures pertaining to staff training. She stated that she had never received any specialized education in regard to first aid related to restraint training and just showed staff the correct way to place and remove restraints. Staff Z also stated that she had received no orientation for the Staff Educator position.