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Based on record review and interview, the hospital failed to ensure the effective operation of the grievance process for 1 of 3 patients (Patient #2) reviewed for the effective operation of the grievance process out of a total sample of 9 patients. This was evidenced by the hospital's failure to initiate an immediate investigation into allegations of staff to patient abuse and by the hospital's failure to conduct a thorough investigation into allegations of staff to patient abuse resulting in the hospital reaching a conclusion that was not confirmed to be accurate. Findings:

Review of the ED (Emergency Department) Log revealed Patient #2 presented to the ED on 9/23/11 and 10/19/11.

The medical record relating to Patient #2's admission to the ED on 9/23/11 was reviewed. This review revealed Patient #2 was transported by ambulance to the ED on 9/23/11 at 5:43 p.m. Documentation revealed the chief complaint as suicidal thoughts. Documentation revealed Patient #2 was placed on a PEC (Physician Emergency Certificate) on 9/23/11 at 9:10 p.m. for being a danger to self and a danger to others. Documentation revealed Patient #2 was combative and verbally abusive to staff. Review of the ED physician documentation revealed "56 year old male brought by ambulance for suicidal and homicidal ideation. Was threatening self and police with gun. No history of episode as bad as today per sister. Never been hospitalized for psych issues in past. History from sister as patient will not cooperate and very combative". Documentation revealed orders dated 9/23/11 at 6:29 p.m. to "Place upper ext. leather restraints" on Patient #2. Review of the "Restraint Assessment/Documentation" form revealed Patient #2 was placed in 4 point restraints on 9/23/11 from 7:00 p.m. till 11:00 p.m. Review of the nursing notes revealed an entry dated 9/23/11 at 11:26 p.m. indicating "Pt is no longer in 4 point leather restraints. Pt states 'someone broke my finger it hurts' Pt takes finger and pulls it backwards pulling hard. Pts left middle finger is swollen and bruised. MD notified". Documentation revealed a x-ray of the left hand was ordered on 9/23/11 at 11:24 p.m. and the impression was "Fracture Proximal Phalanx Third Finger". There was no documentation to indicate that efforts were made to identify who Patient #2 was referring to when he stated "someone broke my finger it hurts".

S3 (ED physician) was interviewed on 11/07/11 at 9:30 a.m. S3 reviewed the medical record relating to Patient #2's visit to the ED on 9/23/11 and reported he did remember the patient. S3 reported Patient #2 was transported to the ED by ambulance with suicidal ideations after being found with a gun at his home. S3 reported Patient #2 was screaming, yelling, threatening and stating that he would hurt anyone in his way. S3 reported Patient #2 was placed on a PEC for being suicidal and homicidal. S3 reported Patient #2 was a paraplegic with no movement from the waist down. S3 indicated Patient #2 had significant movement in his upper body with very good upper body strength. S3 reported Patient #2 was combative with staff and was placed in 4 point leather restraints for the safety of the patient and staff. S3 indicated that Patient #2 was swinging at staff. When asked what happened to Patient #2's finger, S3 reported Patient #2 had a spiral fracture to the finger on his left hand. S3 reported Patient #2 informed him that a staff member broke his finger. S3 reported Patient #2 told him a staff member pulled his finger back and he (Patient #2) grabbed his (Patient #2) own finger pulling it back toward the wrist. S3 reported he was not sure of how the fracture occurred.

In an interview on 11/08/11 at 9:40 a.m., S2 (Emergency Department Unit Director) confirmed that documentation in the medical record revealed Patient #2 reported allegations of someone breaking his finger on 9/23/11 at 11:26 p.m. S2 reported that an internal investigation relating to Patient #2's allegations was initiated by the hospital on 10/20/11 (27 days after initially reported to hospital personnel). S2 confirmed that the internal investigation should have been conducted after Patient #2 reported the alleged incident to the ED nurse and the ED physician.

S14 (Manager of Patient Relations), S15 (Patient Relations Specialist), and S16 (Operational Coordinator) were interviewed on 11/08/11 at 10:05 a.m. S14 confirmed that an internal investigation relating to allegations made by Patient #2 was conducted by the hospital. S14 indicated the internal investigation was completed by S15. S15 indicated that she received a call from a critical care nurse on 10/20/11 who informed her that Patient #2 was reporting that a staff member had broke his finger while in the ED. S15 reported she (S15) met with Patient #2 on 10/20/11 and indicated Patient #2 told her a nurse in the ED broke his finger while in the ED on 9/23/11 and the same nurse punched him on 10/19/11. S15 indicated that an internal investigation was completed by the hospital and a letter was mailed to Patient #2 on 11/01/11. S15 indicated that S16 assisted with the internal investigation by interviewing and/or obtaining statements from ED nursing staff. S15 presented a copy of the letter that was mailed to Patient #2. (Review of the letter revealed, in part, the following "On September 23, 2011, you arrived via ambulance due to suicidal thoughts. Interviews with the nursing staff involved in your care indicate you stuck your finger in the leather restraints and broke your finger. It is noted in your medical record the physician treated your finger by buddy taping to another finger. On the second visit to our Emergency Department on October 19, 2011, you were treated by the same male nurse involved in your care previously. It is documented you presented to room 3, lethargic, the nurse rubbed your sternum a few times to get a response. It appears you then struck the nurse in the face. Following the incident, you were placed in restraints in the Emergency Department before being admitted to CCU. Lastly, the room you were assigned to in the Emergency Department does not have a camera and you were not being recorded. We have conducted a thorough investigation, including reviewing your medical records and interviewing all staff involved in your care".) When asked how the hospital came to the conclusion that Patient #2 broke his own finger as documented in the letter, S16 indicated that after interviewing the nurses involved it was her understanding that the ED physician (S3) had witnessed Patient #2 break his own finger. When asked if the ED physician (S3) was interviewed as part of the hospital's internal investigation, S14, S15, and S16 reported S3 was not interviewed during the hospital's internal investigation. When informed that S3 was interviewed by this surveyor as part of the complaint investigation and he (S3) reported that he did not know how the injury occurred to Patient #2's finger, S15 and S16 reported that S3 should have been interviewed as part of the hospital's internal investigation prior to concluding that Patient #2 broke his own finger. S15 and S16 confirmed the letter sent to Patient #2 may not be accurate as it was based on information reported to have been witnessed by S3 when in fact S3 did not know how the injury occurred.

Based on record review and interview, the hospital failed to ensure the application of restraints were in compliance with the orders of the licensed practitioner for 1 of 3 patients (Patient #2) reviewed for the application of restraints out of a total sample of 9 patients. Findings:

The medical record relating to Patient #2's admission to the ED on 9/23/11 was reviewed. This review revealed Patient #2 was transported by ambulance to the ED on 9/23/11 at 5:43 p.m. Documentation revealed the chief complaint as suicidal thoughts. Documentation revealed Patient #2 was placed on a PEC (Physician Emergency Certificate) on 9/23/11 at 9:10 p.m. for being a danger to self and a danger to others. Documentation revealed Patient #2 was combative and verbally abusive to staff. Documentation revealed orders dated 9/23/11 at 6:29 p.m. to "Place upper ext. leather restraints" on Patient #2. Review of the "Restraint Assessment/Documentation" form revealed Patient #2 was placed in 4 point restraints on 9/23/11 from 7:00 p.m. till 11:00 p.m.

S2 (Emergency Department Unit Director) was interviewed on 11/07/11 at 10:20 a.m. S2 reviewed the medical record of Patient #2 and confirmed the restraints applied to Patient #2 were not in compliance with the orders of the practitioner. S2 confirmed the order was for upper extremity leather restraints and the documentation indicates that Patient #2 was placed in 4 point leather restraints.

Based on record review and interview, the registered nurse failed to ensure the supervision and evaluation of care provided to 1 of 9 sampled patients (Patient #2) as evidenced by not following policies/procedures for psychiatric patients in the hospital's Emergency Department. Findings:

The medical record relating to Patient #2's admission to the ED on 10/19/11 was reviewed. This review revealed Patient #2 was transported by ambulance to the ED on 10/19/11 at 12:20 a.m. Documentation revealed the chief complaint as suicide attempt. Documentation revealed Patient #2 was placed on a PEC (Physician Emergency Certificate) on 10/19/11 at 12:20 a.m. for being a danger to self.

The hospital's policy/procedure titled "Care of the Psychiatric Patient in the Emergency Department" was reviewed. The policy/procedure documents the purpose as "To establish guidelines for the patient presenting with a psychiatric complaint in the Emergency Department. To provide guidelines for required psychiatric observation and documentation for those patients that are OPC/PEC/CEC or meet a score of 5 or greater on the Suicide Assessment Tool". The policy/procedure documents "Psychiatric observation will be ordered to decrease the risk of elopement, risk of suicide and ensure patient and staff safety. Documentation of observation will be completed at a minimum of every 15 minutes on the precautionary measures flow sheet and be retained as part of the medical record".

Review of the "Precautionary Measures Guide to Risk Sitting Flowsheet" revealed no documentation of observation at a minimum of every 15 minutes from 3:45 a.m. through 6:45 a.m. on 10/19/11 for Patient #2.

S2 (Emergency Department Unit Director) was interviewed on 11/07/11 at 10:25 a.m. S2 reviewed the medical record of Patient #2 and confirmed Patient #2 was placed on a PEC on 10/19/11 at 12:20 a.m. S2 confirmed the 15 minute observations were not documented for Patient #2 on 10/19/11 from 3:45 a.m. through 6:45 a.m. on the "Precautionary Measures Guide to Risk Sitting Flowsheet".