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Based on review of records and interviews with hospital staff, the hospital does not ensure the hospital protects and promotes the rights of patients. The hospital does not comply with Medicare Condition of Participation: 482.13 - Patient Rights.

Findings:

1. The hospital failed to establish a grievance process approved by the governing body that reviews and resolves grievances. Refer to Tag A-119.

2. The hospital failed to establish a grievance process that specifies the time frames for a review of the grievance and a response to the grievance. Refer to Tag A-122.

3. The hospital failed to ensure all complaints/grievances requiring investigations and are not immediately resolved are treated as a grievance and receive a written response containing the steps taken in the investigation and the results of the grievance process and the date of completion. Refer to Tag A-122.

4. The hospital failed to ensure patients receive care in a safe setting. Refer to Tag A-144

5. The hospital does not have mechanisms/methods defined in its policies that describe the procedure to follow when a patient alleges abuse by a hospital employee or worker and includes all the components necessary for effective abuse protection. Refer to Tag A-145

6. The hospital failed to implement a restraint and seclusion policy. Refer to Tag A-154

7. The hospital failed to ensure physical hold/immobilizations were identifed as restraints. Refer to Tag A-159

Based on record review and interviews with hospital staff, the governing body does not ensure quality of care is provided to patients which includes patient rights and the assurance of freedom from abuse and neglect. The hospital does not ensure that patients receive care in a safe setting.

Findings:

1. Patients in the Adult Mental Health unit on the 3 pm to 11pm shift had twelve complaints/grievances alleging abuse and neglect ranging from April 2010 through July 2010. The hospital had not investigated, taken action or had methods to identify incidents or patterns to protect patients from abuse or neglect.

2. The hospital did not have policies and procedures in place to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker or contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

3. According to Staff J the hospital does not have the capability of trending the complaints/grievances to see if there are any common traits and if all complaints/grievances are being received.

4. Administrative staff ( H, J, M & N ) stated on 08/12/10 and 08/13/10 multiple times during the course of the survey that they were unaware of these complaints/grievances. They also stated during the course of the survey they were unaware of the process for patient complaints/grievances used in the Adult Mental Health unit. The complaint process on the Adult Unit was a paper complaint. The above staff stated they were only aware of an electronic method of lodging complaints/grievances.

5. Review of Governing Body meeting minutes from January 2010 through July 2010 only had one reference concerning the offsite mental health facility, Deaconess at Bethany. This reference only concerned the renovations at the offsite facility.

Based on review of records, interviews with staff, and review of policies, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent in the hospital's grievance process. Twelve of twelve written patient grievances filed had no evidence of investigation and were not on the grievance log. One written complaint to the Oklahoma State Department of Health was not listed in the grievance log but a telephone grievance by the same patient was listed.

Findings:

1 A complaint that was received by the Oklahoma State Department of Health alleging abuse was not listed on the grievance log but a telephone complaint from the same patient (#1) was in the complaint log and alleged abuse. Patient #1 indicated there had been five formal complaints filed during his admission. These were not on the grievance log. The telephone grievance listed on the log indicated the investigation was not completed prior to a written response letter being sent to the patient stating all staff involved had been spoken with. On the day of the survey, four of the staff involved in the allegations of the complaint were scheduled to provide patient care through the end of the month. Staff N stated two personnel had been terminated 7/31/2010 based on these allegations. Surveyors asked if administration had been in the terminated manager's office to determine if other grievances were lacking investigation. Surveyors were told "no" by Staff N, J, H, I and M. No other investigation had been done. This was confirmed with administration in the exit conference.

2. Interviews of Staff K, J, and N indicated the off site facility was not following the current grievance process. On 8/12/2010 Staff K provided surveyors nine patient grievances left in a box for the terminated manager. None of these grievances had been investigated. 8/13/2010 surveyors were provided with three additional grievances filed by patients on the unit. 12 of 12 grievances were not investigated as of 8/13/2010. This was confirmed with administrative staff in the exit conference.

3. Patient #1's investigation included a misplaced phone call by the terminated nurse manager to a different patient's family member. This phone call concerned alleged sexual misconduct by staff A. Staff C said in an e-mail concerning Patient #1 that she had gotten the two patients mixed up. There was no patient identification available on the second patient. On 8/13/2010 surveyors asked the patient advocate Staff J if there had been an investigation into the alleged sexual misconduct of the second patient. Staff J stated he was not aware of any.

Based on review of the hospital's grievance/complaint policy, grievance log, multiple grievances and interviews with hospital staff, the hospital failed to follow its grievance/ complaint policy for investigating complaints. This occurred for 12 of 12 patients/patients' representatives who filed grievances.

Findings:

1. The hospital's grievance policy, LD-009, defined a grievance as a written or verbal complaint concerning patient care that was not resolved at the time of the complaint by staff present. The policy, in #3 on page 1 stipulated that a written complaint is always considered a grievance, whether from an inpatient, outpatient, released or discharged patient or their representative. It also stipulated that a response letter shall be forwarded to the patient or patient representative no later than 7 days after receipt of the complaint/grievance even though the hospital's resolution need not be complete within the seven day limit.

2. In an interview on the afternoon of 8/12/2010, Staff K was asked by surveyors how patients can file grievances on the Adult Mental Health Unit. Staff K stated patients were given a form titled "Suggestion or Complaint form". Once the form is completed by the patient the staff member receiving the complaint puts it in a box in the nurse managers office. Staff K was unable to verbalize how the complaints were handled from there. Staff N, who was present in the room during the interview with Staff K, was asked by surveyors if the form Staff K mentioned was used in the complaint/grievance process. Staff N stated she had not seen this form before and was not aware anyone was using this form. Staff K left the room and returned shortly with nine handwritten patient "suggestion/complaint" forms. Staff K stated they were in the box in Staff C's office. Surveyors asked Staff N if anyone had looked in Staff C's office for other complaints. Staff N stated no. On the morning of 8/13/2010, surveyors were provided with three additional patient complaints found in Staff C's office. None of these were written by Patient #1 the patient mentioned in the complaint. 12 of 12 complaints had no evidence of being investigated.

3. The surveyors and Staff H, reviewed the grievance documentation and notification in Patient #1's complaint (the patient mentioned in the complaint). According to staff H all patient complaints are to be entered in the HEAT system upon receipt of the complaint. Patient #1 stated five complaints were filed with the night nurse on one of the nights during the hospitalization. The surveyors requested review of these complaints and were told by administrative staff the complaints during his stay could not be found. On 4/12/2010, Patient #1 called and complained to Staff J in a voice mail regarding alleged abuse and neglect, Patient #1 also informed administration in his message there had been five grievances filed during his stay. The following occurred with Pt's 1's complaint:
a. On 4/12/10 Pt's complaint was logged into the HEAT system
b. On 4/12/2010 an acknowledgement letter of receipt of telephone complaint was sent by staff J.
c. On 4/13/2010 e-mail exchanges between the manager and Staff H.
d. On 4/26/2010 Staff H reminds manager about open complaint
e. On 6/24/2010 e-mail to Staff H from Staff C stating pulling chart to try to find another contact, stating had been calling the wrong patient Pt #, mother not Pt #1.
f. 6/25/10 Staff C contacts Pt#1 and informs Staff H, M, J the investigation is partially complete but is pending completion as Staff C needs to interview staff (A, B, D, F,G) before the investigation can be closed.
g. 7/6/2010 Staff C e-mails Staff H and J the complainant has been called and explained a thorough investigation would be done.
h. 8/2/2010 Staff J emails Staff C to close the complaint based on a the phone call mentioned in (g). There was no documentation to reflect Staff C had completed the investigation or finished interviewing involved staff.
i. On 8/2/2010 a letter was sent to Patient #1 which stipulated "all involved staff has been spoken to, and steps taken so that future patient satisfaction is met".

On the afternoon of 8/12/2010, surveyors asked for documentation of the grievance investigation. Staff N told surveyors there was no other documentation. Surveyors also requested the five grievances filed during Pt's 1's stay. Staff N told surveyors the facility could not find these. Staff N also stated two personnel were terminated (B,C) as a result of the investigation. Surveyors asked about the other staff mentioned in the complaint (A,D,F,G). Staff N stated there was no further documentation on those personnel. Surveyors asked if any administrative staff had been in the terminated manager's office for follow up on the investigation and Staff N said no.

On the morning of 8/13/2010, Staff N told surveyors Staff A had been put on investigative leave. Surveyors asked if other personnel mentioned (D,F,G) in the complaint were also being investigated. Staff N was not aware of an investigation.

On afternoon of 8/13/2010 surveyors spoke with Staff J, Patient Advocate. Surveyors asked if Staff J had seen any of the other grievances filed by Pt #1. Staff J was not aware of any. Staff J was asked by surveyors if there was any other grievance documentation on Pt #1. Staff J was not aware of any. Staff J also stated he relied on the managers to take care of the investigation of the complaint. Staff J was asked by surveyors who besides the terminated manager investigated the grievance and Staff J did not know of any other administrator investigating. Staff J had not been in the facility to investigate any of the allegations. Staff J told surveyors he was not aware of the grievances provided to surveyors on 8/12/2010 and 8/13/2010 found in the terminated managers office until 8/13/2010.

Surveyors were provided documentation from the HEAT system regarding Pt #1 from 4/12/2010 through 8/3/2010. At the time of the survey, Staff N stated the investigation was pending further investigation of four personnel (Staff A,D,F,G). Staff N stated two personnel (Staff B, C) were terminated as a result of the investigation of the complaint. Surveyors reviewed staffing schedules and noted Staff A,D,F,G were scheduled to provide patient care on the Adult Mental Health Unit through the current schedule. According to documentation in the HEAT system, Staff J closed the investigation based on a conversation Staff C had with the patient. There was no documentation provided that all of the staff members involved had been investigated. On the morning of 8/13/2010, Staff N told surveyors Staff A had been put on investigative leave.

Based on record review and interviews with hospital staff, the hospital does not ensure that patients receive care in a safe setting. Patients in the Adult Mental Health unit on the 3 to 11 shift had numerous complaints/grievances alleging abuse and neglect and the hospital had not investigated, taken action or had a method to identify incidents or patterns to protect patients.

Findings:

1. The hospital did not have policies and procedures in place to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker or contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

2. Twelve patient complaints/grievances alleging abusive language toward patients, threats against patients, harassment by staff, inappropriate contraband search and neglectful care were discovered , nine on 08/12/10 and three more on 08/13/10 by staff in the terminated Nurse Manager's office. The administrative staff was unaware of any of these allegations of abuse and neglect and nothing had been done to investigate the allegations. These complaints/grievances ranged from April 2010 through July 2010.

3. The complaints/grievances contained documentation that the 3 to 11 staff said such things as " Stop being a dumbass and eat your f----kin crackers and go to bed - you don't have to call anyone-I f---kin just said I'm already here so you understand that I am f---kin telling you." Allegations of a "strip search" with only one male tech present. Allegation of a patient having an accidental bowel movement at 4 am and the staff making the patient wait until 6am to be able to clean themselves. Multiple allegations of staff harassing patients and laughing at them. Allegations of the staff threatening to "taser" patients if they didn't shut up and go to bed.

4. On both days of the investigation two ( A & D ) of three ( A, B & D ) staff on the 3 to 11 shift on the Adult Mental Health Unit who were accused of abusive treatment of patients were still on the schedule to work. One ( B ) of the three alleged perpertrators mentioned in the patient complaints had been terminated and Staff A was put on administrative leave on 08/13/10, according to administrative Staff N.

Based on the review of abuse and neglect policies and procedures, a written letter from a hospital staff member, patient complaints/grievances and interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describes the procedures to follow when a patient alleges abuse by a hospital employee.

Findings:

1. The hospital provided policies for review. The policies concerned child abuse, elder abuse, sexual abuse and spousal/domestic abuse concerning patients who present to the hospital. The policies did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker or contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

2. Interviews with hospital Staff N on 08/12/10 in the afternoon verified that the hospital does not have a written policy that includes the required elements for effective abuse protection.

3. Hospital staff on 08/12/10, Staff O in the morning and Staff K and L in the afternoon stated various ways they would handle an allegation of abuse or neglect of a patient or witnessed abuse and neglect. These staff could not identify exactly and verbalize what to do if they witnessed an incident of abuse or neglect of a patient by a staff member.

4. Complaint allegations of abuse and neglect written by patients were discovered during the survey by staff located in the terminated Nurse Manager's office. These complaints ranged from April 2010 through July 2010. There was no evidence that the hospital had taken any action to investigate the allegations.

5. A letter from Staff P alleging abusive treatment by the 3 to 11 staff was discovered in the terminated Nurse Manager's office and there was no evidence that any action had been taken to investigate the allegation.

Based on review of policies and procedures, review of restraint log, interviews with staff, interviews with Creating a Positive Environment (CAPE) trainer and review of other hospital documents the hospital failed to implement a"restraint and seclusion" policy and procedure.
Findings:

1. On 8/12/2010 in the entrance conference the surveyors requested copies of current restraint and seclusion policy. Staff M initially provided surveyors with a policy "Restraints TX-014, revised 1/1/2004". On the afternoon 8/12/2010 two other restraint policies were provided to the surveyors-"Restraints: NS #019, 1/2004 and Restraints NPSG-005, revised 6/11/09". The policy in the restraint log provided from the Adult Mental Health Unit was not the policy Staff M identified as the correct policy for use of restraints.

On the afternoon of 8/12/2010 Staff M stated the policy with the revision date of 6/11/09 was the correct policy. Restraint policy NPSG-005, stipulates restraint: is any physical or mechanical device, material medication or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Further in the same policy it stipulates: "E. Orders for Restraints, iii., when a restraint or seclusion is used for the management of violent and/or self destructive behavior that jeopardizes safety, the registered nurse immediately notifies the LIP to obtain an order. The LIP performs an in person evaluation within 1 hour of initiation of restraint or seclusion and provides a written or verbal order." The policy also stipulates there must be documentation of a debriefing within 24 hours after restraint or seclusion is used for violent and/or self destructive behavior.

A. The morning of 8/12/2010 surveyors met with Staff O identified as the CAPE trainer. Staff O stated CAPE holds were not documented in the restraint log only in the patient narrative. Staff O stated mechanical restraints and seclusion were the only items documented in the restraint log. Staff O stated he had not been told at what point in time a hold would be considered a restraint. Staff O stated he did not teach that CAPE holds required a physician order. Staff O was also not aware of any debriefing sessions being done after CAPE holds.

B. The afternoon of 8/12/2010 Staff K was asked about CAPE holds. Staff K also stated these would only be found in the patient documentation. Staff K stated the teaching in CAPE did not include CAPE holds requiring a order. Staff K was not aware of the required debriefing for CAPE holds.

C. On the afternoon of 8/12/2010, Surveyors reviewed Pt #1's (the patient mentioned in the complaint) medical record. Documentation in the chart indicates patient was refusing to cooperate and became combative and agitated. The physician was notified and intramuscular (IM) Ativan, Haldol, and Benadryl were given. There was no documentation in the chart to reflect the patient was restrained or placed in an approved CAPE hold. The physician's order sheet does not contain an order for restraints. On 8/13/2010, Staff N provided surveyors with additional information. Statements taken from staff members present for the incident indicate the patient was taken to the floor and staff member "had" the patient's shoulder, one "had" the patient's midsection" and one "had" the patient's legs.

Based on hospital documents and interviews with staff, the hospital failed to ensure physical hold/immobilizations were identified as restraints. In two of five (Records #1 and 15) patient medical records reviewed, the patients were placed in physical holds/immobilizations without a physician's order.

Findings:

1. The Restraint Log did not contain the current Restrain policy. The policy, entitled Restraints with an effective date of January 1, 2004, did not address physical holds/restraints. It did not identify CAPE holds or CAPE immobilizations as restraints.

2. The Order For Restraint form did not identify CAPE holds or immobilizations as a type of restraint.

3. Staff M and Staff O stated on the afternoon of 08/12/2010 that Staff O did not teach that CAPE holds and immobilizations required a physician's order.

Based on review of policy and procedure, staff interviews, and review of training documents the hospital failed to provide restraints in a safe and effective manner in accordance with facility approved techniques. This occurred in one of two medical records reviewed (Record #1 of Records #1 and 15) reviewed of patient who were restrained.

Findings:

1. Staff L, M and O told the surveyors on the morning of 08/12/2010 that the facility used CAPE (Creating A Positive Environment) as the facility approved method to hold/immobilize/restrain patients.

2. The instruction manual listed side-to-side as the only "on the ground/floor" method to immobilize a patient. This was the procedure described by the CAPE instructor, when interviewed on 08/12/2010 at 0900. He stated if a patient lowered himself to the floor, the staff member would follow and should place the patient on his side. He demonstrated that both patient and staff should be on their sides. He told the surveyors that the patient should not be place prone/chest/face down on the floor.

3. Although the medical record did not document Patient #1 was restrained on the floor, the record did document, "Pt. (patient) initially refusing to cooperate with (symbol used) admission, or give up all contraband and became combative and agitated."

4. Documents supplied to the surveyor on the afternoon of 08/13/2010 contained four written statements from staff concerning Patient #1 and the event mention in Finding #3. According to the staffs' written statements, the patient was taken to the floor and one staff member "had" the patient's shoulder, one "had" the patient's "midsection" and one "had" the patient's legs.

5. Interview the Patient #1 on 08/13/2010, the patient stated he was not held in a CAPE hold, but "put to the floor, face down" by three male staff. He stated he was held there for awhile and then a female staff gave him an injection.

Based on review of medical records, hospital policies and procedures and documents, and interviews with staff, the hospital failed to ensure restraints were used in accordance with the order of a physician. In two of two medical records reviewed (Records #1 and 15), of patients who were restrained, the patients were placed in CAPE (Creating A Positive Environment) holds/immobilizations/restraints without a physician's order.

Findings:

1. The policy and procedure, identified by Staff M and N as the current restraint policy, identified physical holds as a type of restraint and needed a physician's order.

2. According to the patient's medical record and other documents supplied by Staff N, Patient #1 was restrained on the floor shortly after admission on 03/21/2010. (See Tag A-167 for details.) The medical record did not contain an order for the physical restraint. This finding was confirmed with Staff M at the time of review.

3. Patient #15 - The nurse recorded on the admission note, "Pt (patient) assisted with removal of jewelry and keeping her from harming self...started to pound on her head with both fists around and on her healing scar/laceration. Staff assists in keeping pt. from harming self." The medical record did not contain an order for the physical restraint, only an order for the mechanical/leather restraint that followed later. Staff M and L reviewed the documentation and agreed the medical record did not contain an order for the physical restraint.

Based on review of patient medical records and an interview with hospital staff, the hospital failed to ensure medication were administered according to physician's orders. In one of five (Record #17 of Records #1, 14, 15, 16, and 17) medical records reviewed, medications were administered without a physician's order.

Findings:

1. Record #17 - The patient, a 41 year old, admitted on 03/02/2010 and discharged on 03/15/2010, received Haldol 5 mg three times (03/05/2010 at 0855, 03/06/2010 at 1730 and 03/08/2010 at 1530) and Ativan 2 mg three times (03/05/2010 at 0900, 03/06/2010 at 1730 and 03/08/2010 at 1530) without physician orders.

2. The above finding was reviewed and verified with the Chief Nursing Officer at the time of review on 08/12/2010 at 1430.