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Based on medical record review, staff interview, review of the hospital's policy/procedure and the hospital's documentation of the investigation of the allegation of an abuse occurrence, the hospital's failed to ensure; that patients' rights were protected by failing to ensure complaints of abuse were immediately and effectively investigated in accordance with the hospital's policy, (A118)
that patients' grievances were reviewed and resolved, (A119)
and followed up in a timely manner to ensure the patient/family was provided with a written resolution to prevent possible reoccurrence of alleged abuse, (A122) and the hospital failed to follow the hospital's complaint resolution policy's time frames and therefore failed to ensure a safe setting was provided in a timely manner (A144) for one (Patient #1) of ten patients who whose medical records were reviewed. The cumulative effect of these systemic practices resulted in the hospital's inability to ensure the patients' rights were protected and promoted.

Based on staff interview and review of the hospital's policy/procedure regarding grievances and the hospital's documentation of the investigation of the grievance, the hospital failed to follow it's policy and procedure to ensure that a complaint of patient abuse was immediately and effectively investigated for one (Patient #1) of ten sampled patients. The hospital census at the time of this survey was 73.



Findings include:

The medical record of patient #1 was reviewed on 10/01/2012. The patient was admitted to the hospital rehabilitation unit from the University Hospital on 08/15/2012 with a diagnosis of altered mental status, nausea and vomiting, fluid overload, and hypoxic and hyper respiratory failure. The patient has had multiple admissions to the Drake Center and University Hospital over the last several months. Prior to being readmitted to the hospital, the patient was at University hospital where a tunneled catheter was place to facilitate hemodialysis.

On 8/16/2012 at 9:45 PM, the nursing supervisor (staff A) had documentation in Midas (computer) that the patient's spouse voiced a complaint to the respiratory therapist (Staff B) that the patient had been punched in the face. The supervisor stated that about 15 minutes later as he/she was getting on the elevator that she/he recognized the patient's spouse. The spouse told the supervisor that she/he was concerns because the patient had stated that he/she had been punched with a clenched fist by a 2 toned hair certified nurse aide the night of 8/15/2012. The spouse then pointed to a dime-size bruise on the patient's right cheekbone.

The supervisor further documented that he/she was able to recall a conversation shared with the spouse when the patient was admitted. The spouse was questioning the patient if the nurse from the other hospital (University Hospital) slapped the patient in the face before discharge and the patient had said "yes".

However, the admission assessment reviewed by the surveyor on 10/01/12 dated 8/15/2012 when the patient was admitted to the Drake Center was silent to any facial bruising and/or markings. There were no notations in the nurse's assessment and/or nurse's notes or physician's initial examination and/or progress notes that address any facial bruising or discoloration on admission on 8/15/2012, nor was there any nursing documentation by the supervisor regarding any facial marks on the patient. There was no follow up documentation by the supervisor regarding his/her conversation shared with the patient and spouse regarding the patient's allegation that the patient had been slapped prior to admission. there was no documentation the physician was called regarding the alleged incident that had been reported by the patient to the supervisor. The hospital lacked documentation of the following; an incident report had been initiated, security was notified, and/or hospital administration notification of the alleged abuse had occurred.

The spouse continued to complain and the supervisor told the spouse that he/she would request that the charge nurses not assign the described certified nurse aide to the patient anymore.

On 8/17/2012 at 2:30 PM, another nursing supervisor (staff C) documented that the spouse of the specified patient called in a complaint and stated that his/her spouse was punched in the face resulting in injury to the face of the specified patient by a nurse aide. The spouse also indicated that he/she was coming in to take pictures of the patient. Interview of staff C at 10:00 AM on 10/2/2012 revealed that he/she told the spouse the hospital policy was that visitors could not take pictures of the patients. However, there was no such policy and procedure. Staff C stated that she notified staff D, E and F to start the investigation. The nurse manager (staff D) on the unit was interviewed on 10/1/2012 and 10/2/2012 and the nurse manager stated that he/she talked to the certified nurse aide in question and obtained a written statement from the certified nurse aide. The nurse aide statement was given to the patient advocate and security to complete the investigation. Staff D and E did not follow up with the staff on the unit. There was no systematic medical follow up initiated by the hospital medical staff. Nurses notes and physician notes were silent to the alleged abuse incident. No root cause analysis and/or any other internal investigation was done by any medical staff. Staff D gave the surveyor an e-mail dated 9/5/2012 (20 days after the allege incident) that he/she sent to patient advocate/patient relations coordinator which stated, "I received a statement from the employee accused of hitting this patient and gave the statement to human resources. Security will continue to follow, and the accused employee will not be able to care for the patient. I updated the wife a couple a weeks ago, and she was happy with care as of 2 weeks ago." There was no documentation to support that the spouse was updated at all regarding the alleged abuse in writing until the letter was sent by the patient relation coordinator on 9/07/2012.

The patient advocate/patient relations coordinator's (staff F) gave the surveyor an e-mail dated 9/05/2012 (20 days after the alleged incident) that was sent to the patient coordinator which questioned on the status of the abuse complaint, and Staff F stated, " I never put this into Midas. I need to now. Wife never returned my calls about this, so I never talked to her or did anything with this. Can you send me what was said and done, I will put it in Midas (computer reporting system)."

The surveyor questioned Staff D and F as to why they waited to formally initiate the complaint process, and neither Staff D nor F could give an explanation. Staff D said I talked to my staff regarding the alleged incident. However, there was no documentation the nurse manager had talked to her staff and/or mentioned the incident in any of Staff D's weekly staff meeting with the 3 South staff. The hospital provided no staff inservice documentation, or any type of documentation indicating the hospital's policy and procedures regarding patient rights were discussed with the staff. Patient #1's medical record lacked documentation to support that the nurse manager ever assessed/looked at the patient.

Staff stated on 10/2/2012 at 11:00 AM that the investigation was to be conducted by the patient advocate and security.

The investigation conducted by a patient advocate/relations coordinator (Staff F) identified there was an incident an incident on 8/15/12, Patient #1's behavior was unsafe due to the patient's agitation and aggression. The patient had to be restrained and sedated. The medical record documented the patient's spouse was there at the time of specified patient's agitation and aggression. Two of the staff members had to hold the patient down in order to apply the restraints due to the patient's agitation. The medical record contained no documentation to indicate Patient #1 had been punched in the face.

According to security (Staff G) on 10/1/12 at 4:00 PM, an investigation was done. Pictures were taken of the specified patient's face by security. All staff involved were interviewed and this was discussed with Staff F.

Staff F stated on 10/2/12 at 3:00 PM that the investigation determined that the facial bruises in the pictures were not consistent with someone being punched in the face. However, there was no documentation a systematic investigation, including a thorough medical investigation. None of the physician and nursing daily assessment documentation addressed the patient's facial bruising. Staff F said the investigation concluded there was no wrong doing and that the care was consistent with the hospital policy and procedures. There was no documentation of how the hospital evaluated the information and formulated the final conclusion that the facial bruises were not consistent with someone being punched in the face.

The nurse manager (Staff D) stated on 10/2/2012 that the investigation was turned over to security. There was no documentation of staff inservice on the 3 South Unit or interviews of staff working during the time of the alleged incident. The only thing done was that the staff in question fitting the description by the patient as African American and/or Mexican was removed from the patient's care. The patient described two different providing persons but could not identify any specific staff. More frequent rounds were made to make the patient and family feel more comfortable about the patient's safety. The case was considered closed as of 09/07/2012.

The hospital had a policy and procedure in place entitled, "Patient/Family Complaint Resolution", policy number: LTACH-RI-2008030180081601 which was reviewed. The policy required the hospital staff to talk to the complainant, examine any physical evidence, interview anyone involved, document interviews, document the evidence discovered and document the relevant documentation that had been reviewed, document the evaluation of what apparently had happened and document the conclusions that had been formulated conclusions. The policy on page 1 of 5 required the hospital to "Respond to, investigate, and attempt to reasonably resolve all customer questions, complaints or grievances within five to seven calendar days", to "Regularly apprize the patient/familty of progress toward resolution" and to "Maintain central files of appropriate documentation outlining each feedback incidence." The policy on page 5 of 5 at 7.b. required "ALL grievances must have a final letter sent to the patient/family within 7 calendar days of resolution, or within a maximun of 15 business days of receipt of the grievance.

The hospital's lack of documentation the patient and family had been kept informed of the investigation, demonstrated the hospital's failure to follow the hospital's process for a prompt resolution of the patient's grievance.


The hospital's lack of documentation was indicative of the lack of a systematic investigation, in accordance with the hospital's policy, of the 8/15/2012, allegation of abuse.

The hospital lacked documentation the patient and family was kept informed of the investigation. The hospital failed to demonstrate a process for prompt resolution of the patient's grievance.

The above findings was confirmed with the administrative and compliance staff on 10/2/2012 at 4:30 PM.

Based on staff interviews, medical record review, and review of hospital's documentation of the investigation of the complaint of abuse, the hospital failed to promptly resolve a patient's allegation of patient abuse.


Findings include:

Please refer to A 118 for the specifics regarding the hospital failure to process the allegation of abuse for the prompt resolution to the grievance in accordance with the hospital's policy.

Based on medical record review, interview of staff, review of the hospital's complaint log, and the hospital's complaint resolution policy, the hospital failed to resolve the patient's grievance and failed to provide the patient or patient representative with a written response to the complaint within the time frame as stated in the hospital's patient complaint resolution policy. (A122)


Findings include:

Please refer to A 118 regarding the hospital not review, investigate and resolve Patient #1's grievance within a reasonable time frame.

Based on medical record review, staff interviews, and review of the hospital's incident reports, the hospital failed to follow the hospital's complaint resolution policy's time frames and therefore failed to ensure a safe setting was provided in a timely manner for one (Patient #1) of ten sampled patients. The hospital had a census of 73 patients at the time of this survey.


Findings include:

Please see A 118 for the findings regarding the number of days before Patient #1 felt safe on the 3 South unit.