25957 Based on staff interview, policy review, and medical record review, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This resulted in the failure to provide stabilizing treatment prior to discharge for a patient who presented to the ED seeking services. Findings include: Refer to A2407 as it relates to the failure of the hospital to provide stabilizing treatment for an identified EMC prior to dischatrge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25957 Based on staff interview, and review of facility policies and medical records, it was determined the hospital failed to ensure 1 of 34 patients (Patient #1) with emergency medical conditions, whose records were reviewed, received necessary treatment required to stabilize his presenting emergency medical condition prior to discharge. This failure to stabilize placed the patient and the community at risk of injury. Findings include: A facility policy titled EMTALA - Medical Screening Examination and Stabilization Policy, dated 1/29/19, stated if an EMC is determined to exist, the individual will be provided the necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilization treatment shall be applied in a non-discriminatory manner . a. Patient #1's medical record documented a [AGE] year old male who was brought to the ED by local police on 7/06/19 at 5:48 PM, with a chief complaint of aggressive behavior. He was accompanied by staff from the group home where he resided. Additional medical history, obtained during triage, included diagnoses of developmental disability, reactive attachment disorder, fetal alcohol syndrome, and schizophrenia. A suicide assessment was performed on 7/06/19 at 6:35 PM by the admitting RN. She documented Patient #1 was at risk for suicide and his treatment room was secured with the removal of ligature prone items, extra linen, trash bags, unnecessary cords, and sharps. Patient #1 completed a violence/aggression assessment on 7/06/19 at 6:40 PM. The assessment documented Patient #1 as being high risk with positive responses to irritability, verbal threats, physical threats, and attacking objects. A face to face behavioral health assessment was performed on 7/06/19 at 8:24 PM by the facility's MSW. During the assessment, Patient #1 stated I lost my temper. I can't go home. I can't be safe. He reported auditory hallucinations as Voices interact with my mood and tell me things I don't want to do. The assessment documented the following: Staff from the group home stated Patient #1 had increased physical aggression and homicidal ideation in the past week. Pt was admitted to the ED five days ago and was released on a safety plan. Staff and pt report that pt cannot be safe at home at this time. Pt reports suicidal ideation but denies having a plan. Staff states pt attempted to cut his wrists within the past two weeks and attempted to jump in front of traffic less than seven days ago. Pt reported homicidal ideation towards group home staff and clients. The MSW's assessment stated Patient #1's thought processes were disorganized and illogical. She documented Due to pt's increasing homicidal and suicidal ideation, he presents a danger to himself and others. Pt is seeking inpatient placement. Her recommendation for Patient #1 was Transfer to IP psych. Documentation showed this recommendation was discussed with the EDMD. She then contacted ARC to request they initiate the placement process for Patient #1. On 7/06/19 at 9:06 PM, Patient #1 was given an IM injection of Geodon 10 mg (an antipsychotic medication used for treatment of bipolar disorder and schizophrenia.) His home medications included Geodon 160 mg daily. b. The facility provided on site staff for behavioral assessments Monday through Friday from 8:00 AM until 11:00 PM, and on weekends from 1:00 PM until 9:00 PM. Assessments were provided during other hours by ARC, an off site, corporately owned, telehealth system. Patient #1's record documented several attempts at inpatient placement beginning on 7/06/19 at 9:44 PM. Documentation showed a response from ARC stating pt meets exclusionary criteria and will likely be denied by placement options. The facility's Behavioral Health Center Admission Criteria was reviewed. It stated There may be circumstances wherein a patient is determined not to be appropriate for an acute Behavioral Health setting due to factors such as TBI, intellectual disability, an acute medical condition, medically-based delirium, forensic issues, violent behavior, or poor impulse control beyond the capability and capacity of staff & environment to treat the patient in a safe manner. Status of such will be determined by the accepting psychiatrist. Patients must be free from mechanical restraints before admission takes place. On 7/07/19 at 1:27 AM the facility's Behavioral Health Center, as well as all Behavioral Health Centers at hospitals owned by the corporation, denied Patient #1 admission due to exclusionary criteria. At 8:29 AM, two other in state facilities denied admission to Patient #1 with no reason documented. The group home QIDP, the group home clinician, the facility's Behavioral Health Center supervisor, and Patient #1's guardian/mother requested that ARC continue to pursue inpatient treatment placement. c. On 7/07/19 at 12:11 PM a behavioral assessment of Patient #1 was performed by a licensed professional counselor via the off site ARC telehealth system. The assessment documented the following: Suicidal thoughts: Current. Patient reports he cannot be safe w/ group home staff and clients. Patient is at risk for suicide: Yes. Homicidal/violent ideation: Yes. Patient is at risk for committing homicidal/violent behavior: Yes. Pt is impulsive with SI and HI statements hx cutting anger [sic]. Pt and ALF is seeking medication evaluation for depression and aggressive behaviors before returning; spoke with [EDMD's name] supporting inpatient admission for further evaluation with medication and stabilization. The counselor documented at 1:07 PM Staffed with MSTAR Director [director's name] regarding disposition. Pt does not meet inpatient criteria with primary dx mental retardation. The counselor then recommended Patient #1 be discharged from the facility and left a message at the group home to come and pick up Patient #1. Patient #1 was discharged from the facility on 7/07/19 at 3:15 PM to home/self care with a documented primary impression: Psychosis. In an interview on 7/17/19 at 12:30 PM, the facility's BHC flow coordinator stated a psychiatrist was on call for the facility at all times and a consult could have been called by the EDMD. He confirmed this would have been the same psychiatrist included in the group determining Patient #1's admission to the facility's BHC. When asked what resources were available to Patient #1, he said there were none because DD services do not include patients with MI and MI services do not include patients with DD. In an interview on 7/17/19 at 2:30 PM, the facility's BHC Director confirmed the exclusionary criteria. He stated a patient's admission could be decided by the center's administrative group that included the on call psychiatrist, or solely by the on call psychiatrist. In an interview on 7/18/19 at 9:00 AM, Patient #1's admitting EDMD said he depended on behavioral health personnel to evaluate and place patients. He stated he would ask for a psychiatrist consult if a patient remained in the ED for greater than 24 hours and BHC personnel usually facilitated the consult. He also stated he would place a patient on an emergency hold if he knew the patient was an imminent risk to themselves or others. However, he said the BHC personnel play a big part in placing a patient on hold. In an interview on 7/18/19 at 10:15 AM, Patient #1's discharging EDMD stated he never saw Patient #1. He said he was unaware Patient #1 was suicidal until he was told by surveyors in this interview. He also stated he rarely contacted the on call psychiatrist for an evaluation and would only do so if a patient had been in the ED for days and couldn't be placed. He stated he depended on behavioral health personnel to let him know what was going on with patients. In an interview on 7/18/19 at 10:45 AM, the facility MSW, who performed the initial behavioral assessment on Patient #1 on 7/06/19 at 8:24 PM, confirmed her recommendation for inpatient treatment after the assessment. She said she had a conversation with ARC about Patient #1's need for placement. She said she was told it didn't matter what the patient was presenting with, he was excluded from admission because of his history of TBI, FAS, and MMR. She said this was the first time ARC had disagreed with her evaluation or recommendation. She asked ARC for resources to provide to Patient #1 and was told they did not have any and it was up to the group home to find resources. She said it was ARC's decision to discharge Patient #1. She stated she could not assign a developmental age to Patient #1, but he understood her questions and his situation and knew what was going on with himself. She confirmed group home personnel wanted to pursue inpatient placement. In an interview on 7/17/19 at 4:00 PM, the ARC counselor, who performed the behavioral assessment on Patient #1 on 7/07/19 at 12:11 PM, stated Patient #1 had indicated sorrow for his actions, did not want to be admitted as an inpatient, and had no intention of harming himself or others. When asked why this information did not match documentation, she had no explanation. She said she discussed Patient #1 with her supervisor and it was decided Patient #1 was not at risk. She said the group home staff at the bedside and the group home nurse assured her Patient #1 would be returned to the group home under suicide watch and would be safe. The facility's Director of Quality, Risk and Patient Safety was present during the interview and confirmed the counselor's statements did not reflect documentation. In an interview on 7/18/19 at 8:30 AM, the group home QIDP stated he, the group home nurse, the group home bedside staff and the group home clinician had informed the facility staff that Patient #1 could not be returned to the group home because it was not possible to keep him safe. In an interview on 7/18/19 at 8:50 AM, the group home regional supervisor stated he was present at the facility when Patient #1 was discharged . He said facility staff told him Patient #1 was not admitted for inpatient mental health treatment because he would not be responsive to medication changes or counseling. He stated Patient #1 was not taken back to the group home due to safety concerns for Patient #1 as well as other group home residents and staff. He stated Patient #1 was discharged from the group home to the care of his guardian/mother. In an interview on 7/18/19 at 9:15 AM, the group home clinician stated the facility's MSW contacted him on 7/07/19. She told him that, per her supervisor at ARC, Patient #1 was being discharged and it was the group home's responsibility to take care of him. When he asked her where the liability fell , she replied it was no longer the facility's concern or responsibility and it was up to the group home to figure it out. He asked her for resources for Patient #1's continued mental health care and was told she had no resource information to give him. In an interview on 7/18/19 at 2:10 PM, the discharging RN stated he was aware the group home did not want to take Patient #1 back, but he did not know why. He said the group home bedside staff was on the phone to the group home regional supervisor. The RN overheard a discussion related to Patient #1 being taken to a hotel rather than back to the group home. He said he reported the conversation to the ED manager. The facility failed to provide stabilizing treatment for Patient #1's presenting EMC prior to discharge.

37262 Based on hospital grievance response letter review and staff interview, it was determined the hospital failed to ensure patients were informed of the time frame for review and response to grievances. This impacted all patients who had filed a grievance with the hospital and had the potential to interfere with understanding of the grievance process. Findings include: Initial response letters to patient grievances which required additional time to investigate were reviewed. All initial response letters issued by the hospital followed a pre-formatted template which stated the hospital would require, additional time to complete. However, the template did not include a time frame for this additional grievance response. The Patient Advocate was interviewed on 6/13/19, beginning at 8:29 AM, and the hospital's initial grievance response template was reviewed in her presence. She confirmed the template did not include a time frame for the grievance response. The Patient Advocate stated a time frame would be added to the template immediately. Patients were not informed of the time frame for review and response to their grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37262 Based on medical record review, observation, education materials review, document review, policy review, and staff interview, it was determined the hospital failed to ensure staff were trained and competent to operate emergency equipment. Additionally, the hospital failed to ensure suicide precautions were followed for 1 of 1 patient (Patient #3) who was a minor with SI and whose record was reviewed. These issues had the potential for care to be provided in a setting which was unsafe. Findings include: The hospital failed to ensure care in a safe setting. Examples include: 1. A tour of the hospital's ASU was conducted on 6/12/19, beginning at 8:15 AM, in the presence of the Unit Manager. Eight beds in the ASU [3rd floor] were currently occupied by 4th floor [step-down] overflow patients. A 4th floor RN, who had floated to the ASU to care for the 4th floor overflow patients, was interviewed on 6/12/19, beginning at 8:19 AM. When asked how non-ambulatory patients would be evacuated to the lower hospital floors in the event of a fire, the RN stated a stair-chair [Stryker Evacuation Chair] would be used. When asked if he could locate a stair-chair in the ASU, he stated he could not. When asked if she could locate a stair-chair in the ASU, the Unit Manager stated she could not. At that point, it was discovered the ASU floor did not have a stair-chair. The closest unit to have a stair-chair was located in an adjacent building separated by a long hallway. A tour of the hospital's 2nd floor was conducted on 6/12/19, beginning at 3:00 PM, in the presence of the Stroke Program Manager and ICU Director. During the tour, an ICU RN was interviewed and asked to locate a stair-chair for use in a fire emergency. One stair-chair was located, however, the RN was unable to operate it. When asked if she could operate the stair-chair, the ICU Director stated, no. The ICU Director stated she had trained to use the stair-chair, one time a long time ago. A tour of the hospital's 6th floor was conducted on 6/13/19, beginning at 1:10 PM, in the presence of the Stroke Program Manager. During the tour, the 6th floor CN was interviewed and asked to locate a stair-chair for use in a fire emergency. Two stair-chairs were located; however, the CN was unable to operate either. When asked if she had received training on how to operate the stair-chair, the CN stated she believed she had, last year. A tour of the hospital's 4th floor was conducted on 6/13/19, beginning at 1:26 PM, in the presence of the Stroke Program Manager. During the tour, a 4th floor CNA was interviewed and asked to locate a stair-chair for use in a fire emergency. One stair-chair was located in an equipment storage room, located in the back-left corner, blocked by numerous large pieces of patient care equipment. When asked if she was able to operate the stair-chair, the CNA stated, no, I never received training. A blank EIRMC FIRE DRILL form was requested and reviewed. The form included several actions for staff to complete in the event of a fire. The form did not include locating and operating a stair-chair for emergency patient evacuation in the event of a fire. Stair-chair education and training were requested. An email with a picture of the Stryker Evacuation Chair was provided with the words Annual training - Safety Exam handwritten at the top. The email did not include a safety exam or instructions on how to use the stair-chair. The email did not include a staff roster of who had participated in the training. The Director of Patient Safety was interviewed on 6/12/19, beginning at 5:01 PM. When asked if stair-chairs were included on daily emergency equipment checks by hospital staff, she stated, no. The Director of Patient Safety confirmed the observational findings on staff's inability to locate and safely operate stair-chairs in the event of an emergency. The hospital failed to ensure staff were educated and trained on the use of emergency equipment in the event of a fire. 33951 2. The hospital's policy, Patient Safety Attendant for Patient Observation (Sitter), effective 3/14/19, stated, A patient who has demonstrated that they are at risk for harm to self, others or property, and have not responded to alternative methods of care will be continually visually observed by a PSA until the Clinical Nurse Supervisor/House Supervisor/Designee determine that the patient is no longer at risk and/or obtains a Physician order that suicide risk has been removed. The policy included ADDENDUM A, Patient Safety Attendant (PSA) Guidelines/Responsibilities/Competencies. The addendum stated, The PSA will document the patients' continuous observation on a designated paper flow sheet every 15 minutes for Suicidal/High Risk patients and every 30 minutes for Safety Risk patients. The flowsheet is a permanent part of the medical record and must be signed off by the RN each shift. This policy was not followed. An example includes: Patient #3 was a [AGE] year old male admitted to the PICU on 4/28/19, following a suicide attempt. He was transferred from the PICU to the BHC on 4/30/19. His PICU record was reviewed. Patient #3's record included a physician's order for suicide precautions, dated 4/28/19. Patient #3's record included an RN shift assessment, dated 4/28/19 at 9:30 PM. The assessment stated he was at risk for suicide, as evidenced by his recent suicide attempt and seeking ways to harm self. The assessment stated a sitter was at Patient #3's bedside. Patient #3's next RN shift assessment was documented on 4/29/19 at 8:00 AM. It did not include a suicide risk assessment. It stated a sitter was at Patient #3's bedside. Patient #3's record included a Behavior Health Assessment, dated 4/29/19 at 1:31 PM, signed by a Psychiatric Technician. It stated Patient #3 was at risk for suicide and documented the warning signs Seeking ways to harm self and Current plan [with] lethality. Patient #3's next RN shift assessment, dated 4/29/19 at 8:40 PM, included a suicide risk assessment. It did not state Patient #3 had a sitter. There was no physician's order or documented determination by a supervisor to discontinue the sitter. Patient #3's record did not include a flow sheet with documentation of continuous observation by a sitter every 15 minutes as required per hospital policy. It could not be determined from his record if a sitter was provided for his safety during his entire stay on the PICU. The Division VP of Nursing Operations was interviewed on 6/13/19 at 2:15 PM, and Patient #3's record was reviewed in her presence. She stated a suicide risk assessment was a required component of each RN shift assessment, and confirmed it was not completed as part of Patient #3's RN day shift assessment on 4/29/19. The Division VP of Nursing Operations confirmed there was no PSA flow sheet to document continuous observation of Patient #3. She stated the PSA policy, addendum, and flow sheet were effective 3/14/19, but had not been implemented by the hospital at the time of Patient #3's PICU admission, 4/28/19 to 4/30/19. The hospital failed to ensure Patient #3's safety by performing suicide risk assessments every shift and providing a PSA during his entire PICU stay.

37262 Based on patient rights and responsibilities information review and staff interview, it was determined the hospital failed to ensure patients were informed of how to file a grievance with Idaho SA. This lack of information had the potential to prevent patients from filing grievances regarding their care. Findings include: A patient rights and responsibilities brochure, which is provided to patients and their representatives, included information on how to file a grievance with the contracted QIO, accrediting body, OCR, and hospital. The brochure did not include information on how patients and their representatives could file a grievance with the Idaho SA. The Patient Advocate was interviewed on 6/13/19, beginning at 9:45 AM, and the patient rights and responsibilities brochure was reviewed in her presence. She confirmed the brochure did not include information on how patients and their representatives could file a grievance with the Idaho SA. The hospital failed to inform patients and their representatives how to file a grievance with the Idaho SA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37262 Based on hospital policy review, job description review, restraint log review, security log review, review of incident reports, and staff interview, it was determined the hospital failed to ensure adverse events documented in security logs were identified and analyzed. Additionally, the hospital failed to ensure restraints applied by armed and unarmed hospital security staff on patients were identified and analyzed. This had the potential for unidentified adverse patient events and incomplete quality data used to analyze patient care. Findings include: 1. A hospital job description Security Officer - Armed, revised 2/2019, stated, This position requires logging of daily tasks, conducting thorough investigations and completing detailed incident reports. A hospital policy Occurrence Reporting, effective 9/11/18, stated, Meditech is the HCA-designed system used to report events and close calls and should be available to all staff. An armed security officer was interviewed on 6/11/19, beginning at 2:46 PM. When asked if he submitted hospital incident reports, he stated, yes. When asked if he had access to the hospital's EMR system to enter incident reports, he stated, no. The hospital's armed security officer log from 4/01/19 through 6/09/19, was reviewed. An entry dated 4/08/19 at 7:03 PM, by an armed security officer, stated, I completed a an [sic] IFPD case report along with an EIRMC Incident Report [sic]. The incident report was placed in the basket. The hospital incident report log from 1/01/19 to 6/10/19, was reviewed. All incident report entries documented in the log had been entered into the hospital's EMR system, Meditech. It was unclear if the incident report log included incidents generated by armed and unarmed hospital security officers. The Director of Plant Operations and Security was interviewed on 6/13/19, beginning at 4:02 PM. He stated he was the hospital's supervisor for armed and unarmed security services. When asked if armed and unarmed hospital security officers had the ability to enter incident reports in Meditech, he stated, no. When asked if armed security officers were employees of the hospital, The Director of Plant Operations and Security stated, yes. He stated unarmed hospital security officers were contracted and also did not have access to Meditech. The Director of Plant Operations and Security stated armed and unarmed hospital security officers would submit incident reports via their own paper reporting system. When asked if the paper incident report forms used by armed and unarmed hospital security officers had been vetted and approved by the hospital's Governing Body, the Director of Plant Operations and Security stated, no. When asked if the hospital's QAPI program identified and analyzed armed and unarmed hospital security incident reports, the Director of Plant Operations and Security stated, no. The Director of Plant Operations and Security confirmed the job description for armed hospital security officers conflicted with hospital policy in regard to their ability to enter incident reports. Hospital security incident reports were not identified and analyzed by the hospital's QAPI program. 2. The hospital's armed security officer log from 4/01/19 through 6/09/19, was reviewed. The log included 4 entries by armed hospital security staff who documented applying patient restraints: a. 4/01/19 at 2:00 PM: .They needed help to restrain her while they gave the medication. Myself and [unarmed hospital security] restrained her while medication was administered. She didn't fight while we were restraining her. Once medication was given she was released. b. 4/10/19 at 4:50 AM: .I restrained her with a straight arm bar [sic] and escorted her back to room [ROOM NUMBER]. c. 4/28/19 at 8:35 PM: Male that was highly agitated was given medication. A cathator [sic] was placed and he became upset. I held his legs as he got agitated so he would not kick staff. d. 5/31/19 at 6:00 PM: Assisted medical in holding down intoxicated suicidal pt while they obtained blood and urine. I stood by until she calm [sic] down. The hospital restraint log from 1/01/19 to 6/11/19, was reviewed. All restraint entries documented in the log had been entered into the hospital's EMR system, Meditech. The 4 examples above were not documented on the hospital restraint log. The Director of Plant Operations and Security was interviewed on 6/13/19, beginning at 4:02 PM. When asked if armed and unarmed hospital security officer patient restraints were documented in the hospital's restraint log, he stated, no. When asked if the hospital's QAPI program identified and analyzed armed and unarmed hospital security restraints, the Director of Plant Operations and Security stated, no. Patient restraints applied by hospital security staff were not identified and analyzed by the hospital's QAPI program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40733 Based on medical record review, hospital policy review, and staff interview, it was determined the hospital failed to ensure a thorough nursing care plan was developed for 1 of 2 Postpartum patients (Patient #42) whose care plans were reviewed. Lack of a complete care plan had the potential for unmet patient needs. Findings include: The hospital's policy, Interdisciplinary Care Planning Process, dated 4/16/19, stated, [The facility] ensures that care is planned to respond to each patient's unique needs (including age-specific needs), expectations and characteristics with effective, efficient and individualized care based on needs identified in the assessment process . The care planning process identifies goal for care, treatment and rehabilitation in the most appropriate setting with services required to meet the goals. This policy was not followed. An example includes: Patient #42 was a [AGE] year old female admitted on [DATE], for a cesarean section. Her diagnoses included pregnancy induced hypertension, gestational diabetes, and pre-eclampsia. Patient #42's medical record included a care plan, initiated at the time of admission to the Postpartum unit on 6/08/19. It did not include interventions or goals for pre-eclampsia. The Women's Center Director and the Postpartum Unit Charge RN were interviewed together on 6/12/19 at 9:00 AM. They confirmed Patient #42's care plan did not include interventions or goals for pre-eclampsia. The hospital failed to ensure a care plan was developed to address care for Patient #42's diagnosis of pre-eclampsia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on review of medical records and hospital policy, and staff interview, it was determined the hospital failed to ensure written consent forms for admission and treatment were properly executed for 3 of 3 pediatric patients (#2, #3, and #60) whose records were reviewed. This had the potential for minors' treatment being provided without the consent of their legal representative. Findings include: The hospital's policy, Consent for Treatment, effective 7/12/18, stated, EIRMC requires that written consents for treatment be obtained and made a part of the patient's medical record .when the patient is a minor, either the parent(s) or an appropriately designated legal guardian must give consent to medical treatment. 1. Patient #3 was a [AGE] year old male admitted to the PICU on 4/28/19, following a suicide attempt. He was transferred from the PICU to the BHC on 4/30/19. His PICU record was reviewed. Patient #3's record included a Conditions of Admission and Consent for Outpatient Care, dated 4/28/19. The form included a section titled, Patient/Patient Representative Signature, that included a signature. The section stated, If you are not the Patient, please identify your Relationship to the Patient. (Mark relationship(s) from List below): Patient. Patient #3 was a minor and unable to consent to care. It could not be determined who signed his consent form. The Director of Quality was interviewed on 6/14/19 at 7:55 AM. She reviewed Patient #3's consent form and confirmed it did not state who signed the form to give consent for his care. Patient #3's consent form did not accurately state who gave consent for his hospital care. 2. Patient #2 was a 7 year old male admitted to the hospital on 6/07/19, with a primary diagnosis of osteomyelitis of his finger. He was a current patient as of 6/11/19. Patient #2's record included a Conditions of Admission and Consent for Outpatient Care, dated 6/07/19. The form included a section titled, Patient/Patient Representative Signature, that included a signature. The section stated, If you are not the Patient, please identify your Relationship to the Patient. (Mark relationship(s) from List below): Patient. Patient #2 was a minor and unable to consent to care. It could not be determined who signed his consent form. The Director of Quality was interviewed on 6/14/19 at 7:58 AM. She reviewed Patient #2's consent form and confirmed it did not state who signed the form to give consent for his care. Patient #2's consent form did not accurately state who gave consent for his hospital care. 3. Patient #60 was a 12 month old female admitted to the hospital on 4/11/19, with a diagnosis of pneumonia. She was transferred to a pediatric hospital on 4/13/19. Patient #60's face sheet stated she was admitted to the hospital on 4/11/19 at 1:03 PM. Her record did not include a consent for treatment. The consent was requested, and documentation was provided that stated, PARENTS NOT HERE TO SIGN COA'S [Conditions of Admission]. The documentation was dated 4/12/19 at 10:47 AM. Patient #60's record included documentation signed by the Child Life Specialist, dated 4/11/19 at 1:10 PM, 7 minutes after her admission. It stated Specialist met with: Parent. It could not be determined why consent for admission was not obtained from Patient #60's parent at that time. The Director of Quality was interviewed on 6/14/19 at 8:00 AM. She stated Patient #60 was a direct admit to the pediatric floor, and the Registrar went to the floor the following day to obtain consent for admission. Patient #60's parents were not present at that time. The Director of Quality stated the Registrar should have made another attempt to get the consent signed and confirmed there was no documentation of an additional attempt. She confirmed Patient #60's record did not include consent for her hospital services. The hospital failed to obtain consent for admission for Patient #60.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39430 Based on medical record review, hospital document review, observation, hospital policy review, AORN guidelines review, ASHRAE standards review, and staff interview, it was determined the hospital failed to ensure clinical staff followed effective infection control practices, including hand hygiene, and identified potential infections for patients and personnel. This had the potential for inadequate interventions to mitigate environmental and surgical infection risks. Additionally, the facility failed to demonstrate specific parameters of a water management program for waterborne pathogens such as Legionella. Failure to consider the ASHRAE industry standards and utilize parameters defined in the CDC toolkit, has the potential to limit relevant facility awareness and expose residents to Legionella and other opportunistic waterborne pathogens based on incomplete or inconclusive data. This deficient practice could potentially affect all patients and staff on the dates of the survey. Findings include: 1. During review of provided policies and procedures for water management on June 11, 2019, from approximately 8:00 AM to 11:00 AM, records demonstrated the facility had not completed a comprehensive facility risk assessment, taking into consideration risks identified in ASHRAE industry standards and the parameters defined in the CDC toolkit for developing a water management program. Additionally, the facility had not identified acceptable ranges for control measures or documented testing protocols. Interview of the Director of Facilities and Facility Safety Coordinator revealed the facility was unaware the current water management plan was lacking required components. 2. A hospital policy Hand Hygiene, effective date 3/04/19, stated: - Perform hand hygiene using alcohol hand rub or handwashing before planned and unplanned (room entry) patient contact & after contact with patient or patient's environment (room exit). - Decontaminate hands if moving from a contaminated body site to a clean body site during patient care. - Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. - Decontaminate hands after removing gloves. A policy for the disinfection of the IMoblie devices [hospital-provided cell phones utilized by clinical staff] was requested. The Hospital provided a document titled 2015 mobile Device Cleaning and Disinfection Guidelines undated. The document stated: - Devices should be regularly disinfected between use in patient rooms or care areas to reduce the risk of transmission. - If the mobile device was in use or accessed while in a patient's room, sanitize the device before removing gloves. These 2 policies were not followed. Examples include: a. Patient #39 was a [AGE] year old female, admitted to the hospital on 5/30/19, for multiple trauma post motorcycle crash. Additional diagnoses included spleen laceration, liver laceration, and fractured femur. On 6/11/19 at beginning at 1:45 PM, an RN was observed administering medications to Patient #39. Upon entering her room, the RN did not perform hand hygiene prior to donning gloves. After the RN administered Patient #39's medications she retrieved the facility provided IMobile device from her pocket, sent a message, and placed the device back in her pocket. The RN removed her gloves, performed hand hygiene, and left Patient #39's room. The RN did not perform hand hygiene prior to donning gloves and did not disinfect her IMobile device after using it with gloved hands in the patient room. During an interview with the Director of Patient Safety and the RN on 6/11/19 beginning at 3:10 PM, the RN confirmed she did not perform hand hygiene prior to donning gloves. The Director of Patient Safety confirmed the RN should have disinfected the device after use in Patient #39's room per policy. The RN failed to perform hand hygiene per policy and disinfect her device per policy. b. A colonoscopy procedure was observed on 6/12/19 from 1:39 PM to 2:30 PM on the GI unit. During the procedure, the following infection control issues were noted: i. An RN was observed wearing gloves while using a computer keyboard then handling a specimen container which she placed next to the endoscopy tech. The RN did not cleanse her hands or change gloves after using the keyboard and handling the specimen container. ii. The CRNA was observed pen to document then handling the patient's IV port and medication syringes. The CRNA did not cleanse his hands or change gloves after using the pen and handling the patient's IV port and syringes. The Chief Medical Officer and the Director of Quality were interviewed together on 6/13/19 beginning at 1:00 PM. They confirmed the observed actions did not follow their hand hygiene policy. iii. During an observation of endoscope reprocessing, an endoscopy tech was observed placing an unprocessed endoscope into an automated reprocessor, then removing a processed endoscope from another automated reprocessor, and opening the endoscope storage cabinet. The Chief Medical Officer and the Director of Quality were interviewed together on 6/13/19 beginning at 1:00 PM. They confirmed the observed actions did not follow their hand hygiene policy. 37262 3. Patient #53 was a [AGE] year old female who was admitted on [DATE], for left elbow surgery. Her surgical procedure was observed. She was discharged to home on 6/12/19. The following infection control breaches were identified during the observation of Patient #53's surgical procedure on 6/12/19, from 8:58 AM to 9:47 AM: a. A hospital policy OR - OR - Hand Hygiene in the Perioperative Setting, effective 8/11/16, stated, Perform hand washing .Before putting on gloves and after removing gloves or other personal protective equipment (PPE). This policy was not followed. At the conclusion of Patient #53's surgical procedure at 9:36 AM, the circulating RN, while wearing gloves, removed several pieces of blood-soaked gauze from a floor basin, and placed them into individual pouches to be counted. The circulating RN performed this task twice with the same soiled gloves. The circulating RN, while continuing to wear the same soiled gloves, touched and manipulated several patient care items in the OR suite. The circulating RN removed his gloves and exited the OR suite at 9:39 AM, but did not perform hand hygiene. b. A hospital policy OR - Surgical Environment, effective 6/22/15, stated, Eating, drinking and the handling of personal and personal care items (i.e., the application of lip balm, cell phones, etc.) is prohibited within the operating rooms and areas beyond the red line. This policy was not followed. AORN Guidelines 2015, Clean surgical attire should be worn in the semi-restricted and restricted areas of the perioperative setting, Recommendation I.m, states, Cell phones, tablets, and other personal communication or hand-held electronic equipment should be cleaned with a low-level disinfectant. This guideline was not followed. The CRNA pulled a cell phone from his pocket at 9:26 AM with ungloved hands, manipulated the cell phone, and placed the cell phone back in his pocket. He did not perform hand hygiene before or after touching the cell phone. It was unclear how the CRNA's cell phone was sanitized for the OR setting. c. AORN Guidelines 2015, Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair, Recommendation III.a, states, A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of neck should be worn. This guideline was not followed. The surgeon, surgical first assist, scrub nurse, surgical nurse, and CST all wore a surgical head cover which left their ears fully exposed; especially pertinent for those surgical staff directly above the sterile surgical site and sterile surgical equipment. d. Several OR suite horizontal surfaces, approximately greater than 6 feet in height, had a visible layer of dust. This included the wall clock and several ceiling-suspended boom-arms in the periphery of the suite. The Director of Surgical Services was interviewed on 6/12/19, beginning at 10:30 AM, and Patient #53's OR suite observations were reviewed in his presence. When asked what infection control guidelines governed staff in the surgical setting, he stated, AORN. The Director of Surgical Services confirmed surgical staff did not follow hospital policy and AORN guidelines in regards to observed infection control breaches. Hospital surgical staff failed to follow hospital infection control policy and AORN guidelines. 40733 4. Patient #60 was a [AGE] year old female admitted on [DATE], for a colonoscopy. Her procedure was observed on 6/12/19 from 1:39 PM to 2:30 PM on the GI unit. During the procedure, the following infection control issues were observed: a. An RN was observed wearing gloves while using a computer keyboard then handling a specimen container which she placed next to the endoscopy tech. The RN did not perform hand hygiene or change gloves between using the keyboard and handling the specimen container. b. The CRNA was observed using a pen to document, then handling the patient's IV port and medication syringes. The CRNA did not perform hand hygiene or change gloves between using the pen and handling the patient's IV port and syringes. 5. During an observation of endoscope reprocessing, an endoscopy tech placed an unprocessed endoscope into an automated reprocessor then, without performing hand hygiene or changing gloves, removed a processed endoscope from a different automated reprocessor. The Chief Medical Officer and the Director of Quality were interviewed together on 6/13/19, beginning at 1:00 PM. They confirmed the observed actions did not follow their hand hygiene policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on a review of medical records, hospital policies, grievance log, and staff interviews, it was determined the hospital failed to prepare patients for post hospital needs for 2 of 2 patients (#1 and #6) whose records were reviewed for discharge planning. This resulted in patients being discharged without having the knowledge and ability necessary to meet their post-hospitalization needs. Findings include: The hospital's policy, Discharge Planning effective 5/02/19, stated, A multidisciplinary team approach will be utilized to develop a plan to include the patient, family, and significant others as applicable, working together with the healthcare team. The healthcare team will include disciplines with specific expertise as indicated by the needs of the patients. This policy was not followed. Examples include: 1. Patient #6 was a [AGE] year old female admitted to the hospital on 9/19/18, and discharged on [DATE]. During her admission, she had abdominal surgery that resulted in a colostomy. Her record was reviewed for case management and discharge planning services. The hospital's grievance log was requested and reviewed. It included a grievance submitted by a home health RN who completed Patient #6's home health admission assessment following her discharge from the hospital. The grievance stated Patient #6 lived alone and was not able to take care of her colostomy due to arthritis, with Cracked, bleeding and swollen hands. Additionally, it stated Patient #6 did not have colostomy supplies in her home. Patient #6's record included a Wound Team note, dated 10/15/19, signed by an RN. The note stated the RN changed Patient #6's colostomy bag and PATIENT WAS WALKED THROUGH THE CHANGE. It stated, I WILL CONTINUE TO FOLLOW AND EDUCATE. Patient #6's record included a CASE MANAGEMENT REPORT, dated 10/16/19, signed by a Case Manager. The note stated Patient #6 was to be discharged that day, and home health services were set up. It stated an order was sent to an equipment company for a walker. The note did not reference Patient #6's colostomy or her ability to complete colostomy care. It did not reference colostomy supplies or how Patient #6 would obtain them. The wound care RN was interviewed on 6/13/19 at 3:35 PM. She stated she saw Patient #6 on 10/15/18, and began teaching her to care for her colostomy. The wound care RN stated she planned to provide further education and send her home with colostomy supplies. She stated she was not aware Patient #6 was being discharged on [DATE]. The wound care RN stated she was not included in Patient #6's discharge planning, and her discharge planning was not completely appropriately. The Director of Case Management was interviewed on 6/13/19 at 2:15 PM. She confirmed there was no documentation of Patient #6's need for colostomy education or supplies in her case management notes. She stated Patient #6 was discharged from the hospital's 5th floor and the RNs and case managers on that unit are not used to dealing with colostomies. She stated Patient #6 should have received better education and discharge planning. The hospital failed to ensure Patient #6 received the education and discharge planning needed to ensure a safe hospital discharge. 2. Patient #1 was an [AGE] year old female admitted to the hospital on 5/01/19, with a diagnosis of sepsis. She was discharged on [DATE]. Her record was reviewed for case management and discharge planning services. Patient #1's record included a Discharge Summary, dated 5/10/19, signed by a physician. It stated, She remained slightly hypoxic thought to be due to alveolar hypoventilation and will require low flow O2 [oxygen] post discharge. Patient #1's record included discharge instructions, dated 5/10/19. The instructions stated, Equipment/supplies: Oxygen therapy. Patient #1's record included a CASE MANAGEMENT REPORT, dated 5/06/19, signed by a Case Manager. The note stated Oxygen was ordered but she does not meet criteria. The note did not state how it was determined Patient #1 did not meet criteria for oxygen therapy, as ordered by her physician. It did not state her physician was contacted to clarify her need for oxygen. The Division VP of Nursing Operations was interviewed on 6/12/19 at 5:20 PM. She confirmed Patient #1's discharge summary and discharge orders included oxygen therapy. The Division VP of Nursing Operations confirmed her physician was not consulted to clarify her need for oxygen. Additionally, she confirmed discharge instructions provided to Patient #1 included oxygen, although it was not ordered for her. The hospital failed to ensure Patient #1's discharge instructions were complete and accurate.

37692 Based on observation and interview, the facility failed to ensure the fire and smoke resistive properties of the structure were maintained. Failure to maintain rated construction assemblies, has the potential to allow fire, smoke and dangerous gases to pass into unprotected concealed spaces and between compartments. This deficient practice had the potential to affect staff on the dates of the survey. Findings include: During the facility tour on June 12, 2019, from approximately 9:00 AM - 3:30 PM, observation of the main server room on the first floor revealed an approximately 12 x 12 penetration in the wall. Interview of the Director of Facilities at the time of discovery revealed the facility was unaware of the hole in the wall. Actual NFPA standard: 19.1.6 Minimum Construction Requirements. 19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.) 8.2 Construction and Compartmentation. 8.2.1 Construction. 8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43, shall meet the minimum construction requirements of those chapters.

37692 Based on observation and interview, the facility failed to ensure exits were maintained free of obstructions for full use at all times. Failure to maintain means of egress free of obstruction has the potential to disorientate personnel trying to evacuate during an emergency. This deficient practice affected staff on the dates of the survey. Findings include: During the facility tour on June 12, 2019, from approximately 9:00 AM - 3:30 PM, observation of the Catch All storage area, revealed one of two exits were obstructed by a full pallet and other storage items. Interview of the Director of Facilities and Interim Director of Facilities at the time of discovery revealed staff had been instructed to keep the exits clear of storage items and the facility was not aware the exit door had been blocked. Actual NFPA standard: NFPA 101 19.2 Means of Egress Requirements. 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 7.1.10 Means of Egress Reliability. 7.1.10.1% Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

37692 Based on record review and interview the facility failed to provide monthly and annual emergency lighting test documentation. Failure to test the emergency lighting could inhibit egress of patients during an emergency. This deficient practice affected all patients and staff on the dates of the survey. Findings include: During review of provided maintenance inspection/testing records on June 11, 2019, from approximately 8:00 AM to 11:00 AM, no documentation could be produced to indicate the battery powered and the generator powered emergency lighting was being tested for 30 seconds monthly or 90 minutes annually. When asked on June 11, 2019 at approximately 11:30 AM, the Chief Engineer stated the facility did have emergency lighting and battery powered emergency lighting but was unaware of the requirement to document a 30 second monthly and 90-minute annual test of the emergency lighting. Actual NFPA reference: NFPA 101 19.2.9 Emergency Lighting. 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9. 7.9.3 Periodic Testing of Emergency Lighting Equipment. 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3. 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)%The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 1-1/2 hours if the emergency

37692 Based on observation and interview, the facility failed to ensure hazardous areas were protected with self-closing doors. Failure to provide self-closing doors for hazardous areas could allow smoke and dangerous gases to pass freely into corridors and hinder egress of occupants during a fire event. This deficient practice affected two (2) visitors and one (1) staff in the gift shop on the date of the survey. Findings include: During the facility tour on June 12, 2019, from approximately 9:00 AM - 3:30 PM, observation of the gift shop storage room revealed the self-closing door was being chocked open. The room was larger than 50 ft2. When asked, the person working in the gift shop stated the door is always chocked open and has been for years. Actual NFPA standard: NFPA 101 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 19.3.2.1.3 The doors shall be self-closing or automatic-closing. 19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following: (1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2) (3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L) (6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

37692 Based on record review, observation and interview, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were maintained properly. Failure to ensure ABHR dispensers are clear of ignition sources and tested during refilling procedures, has the potential of increasing the risk of fires from flammable liquids. This deficient practice affected all patients and staff on the dates of the survey. Findings include: 1.) During review of provided maintenance inspection/testing records on June 11, 2019, from approximately 8:00 AM to 11:00 AM, no documentation could be produced for the testing of ABHR dispensers each time they are refilled. At approximately 9:00 AM, on June 11, 2019, interview of the Safety Coordinator and Environment of Care Coordinator revealed the facility was unaware of this requirement. The Safety Coordinator stated housekeeping staff check to ensure proper operation of the dispenser but was unaware of any documentation to support this claim. 2.) During the facility tour on June 11, 2019, from approximately 3:00 PM - 5:10 PM, and on June 12, 2019, from approximately 9:00 AM - 3:30 PM, both automatic and manual ABHR dispensers were identified throughout the facility. Further observation revealed the following areas had ABHR dispensers installed over an electrical outlet: a.) First Floor corridor outside of the emergency room Par Room. b.) Kitchen Dietary Office c.) Nuclear Medicine Suite Dressing Room Interview of the Director of Facilities, the Safety Coordinator, and Chief Engineer on June 12, 2019, at approximately 11:00 AM, revealed the facility was unaware ABHR dispensers had been installed above electrical outlets. Actual NFPA standard: NFPA 101 19.3.2.6% Alcohol-Based Hand-Rub Dispensers. Alcoho

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37692 Based on record review, observation and interview, the facility failed to ensure fire suppression systems were maintained properly. Failure to inspect system components and ensure fire suppression system pendants were maintained free of obstructions such as paint or corrosion could hinder system performance during a fire event. This deficient practice affected all patients and staff on the dates of the survey. Findings include: 1.) During the facility tour on June 11, 2019, from approximately 3:00 PM - 5:10 PM, and June 12, 2019, from approximately 9:00 AM - 3:30 PM, observation of the bath in room [ROOM NUMBER] at the Behavioral Health Center (BHC) revealed a corroded sprinkler head, and the SANE room bath in Radiology had a painted sprinkler head. The Behavioral Health Clinic (BHC) Gym was missing eight (8) escutcheon rings, the Gift Shop storage room was missing one (1) escutcheon ring and the Labor & Delivery dressing room was missing one (1) escutcheon ring. 2.) During record review on June 11, 2019, from approximately 8:00 AM to 11:00 AM, no documentation for weekly dry system gauge inspections could be produced. Actual NFPA standard: NFPA 25 1.) 5.2.1 Sprinklers. 5.2.1.1% Sprinklers shall be inspected from the floor level annually. 5.2.1.1.1% Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)%Loading (6) Painting unless painted by the sprinkler manufact

34960 Based on observation and operational testing, the facility failed to maintain doors that protect corridor openings. Failure to maintain corridor doors could allow smoke and dangerous gases to pass freely and hinder protection in place. During the facility tour on June 12, 2019 at approximately 11:00 AM, observation and operational testing of the corridor door leading to the Burn Trauma waiting room was chalked open. After removing the chalk, it was determined the door was self-closing. Observation of the size of the waiting room revealed it was greater than 600 ft2. Actual NFPA Standard 19.3.6.3.1% Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 13.4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes

37692 Based on observation, the facility failed to ensure the fire and smoke resistive properties of the structure were maintained. Failure to maintain rated barriers could allow fire, smoke and dangerous gases to pass between compartments during a fire. This deficient practice affected patients and staff on the second floor, in 1 of 7 smoke compartments on the dates of the survey. Findings include: During the facility tour on June 12, 2019, at 9:45 AM, inspection of the rated barrier above the drop ceiling located in the central supply surgery center near the entrance door, revealed approximately one-fourth of the wall had been cut away. Actual NFPA standard: 8.5.6 Penetrations. 8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.

37692 Based on observation and operational testing, the facility failed to ensure cross corridor doors were maintained to limit the transfer of smoke, fire and dangerous gases between compartments. Failure to ensure rated doors limit the transfer of smoke, has the potential to hinder egress and the ability to shelter in place. This deficient practice affected patients and staff in the burn trauma and medical imaging areas of the facility on the dates of the survey. Findings include: During the facility tour on June 12, 2019, from approximately 9:00 AM - 3:30 PM, observation and operational testing of the cross-corridor smoke barrier doors located on the second floor near the CT-1 room and at the front hall of Medical Imaging, revealed both sets of cross-corridor doors would not self-close and latch when released from the magnetic hold open device. Actual NFPA standard: 19.3.7.8% Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 8.5.4.1% Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of 3.4 in. (19 mm). 8.5.4.4% Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

37692 Based on record review and interview, the facility failed to ensure positive pressure gas central piping, medical-surgical vacuum, and WAGD systems have a documented maintenance program. Failure to inventory all components, create a schedule for inspections/maintenance by a qualified person, and develop a written maintenance program based on a facility risk assessment and manufacturers recommendations, could result in fire, explosion, or a lack of system performance as designed. This deficient practice affected all patients and staff on the dates of the survey. Findings include: During record review on June 11, 2019, from approximately 8:00 AM to 11:00 AM, no documentation of a written maintenance program for the positive pressure gas central piping, medical-surgical vacuum, and WAGD systems could be produced. Interview of the Safety Coordinator and Environment of Care Coordinator at the time of record review, and the Director of Facilities and Chief Engineer on June 12, 2019 at approximately 8:15 AM, confirmed the facility did not have a written maintenance program. All staff interviewed were unaware of the requirement for a written maintenance program based on a facility risk assessment and manufacturers recommendations. Actual NFPA standard: NFPA 99 5.1.14.2.1% General. Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed. 5.1.14.2.2 Maintenance Programs. 5.1.14.2.2.1 Inventories. Inventories of medical gas, vacuum, WAGD, and medical support gas systems shall include at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and outlets

33951 Based on staff interview, and review of medical records and hospital policies, it was determined the hospital failed to develop a system to identify patients who were likely to suffer adverse health consequences upon discharge if there was not adequate discharge planning. This failure affected 10 of 10 patients (#1 thru #10) whose records were reviewed for discharge risk screening. The lack of a system to identify patients with discharge planning needs at an early stage had the potential to delay discharge planning for all patients. Findings include: The hospital's policy Discharge Planning, effective 10/03/18, stated Discharge planning screening will be initiated upon admission and continue throughout hospitalization . Case Management/Social Services will screen high risk patients within 24 hours of admission for appropriateness of admission and potential discharge planning needs. Additionally, it stated, A comprehensive screening is performed to identify those patients who may have complex post-hospital care needs. The policy included a list of 16 items that would indicate a need for a discharge assessment, if identified during the screening. The policy did not state how information related to the 16 items would be obtained from each patient. The 10 patient records reviewed did not include documentation of an initial discharge risk screening. During an interview on 10/16/18 at 8:45 AM, the Director of Case Management stated that every patient admitted to the hospital received a discharge risk screening by an RN Case Manager. She stated the information reviewed by the RN Case Manager included admitting diagnosis, age, insurance, home address, and medical equipment used. It could not be determined how other criteria listed on the hospital's policy was determined, such as suspected abuse or neglect, financial concerns, multiple visits to the ED, multiple hospital admissions, or patients receiving home health or hospice services. During an interview on 10/16/18 at 11:00 AM, an RN Case Manager described her discharge risk screening process. She stated each morning she printed and reviewed a report from the hospital's EMR. The report included the patient's name, diagnosis, address, and insurance information. She reviewed the report to determine which patients needed a discharge risk assessment. When asked how she would determine a patient had financial concerns, she stated lack of medical insurance would indicate financial concerns. The RN Case Manager stated she did not document the discharge risk screening. During an interview on 10/17/18 at 10:05 AM, the Director of Case Management stated in the past the hospital's EMR had a program that pulled criteria that could affect patients' discharge needs from the SN assessment and triggered a case management consult. She stated there was a recent update to the EMR and she did not know if that had changed. The Director of Case Management confirmed the RN Case Managers did not have access to all of the criteria listed on the hospital's policy to determine the need for a discharge risk evaluation. Additionally, she stated the RN Case Managers had not been instructed to document discharge risk screening. She stated it would be very time consuming for the risk managers to document a screening for each patient. The hospital failed to develop a system to ensure patients with discharge planning needs were identified at an early stage of hospitalization .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on review of medical records, and patient and staff interview, it was determined the hospital failed to ensure discharge planning needs for 1 of 5 patients (Patient #10) who were interviewed, were evaluated and re-evaluated on a timely basis to ensure the patient's needs were met. This prevented the hospital from identifying and addressing discharge needs in a timely manner. Findings include: Patient #10 was a [AGE] year old female, who presented to the ED on 10/08/18, with complaints of numbness. She was admitted to the hospital, and diagnosed with osteomyelitis of her cervical spine. A physician's note dated 10/12/18, stated she would need at least 6 weeks of IV antibiotic therapy. An IDG meeting was observed on 10/16/18 beginning at 2:00 PM. During the meeting, the physician stated Patient #10 would be discharged the following day, and would continue her IV antibiotic therapy as an outpatient. Patient #10 was interviewed on Tuesday, 10/16/18 beginning at 2:40 PM. She stated she was scheduled for discharge the following day. When asked how she felt about her discharge, she stated it was not a good situation. Patient #10 stated she had no electricity at her home, lived alone, had no transportation, and was unable to take care of herself. When asked if she had talked to a social worker or case manager, she stated a case manager came to see her on Saturday, 10/13/18. Patient #10 stated she told the case manager she did not have electricity at her home. She stated she had no further contact with a social worker or case manager, and was concerned as she was scheduled to be discharged the next day with daily IV antibiotic treatments at the hospital. Patient #10's record was reviewed with the Director of Advanced Clinicals on 10/16/18 at 3:15 PM. It included a case management note, dated 10/13/18, signed by an RN Case Manager. The note stated Patient lives alone and states that she has not been able to take care of herself. States that she does not currently have electricity . No additional case management note was documented. The LSW responsible for Patient #10 on 10/16/18, was interviewed on Tuesday, 10/16/18 at 3:45 PM. She stated she was aware Patient #10 was to be discharged the following day, with orders for IV therapy as an outpatient. The LSW stated she had not seen Patient #10 because she was busy. She stated Patient #10 may have been seen by a case manager over the weekend, but she did not know who had seen her. The LSW stated she may have received an email from the weekend case manager regarding Patient #10, but she had been too busy to read the email. She confirmed no discharge planning evaluation was completed and no discharge plan had been initiated to address Patient #10's needs. The hospital failed to ensure Patient #10 was evaluated for discharge risk in a timely manner, and failed to ensure a discharge plan was developed to prevent a potential for delayed discharge.

37262 Based on medical record review, hospital policy review, hospital document review, review of incident reports, and staff interview, it was determined the hospital failed to ensure an effective, ongoing, hospital-wide, data-driven QAPI program focused on improved health outcomes. This resulted in the inability of the hospital to monitor the quality of patient care services and safety. Findings include: 1. Refer to A286 as it relates to the failure of the hospital to ensure adverse patient events were analyzed and actions were taken to prevent further incidents. 2. Refer to A843 as it relates to the failure of the hospital to ensure its discharge planning process was reassessed on an on-going basis. The cumulative effect of these negative systemic practices prevented the hospital from evaluating the care and services it provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37262 Based on medical record review, hospital policy review, hospital document review, review of incident reports, and staff interview, it was determined the hospital failed to ensure adverse patient events were identified, analyzed, and actions were taken to prevent further incidents for 1 of 1 patients (Patient #5) who had an adverse event and whose record was reviewed. This resulted in lack of analysis and evaluation of safe patient care and had the potential for unidentified adverse patient events for all patients receiving care at the hospital. Findings include: A hospital document Quality, Risk, and Safety Plan, effective [DATE], stated Duty to Report .All health care providers, agents and employees of the facility have an affirmative duty to report events and close calls to the Patient Safety Director, Risk Manager or to his or her designee. New-hire and ongoing education .Staff education includes information about the need to report close calls and unanticipated adverse events as well as how to report these events. This plan was not followed. Patient #5 was a [AGE] year old female who was admitted to the hospital on [DATE] with diagnoses including ESLD, cirrhosis, and history of gastrointestinal bleeding. She was a DNR/DNI and expired in the hospital on [DATE]. The Mayo Clinic website, accessed [DATE], states Vomiting blood (hematemesis) refers to significant amounts of blood in your vomit. Blood in vomit may be bright red, or it may appear black or dark brown life coffee grounds. Bleeding in your upper gastrointestinal tract (mouth, esophagus, stomach and upper small intestine) from peptic (stomach or duodenal) ulcers or torn blood vessels is a common cause of vomiting blood. .truly vomiting blood usually represents something more serious and requires immediate medical attention. Additionally, the Mayo Clinic website, accessed [DATE], states Normal blood pressure XXX,d+[DATE]. A blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top number (systolic) or 60 mm Hg for the bottom number (diastolic) is generally considered low blood pressure. Conditions that can cause low blood pressure .Blood loss. Losing a lot of blood, such as from a major injury or internal bleeding, reduces the amount of blood in your body, leading to a severe drop in blood pressure. Further, the Mayo Clinic website, accessed [DATE], states A low hemoglobin count is defined as less than .12 grams per deciliter [of blood] for women. A low hemoglobin count can also be due to blood loss, which can occur because of .Bleeding in your digestive tract . The Cleveland Clinic website, accessed [DATE], states Esophageal varices are enlarged or swollen veins that occur on the lining of the esophagus. Varices can be life-threatening if the break open and bleed. They usually occur in people with cirrhosis of the liver. Patient #5's medical record included the following nursing notes, dated [DATE], signed by her RN: - 2:10 AM: Blood pressure ,d+[DATE] .PATIENT HAS BEEN REPORTING BLACK VOMIT. HOWEVER I HAVE YET TO SEE ANYTHING SINCE THE ONE EVENT OF RED BLOODY EMESIS [vomit] LAST NIGHT. - 3:11 AM: Blood pressure ,d+[DATE]. - 5:18 AM: Blood pressure ,d+[DATE]. - 6:27 AM: Hgb [hemoglobin] 4.9 .order and transfuse [3 units] PRBC as ordered. Patient #5's medical record included a discharge summary, dated [DATE], signed by the physician, which stated However, during her stay the patient developed sever hematemesis [vomiting blood] likely secondary to esophageal variceal bleed and passed away on 0918 on [DATE]. It was not documented if the RN contacted Patient #5's physician regarding her complaint of black vomit or her continuous low blood pressures. It could not be determined by the RN's documentation if Patient #5 received her ordered blood, as there was no blood administration forms in her medical record. Due to lack of RN documentation, it was unclear what events transpired on [DATE] between 6:27 AM and 9:18 AM. The Director of Quality, Risk, and Patient Safety was interviewed on [DATE], beginning at 1:46 PM, and Patient #5's medical record was reviewed in her presence. She stated the missing blood administration documentation and subsequent death for Patient #5 had not been identified yet and did not warrant an incident/adverse event report. The Director of Quality, Risk, and Patient Safety stated there had not been a mortality review of Patient #5's chart yet. When asked why a mortality review had not been done, she stated the hospital only had one employee who would do the initial mortality reviews and it would take that person up to 30 days to complete. The Director of Quality, Risk, and Patient Safety stated it takes time and resources and she [the mortality reviewer] has other duties and responsibilities. She stated there was no written policy or procedure for patient mortality reviews to identify potential adverse events in a timely manner. The Director of Quality, Risk, and Patient Safety confirmed Patient #5's RN failed to document physician notification of her complaints and low blood pressure, and blood administration. She confirmed it was unclear whether Patient #5 received her blood transfusion or not. An incident/adverse event report regarding Patient #5's blood administration was requested from the Director of Quality, Risk, and Patient Safety on [DATE]. The report provided, dated [DATE], referenced the wasting of unused blood for Patient #5 and stated Blood Administration .Omission. The RN who cared for Patient #5 during the night shift of [DATE] was interviewed by phone on [DATE], beginning at 9:02 AM. When asked if he notified Patient #5's physician regarding her complaint of black vomit and low blood pressure, he stated he did, but confirmed he did not document this. When asked if he administered the ordered blood for Patient #5, he stated he started a new peripheral IV in Patient #5's left arm and started the blood administration prior to leaving his shift, but confirmed he did not document this. The Blood Bank Supervisor was interviewed on [DATE], beginning at 9:50 AM. When asked if she could locate blood administration documentation for Patient #5, she stated there was none. She stated Patient #5 did not receive her ordered blood and the blood was returned to the hospital laboratory following her death. The Blood Bank Supervisor stated [name, Registered Medical Laboratory Scientist] told me the RN spiked the unit of blood, but [Patient #5's] IV was occluded. She [Patient #5] got no blood and died while they were trying to get a new IV. The Clinical Supervisor who was on shift and assisting when Patient #5 expired, and Director of Quality, Risk, and Patient Safety, were interviewed together on [DATE], beginning at 10:39 AM. When asked if Patient #5 received her ordered blood, the Clinical Supervisor stated no. The Clinical Supervisor stated Patient #5 did not have a working IV to administer the ordered blood and expired hemorrhaging from the mouth. When asked if she completed an adverse event report regarding Patient #5's blood administration complications and death, the Clinical Supervisor stated it wasn't needed. When asked what her definition of an adverse event was, the Clinical Supervisor stated something outside the norm. When asked if the situation preceding Patient #5's death was outside normal expected outcomes, the Clinical Supervisor stated yes and confirmed an adverse even form should have been completed. When asked how hospital staff were trained on identifying and reporting adverse events, the Director of Quality, Risk, and Patient Safety stated only during new-hire orientation. When asked how long she had been an employee of the hospital, the Clinical Supervisor stated [AGE] years. The Director of Quality, Risk, and Patient Safety was interviewed on [DATE], beginning at 10:51 AM. She confirmed the conflicting stories of events preceding Patient #5's death and confirmed an adverse event form should have been completed. The hospital failed to ensure adverse patient events were identified, analyzed, and actions were taken to prevent further incidents.

27086 Based on review of policies, procedures, medical records, quality documents, and staff and caregiver interviews, it was determined the hospital failed to ensure the hospital's written policies and procedures addressed all the requirements of 42 CFR 482.43(a) - 482.43(e). The hospital also failed to ensure family members were adequately counseled to prepare them for post-hospital care, that lists of home health agencies were provided to patients/caregivers in accordance with hospital policy, that physicians received necessary medical information post-hospitalization , that a process was established to assess/reassess its discharge planning process. These failures interfered with the implementation of discharge planning and had the potential to result in unmet patient needs. Findings include: 1. Surveyors requested policies and procedures related to discharge planning. The hospital policy Assessment, Patient - Case Managers/Social Workers/Utilization Review, dated 5/04/15, stated The hospital's policies and procedures must be specified in writing. This is a mandatory requirement of the Conditions of Participation for Hospitals. Policies did not address all discharge planning requirements. Examples include: a. Hospital policy did not address the requirements at 482.43(b)6 (A-811) to discuss the results of the discharge planning evaluation with the patient or the patient's representative (and document the communication in the medical record). b. Hospital policy did not address the requirements at 482.43.(c)(2) (A-819) specifying in the absence of a finding by the hospital that a patient needs a discharge plan, the patient's physician may request a discharge plan, and in such a case, the hospital must develop a discharge plan for the patient. c. Hospital policy did not address the requirements at 482.43(d) (A-837) as it relates to providing physician offices with necessary medical information post-hospitalization . d. Hospital policy did not address the requirement at 482.43(e) (A-843) to have a process to reassess its discharge planning process on an on-going basis, including a review of discharge plans. 2. Refer to A-820 as it relates to the failure of the hospital to ensure family members were adequately counseled to prepare them for post-hospital care. 3. Refer to A-823 as it relates to the failure of the hospital to ensure home health agency lists were provided to patients/caregivers in accordance with hospital policy. 4. Refer to A-837 as it relates to the failure of the hospital to ensure a process was established to inform physicians of necessary medical information post-hospitalization . 5. Refer to A-843 as it relates to the failure of the hospital to ensure a process was established to assess/reassess its discharge planning process on an on-going basis as a part of the hospital's QAPI program. The cumulative effect of these negative facility practices impeded the hospital's ability to provide adequate discharge planning services to patients.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27086 Based on record review, policy review, and staff interview, and caregiver interview, it was determined the hospital failed to ensure family members were adequately counseled to prepare them for post-hospital care for 2 of 5 patients (#1 and #5) whose medical records were reviewed. This resulted in a lack of preparation and involvement of family members for patient discharges and had the potential to result in unmet patient needs. Findings include: The hospital policy, Skilled Nursing/Assisted Living Facility Referrals, dated 5/13/16, was reviewed. It stated The Social Worker/Case Manager will meet with the patient, family/significant others to: a. Prepare the patient, family/significant others emotionally for the patient's transfer to the appropriate level of post-acute care as determined by the physician. Family members were not counseled appropriately to prepare them for post-hospital care. Examples follow: 1. Patient #1 was an [AGE] year old female admitted to the hospital on 7/06/18 for delirium in the setting of Alzheimer-type dementia with overlying urinary tract infection. Her daughter was listed on the initial nursing assessment, dated 7/06/18, as her decision-maker and DPOA. At admission, the daughter indicated a preference for a specific ALF after discharge. PT daily notes for Patient #1, on 7/06/18, 7/07/18, and 7/08/18, included documentation that PT recommended Patient #1 be discharged to a SNF or LTC. A physician note, dated 7/08/18, documented a plan for discharge to a SNF. Patient #1 was discharged on [DATE] to the ALF with home health services. Patient #1's DPOA was interviewed by telephone on 8/15/18 at 7:50 AM. The DPOA stated Patient #1's physician explained to her on 7/08/18 (the day prior to Patient #1's discharge) that the Physical Therapist had recommended Patient # 1 be discharged to a SNF or rehabilitation unit due to her condition and he, the physician, agreed with those recommendations and proposed the plan. The DPOA stated she agreed to the plan and was willing to have Patient #1 go to any of 4 or 5 facilities that were presented to her as options. She stated she received a call later letting her know one of the SNFs was not available. She stated she assumed another one would have been arranged. On 7/09/18, the day of Patient #1's discharge, the DPOA arrived at the hospital, expecting to drive Patient #1 to a SNF or rehabilitation unit. Instead, the discharging nurse told her, the DPOA, that Patient #1 was being discharged to the ALF that was initially discussed upon admit. She expressed surprise at hearing this change of plan but she signed the discharge paperwork anyway. She stated she should have protested . She stated no-one contacted her prior to her arrival at the hospital to inform her the plan for discharge had changed or to discuss it with her. There were no clinical notes to indicate Patient #1's caregiver had been counseled as to the change in discharge plans. Patient #1's Case Manager was interviewed. She reviewed Patient #1's medical record and stated she had not considered SNFs, otherwise there would have been a Patient Choice Form in the medical record, and there was not. She stated the family expressed an initial interest in the ALF at admission and she did not recall any other plan. She stated there was not a specific process to coordinate with physical therapy regarding the recommendations of the physical therapists. During an interview on 8/14/18 at 8:20 PM, the Director of Case Management and Social Services stated that if there had been coordination of care it would have been documented in the Case Management notes. The hospital did not prepare Patient #1's family ahead of time related to the discharge to the ALF after recommendations for SNF placement. 37262 2. Patient #3 was a [AGE] year old female who was admitted to the hospital on 7/07/18 with diagnoses including encephalopathy, altered mentation, and DM Type 2. She was discharged to her sister's home with home health services on 7/10/18. Patient #3's medical record included a case management report, dated 7/09/18, signed by her case manager, which stated Physicians asked that we discuss ALF placement with family. Message left for sister [name]. Patient #3's medical record included a case management note, dated 7/09/18, signed by her case manager, which stated Spoke with patient's sister on the phone regarding ALF planning and anticipated discharge tomorrow with [name of home health agency]. Patient #3's medical record included a case management note, dated 7/10/18, signed by her case manager, which stated Discharge orders sent to [name of home health agency]. Patient #3's medical record included a discharge summary, dated 7/10/18, signed by her physician, which stated At discharge she'll be sent home with home health care. The patient and her sister have been provided with information on pursuing placement at an assisted living facility. It was not documented if Patient #3's sister was counseled to prepare her for post-hospital care at home. The Director of Case Management and Social Services was interviewed on 8/14/18, beginning at 10:05 AM, and Patient #3's medical record was reviewed in her presence. She confirmed counseling for Patient #3's sister to prepare her for post-hospital care at home was not documented. The hospital failed to ensure Patient #3's sister was counseled to prepare her for post-hospital care at home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27086 Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure home health agency lists were provided in accordance with hospital policy for 2 of 2 patients (#1 and #3) who were referred to home health services upon discharge. This had the potential to interfere with patient/caregiver understanding of options for home health services. Findings include: The hospital policy Discharge Planning and Referrals of Patients to Post-Discharge, dated 5/04/15, was reviewed. It stated All patients who have orders to arrange post-hospital home health care . will be presented with the available options. This includes patients who have come from a facility or who have previously had post hospital services in the home. The patient or patient's representative makes a selection and signs the Patient Choice Form. The form is placed in the chart and becomes a permanent part of the medical record. It also stated Medicare patients must be presented with a list of available providers, even if the physician or patient already has a preference. The discharge planning documentation must include that the list was provided and the patient was able to choose their provider of care. (Patient Choice Form). The hospital did not provide lists of home health options, in accordance with hospital policy, to patients who had a prior relationship with a home health agency. Examples include: 1. Patient #1 was an [AGE] year old female admitted on [DATE] for delirium in the setting of Alzheimer-type dementia with overlying urinary tract infection. Her daughter was listed on the initial nursing assessment, dated 7/06/18, as her decision-maker and DPOA She was discharged to an ALF with home health services on 7/09/18. There was no documentation a list of home health agencies had been provided to Patient #1 and her DPOA. Patient #1's RN Case Manager was interviewed on 8/15/18 at 9:15 AM. She confirmed a list had not been provided and explained that Patient #1 wanted to return to the same home health agency, so a list was not necessary. A list of home health agencies was not provided to Patient #1 in accordance with hospital policy, which required the list be presented to the patient/caregiver even if the patient had previous services in the home. 37262 2. Patient #3 was a [AGE] year old female who was admitted to the hospital on 7/07/18 with diagnoses including encephalopathy, altered mentation, and DM Type 2. She was discharged to her sister's home with home health services on 7/10/18. Patient #3's medical record included a case management note, dated 7/09/18, signed by her Case Manager, which stated Spoke with patient's sister on the phone regarding ALF planning and anticipated discharge tomorrow with [name of home health agency]. Patient #3's medical record included a discharge summary, dated 7/10/18, signed by her physician, which stated At discharge she'll be sent home with home health care. The patient and her sister have been provided with information on pursuing placement at an assisted living facility. Patient #3's medical record did not include documentation the hospital presented Patient #3 with a list of home health agencies she could choose from in her geographic area. The Director of Case Management and Social Services was interviewed on 8/14/18, beginning at 10:05 AM, and Patient #3's medical record was reviewed in her presence. She confirmed Patient #3's discharge plan did not include a list of home health agencies in her geographic area to choose from. Patient #3's discharge plan did not include a list of home health agencies in her geographic area to choose from. Patients who had prior relationships with home health agencies were not provided with lists of options in accordance with hospital policy, which required the list be presented to the patient/caregiver even if the patient had previous services in the home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27086 Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure a process was established to inform physicians of necessary medical information post-hospitalization . This impacted 2 of 2 patients (#3 and #4) who were referred to physicians for office follow-up and whose records were reviewed. This had the potential to result in patients' physicians being unaware of the outcome of hospital treatment or follow-up care needs and negatively impact the quality of follow-up patient care. Discharge policies were requested for review. Policies addressed the necessity to send necessary medical information when patients were transferred to another inpatient facility, and for discharge to a SNF, ALF, home health agency, and hospice. However, discharge policies did not address the necessity to send necessary medical information to physician offices on behalf of patients sent home or to an ALF and asked to follow-up with their physicians with appointments post-hospitalization . Necessary medical information was not sent to physicians. Examples include: 1. Patient #4 was a [AGE] year old male admitted to the hospital on 7/10/18 related to an unwitnessed seizure and soft tissue trauma. He was transferred to the inpatient rehabilitation unit on 7/13/18. A Physician Discharge Summary included instructions for discharge follow up: He should follow up with his primary care provider in 1-2 weeks for further monitoring of his blood pressure. He should also follow up with urology and I would like to send him referral to [name of urologist] for further evaluation and management of his urinary retention as he is being discharged home with Foley catheter. he should also follow up with neurology in 2-4 weeks for stroke followup [sic] and continued evaluation and management of probable seizure. There was no documentation to indicate any clinical information was sent to Patient #4's physicians to inform them regarding the hospitalization . 2. Patient #3 was a [AGE] year old female who was admitted to the hospital on 7/07/18 with diagnoses including encephalopathy, altered mentation, and DM Type 2. She was discharged to her sister's home with home health services on 7/10/18. Patient #3's medical record included discharge instructions, dated 7/1018, signed by Patient #3, which stated Primary Care Physician Follow UP .[practitioner name] in 5 - 7 days [name] Gastroenterology in 1 - 2 weeks. There was no documentation to indicate any clinical information was sent to Patient #3's physicians to inform them regarding the hospitalization . During an interview on 8/13/18 at 4:10 PM, The Director of Case Management and Social Services stated the hospital did not routinely send information to physicians when patients were sent home. She stated many physicians can access patient information using the electronic portal. When asked if physicians were alerted to patient discharges so they could access the electronic medical record, she stated, not to her knowledge. When asked how physicians accessed information who were out of the area, she stated there was not a process. During an interview on 8/14/18 at 2:00 PM, a Social Worker for the inpatient Rehabilitation Department, stated the nurses set up appointments for patients for post-hospital care. She stated she was not aware of any information sent to the physician offices. She stated many doctors can see the records electronically. The hospital failed to ensure a process was established to inform physicians of necessary medical information post-hospitalization .

27086 Based on review of policies and quality data, and staff interview, it was determined the hospital did not have a process to reassess its discharge planning process on an on-going basis, including a review of discharge plans. This interfered with the identification of problem areas that could be addressed for process improvements. Findings include: Discharge planning policies were requested. None of the policies provided addressed the necessity for the hospital to reassess its discharge planning processes on an ongoing basis. The Director of Case Management and Social Services was interviewed on 8/13/18 4:10 PM. She stated she was not aware of any process to reassess the discharge planning processes. She stated the hospital monitored readmission rates, but she was not aware of how that information was used. The Director of Quality, Risk & Patient Safety was interviewed on 8/14/18 at 11:00 AM. She stated Discharge Planning was not a part of the hospital's quality program. The hospital did not have a policy or process to reassess its discharge planning process on an on-going basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34507 Based on medical record review, policy review, and staff interview, it was determined the facility failed to ensure a face-to-face meeting by a qualified staff member was conducted within 1 hour of the application of behavioral restraints for 1 of 4 patients (Patient #6) who were restrained to manage violent or self-destructive behavior and whose records were reviewed. This failure prevented the facility from evaluating the causes and appropriateness of the need for restraint. Findings include: The policy Patient Restraint/Seclusion, effective 11/23/15, stated A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior . This policy was not followed. Patient #6 was a [AGE] year old female admitted to BHC on 7/17/17, for psychosis. Patient #6 was brought in to the ED by police from a crisis center for abnormal behavior. Patient #6's record included a 1 hour face-to-face evaluation form, dated 7/17/17, which documented the face-to-face was completed at 7:50 PM. The face-to-face documented Patient #6 was placed in physical restraints of all 4 extremities and in seclusion. However, this was not consistent with the restraint/seclusion observation form in Patient #6's record. The restraint/seclusion observation form, dated 7/17/17, documented Patient #6 was in seclusion from 7:00 PM to 8:45 PM. At 8:50 PM, the form documented Patient #6 was placed in restraints for agitation, yelling, and biting. The form documented Patient #6 was in restraints until 10:45 PM. There was no documentation she was in seclusion after 8:50 PM. When Patient #6 was taken out of seclusion and placed into physical restraints, to 4 extremities, there was no documentation in her record of a 1 hour face-to-face for the restraints. During an interview at 1:05 PM on 10/02/17, the interim DON reviewed Patient #6's record and confirmed there was 1 face-to-face form documented by the RN, for seclusion and restraint. He confirmed at the time the face-to-face was documented as completed by the RN, 7:50 PM, Patient #6 was not in restraints. The interim DON also confirmed when Patient #6 was taken out of seclusion and placed in restraints there should have been a second 1 hour face-to-face completed. Patient #6 did not have a 1 hour face-to-face completed after she was placed in physical restraints. Additionally, the 1 hour face-to-face in the record was inconsistent with the seclusion/restraint documentation on the observation form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on policy review, record review, and staff interview, it was determined the hospital failed to ensure patients were informed of the process to file a grievance. This directly affected 2 of 4 adult patients (#1 and #2) who were admitted involuntarily and whose records were reviewed. The lack of information had the potential to prevent patients from filing grievances regarding their care. Findings include: The facility's policy, BHC - PATIENT GRIEVANCE, implemented 6/14/11, stated All patients will be notified of the Patient Grievance Procedure during the orientation process within 24 hours after admission to the BHC. In situations when the patient is not at the mental or emotional status to be oriented, it shall be done at the earliest appropriate time thereafter. Delays in informing the patient shall be charted in the medical record. 1. Patient #1 was a [AGE] year old female admitted involuntarily to the BHC on 7/29/17, with a diagnosis of psychosis. She was discharged on [DATE]. Patient #1's record included a form titled Conditions of Admission. The form stated, I have received the pamphlet entitled 'Your Patient Rights & Responsibilities' and understand the BHC grievance process as it has been explained to me. The form was not signed by Patient #1. The form included a note signed by an RN, stating Patient #1 was admitted involuntarily. Patient #1's record did not include documentation stating she was informed of the process to file a grievance, within 24 hours of admission. Her record did not include documentation of a delay in informing her of the process to file a grievance. During an interview on 9/29/17 beginning at 9:20 AM, the BHC Administrator stated the BHC did not obtain patient signatures on the form titled Conditions of Admission from patients who were admitted on an involuntary status. He confirmed there was no documentation stating the patients were informed of the process to file a grievance. Patient #1 was not informed of the process to file a grievance. 2. Patient #2 was a [AGE] year old male admitted involuntarily to the BHC on 7/01/17, with a diagnosis of psychosis. He was discharged on [DATE]. Patient #2 was admitted involuntarily. His printed record, provided by the facility on 9/27/17, did not include a form titled Conditions of Admission. The form was requested on 10/02/17, but was not provided. Patient #1's record did not include documentation stating he was informed of the process to file a grievance, within 24 hours of admission. His record did not include documentation of a delay in informing him of the process to file a grievance. During an interview on 9/29/17 beginning at 9:20 AM, the BHC Administrator stated the BHC did not obtain patient signatures on the form titled Conditions of Admission from patients who were admitted on an involuntary status. He confirmed there was no documentation stating the patients were informed of the process to file a grievance. Patient #2 was not informed of the process to file a grievance. 3. Patient #3 was a [AGE] year old female admitted involuntarily to the BHC on 9/22/17, with a diagnosis of psychosis. She was currently a patient as of 9/28/17. Patient #3's record included a form titled Conditions of Admission. The form stated, I have received the pamphlet entitled 'Your Patient Rights & Responsibilities' and understand the BHC grievance process as it has been explained to me. The form was not signed by Patient #3. The form included a note signed by an RN, stating Patient #3 was admitted involuntarily. Patient #3's record did not include documentation stating she was informed of the process to file a grievance, within 24 hours of admission. Her record did not include documentation of a delay in informing her of the process to file a grievance. During an interview on 9/29/17 beginning at 10:00 AM, the BHC DON confirmed there was no documentation that Patient #3 was informed of her right to file grievances. Patient #1 was not informed of the process to file a grievance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on record review and staff interview, it was determined the facility failed to ensure the patients' POCs were modified to reflect the use of restraint or seclusion for 1 of 4 patients (Patient #2) for whom restraints and/or seclusion were used. This resulted in a lack of direction to staff regarding ways to decrease restraint/seclusion usage and ways to keep the patient safe. Findings include: The facility's policy Patient Restraint/Seclusion effective 11/23/15, stated The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications. 1. Patient #2 was a [AGE] year old male admitted to the BHC on 7/01/17, with a diagnosis of psychosis. He was discharged on [DATE]. Patient #2's record included documentation of 1 minute physical holds for administration of IM medications at the following times: - 7/07/17 at 8:25 PM - 7/08/17 at 3:50 AM - 7/08/17 at 10:22 AM - 7/08/17 at 4:25 PM - 7/08/17 at 10:25 PM - 7/09/17 at 7:02 PM Patient #2's record included documentation of a 30 minute physical hold for administration of IM medications on 7/10/17 from 10:15 AM to 10:45 AM. Patient #2's record included a treatment plan signed by 4 members of the treatment team on 7/03/17. The plan did not include the use of restraints or physical holds. His treatment plan was not updated on 7/07/17 or 7/08/17, when physical holds were implemented. Patient #2's record included an updated treatment plan signed by 6 members of the treatment team on 7/10/17. The plan included an active problem titled Restraint/Seclusion, with 2 goals listed as follows: PT'S THREATENING, VIOLENT BEHAVIOR WILL DECREASE WHILE AT BHC. PT'S NEED FOR PHYSICAL HOLDS WILL DECREASE BY DC. The interventions listed for both goals were medication administration, and 1 to 1 observation. The treatment plan did not include an assessment of the situation that led to Patient #2's need for physical holds, or of his response to the physical holds. It did not include an evaluation of the restraint use. His POC did not include direction to staff regarding use of restraints, or of interventions to prevent the use of restraints. Patient #2's record included documentation of a 30 minute physical hold for administration of IM medications on 7/10/17 from 10:15 AM to 10:45 AM. A form titled Documentation of Restraint/Seclusion for Violent/Self-Destructive Behavior signed by the RN on 7/10/17 at 11:00 AM, stated Pt becoming assaultive [with] staff/police during med override resulting in physical hold/police intervention. A clinical note signed by the RN on 7/10/17 at 11:00 AM, stated Pt needed physical hold with police involvement and transport to safe area. The RN who completed Patient #2's restraint documentation was interviewed on 9/28/17 at 12:15 PM. He was asked about the police involvement in Patient #2's physical hold on 7/10/17. He stated he believed 3 police officers were involved during the physical hold, and was unable to state whether they had hands on Patient #2. He stated the BHC staff could call the police directly, but it was more typical for the staff to call the hospital security officers, who would call in the city police for reinforcement as needed. During an interview on 9/28/17 at 2:45 PM, the DON stated security officers and/or on duty police officers were involved with several physical holds to administer medication to Patient #2. The DON reviewed Patient #2's record and confirmed his treatment plan was not updated to reflect his need for physical holds initiated on 7/07/17. He confirmed the update to the treatment plan on 7/10/17 did not include specific interventions or direction to staff to achieve the goal of decreased physical holds. He stated the treatment plan did not include the use of security officers or on duty police officers to restrain Patient #2. Patient #2's treatment plan was not updated to include assessment and evaluation related to use of restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34507 Based on record review, policy review, and staff interview, it was determined the facility to ensure policies were followed for specifying the type of restraint in their orders for 1 of 4 patients (Patient #6) who had restraints ordered and whose records were reviewed. This resulted in orders which were unclear as to the type of restraints used and had the potential for the inappropriate use of behavioral restraints. Findings include: The policy Patient Restraint/Seclusion, dated 11/23/15, stated The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release. This order was not followed. Patient #6 was a [AGE] year old female admitted to BHC on 7/17/17, for psychosis. Patient #6 was brought in to the ED by police from a crisis center for abnormal behavior. Patient #6's nursing progress notes stated she was restrained by physical holding and seclusion/restraint on 7/17/17 at 7:02 PM. At 7:49 PM, the progress notes stated Patient #6 was still restrained by physical holding and seclusion/restraint. A nursing progress note at 9:52 PM on 7/17/17 stated Patient #6 was restrained in 4 point restraints. Patient #6's record included an order for physical holding and seclusion/restraint, dated 7/17/17 at 7:02 PM. The seclusion/restraint order did not specify what type of restraint should be utilized. Additionally, the order did not specify whether to restrain 2 or 4 extremities. During an interview at 10:25 AM on 9/29/17, the RN Clinical Supervisor reviewed Patient #6's record and confirmed the order was for physical hold and seclusion/restraint. She also confirmed the order did not specify the type of restraint. The facility failed to follow their policy when ordering restraints and to identify the type of restraints used for Patient #6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34507 Based on record review, policy review, and staff interview, it was determined the facility failed to ensure restraints were discontinued at the earliest possible time for 2 of 4 patients (#2 and #7), who were restrained and whose records were reviewed. This resulted in patients being restrained longer than was necessary to ensure their safety. Findings include: A facility policy Patient Restraint/Seclusion, dated 11/23/15, stated The patient in restraint or seclusion is evaluated frequently and the intervention is ended at the earliest possible time. The time-limited order does not require that the application be continued for the entire period. This policy was not followed. 1. Patient #7 was a [AGE] year old male admitted to BHC on 5/08/17, for major depressive disorder. He was discharged from a residential treatment center due to no participation in programming or therapy, and acting out in the unit by throwing chairs and jumping on top of the nurse's station. Patient #7's record included a Patient Observation Record, dated 5/09/17, which documented he was on the unit and quiet from 2:00 PM to 2:30 PM. The observation record also documented Patient #7 attended group therapy from 1:15 PM to 1:45 PM. At 2:45 PM, the record documented Patient #7 was in a safe room. There was no further documentation why he was placed in the safe room. A restraint/seclusion form documented Patient #7 was in seclusion on 5/09/17 from 2:45 PM to 4:00 PM. The form documented he was initially in a physical hold from 2:30 PM to 2:45 PM, for agitation and yelling. At 2:45 PM, Patient #7 was placed in seclusion and he was beginning to calm down and was crying. From 3:00 PM to 4:00 PM, Patient #7 was described on the form as quiet. The observation form documented Patient #7 was not removed from seclusion until 4:00 PM, 1 hour after he was first documented as beginning to calm and quiet. During an interview at 1:35 PM on 10/02/17, the interim DON reviewed Patient #7's record and confirmed the restraint/seclusion form documented he was quiet for 45 minutes prior to him being released from seclusion. He stated Patient #7 should have been removed from seclusion earlier. Patient #7 remained in seclusion longer than necessary per his documented behavior. 33951 2. Patient #2 was a [AGE] year old male admitted to the BHC on 7/01/17, with a diagnosis of psychosis. He was discharged on [DATE]. Patient #2's record included documentation of 1 minute physical holds for administration of IM medications at the following times: - 7/07/17 at 8:25 PM, behavior documented as agitated and yelling - 7/08/17 at 3:50 AM, behavior documented as agitated and yelling, hitting staff, spitting at staff - 7/08/17 at 10:22 AM, behavior documented as agitated and yelling - 7/08/17 at 4:25 PM, behavior documented as agitated - 7/08/17 at 10:25 PM, behavior documented as agitated and yelling - 7/09/17 at 7:02 PM, behavior documented as agitated and yelling, threats On each of these occasions, the injection was administered and Patient #2 was released from the hold within 1 minute. Patient #2's record included documentation of a 30 minute physical hold for administration of IM medications on 7/10/17 from 10:15 AM to 10:45 AM. His behavior was documented as agitated and yelling at 10:15 AM. Patient #2's medication record documented he was given an IM injection at 10:24 AM, 9 minutes after the hold was initiated. At 10:30 AM, he remained in a physical hold and he continued to be agitated and yelling. There was no documentation of threatening or violent behavior. His restraint record documented release from the physical hold at 10:45 AM, 21 minutes after his injection was administered. There was no documentation stating why he was not released after the injection, as he was on the previous holds. During an interview on 9/28/17 at 2:45 PM, the DON reviewed Patient #2's record and confirmed the IM injection was documented at 10:24 AM. He stated the RN administered the injection, then left the room to dispose of the syringe and needle, while Patient #2 remained in a physical hold. He confirmed the RN documented the injection at 10:24 AM, after it was administered. The DON confirmed the documentation of the physical hold on 7/10/17, did not state why Patient #2 continued to be held for 21 minutes after his injection was administered. The facility failed to ensure Patient #2's physical hold was discontinued at the earliest possible time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on staff interview and medical record review, it was determined the hospital failed to ensure a description of the behavior and intervention used was not documented for 1 of 4 restrained patients (Patient #2) whose records were reviewed. The lack of documentation prevented the hospital from evaluating the efficacy of the restraint. Findings include: Patient #2 was a [AGE] year old male admitted to the BHC on 7/01/17, with a diagnosis of psychosis. He was discharged on [DATE]. Patient #2's record included documentation of a 30 minute physical hold for administration of IM medications on 7/10/17 from 10:15 AM to 10:45 AM. The documentation did not describe the interventions used during the physical hold. Examples include: a. A form titled Documentation of Restraint/Seclusion for Violent/Self-Destructive Behavior signed by the RN on 7/10/17 at 11:00 AM, stated Pt becoming assaultive [with] staff/police during med override resulting in physical hold/police intervention. A clinical note signed by the RN on 7/10/17 at 11:00 AM, stated Pt needed physical hold with police involvement and transport to safe area. The 2 documents did not state how many police officers were present or how the police were involved in the physical hold. b. The form titled Documentation of Restraint/Seclusion for Violent/Self-Destructive Behavior signed by the RN on 7/10/17 at 11:00 AM, documented Patient #2 was placed in a physical hold on 7/10/17 at 10:15 AM, and remained in the hold until 10:45 AM. The document included the first names of 6 people who participated in the physical hold. It did not include titles of the people involved and it did not include names of police officers. The document did not state how many people had hands on Patient #2 during the physical hold. It did not state what type of hold was used, or what position he was in during the hold. The RN who completed Patient #2's restraint documentation was interviewed on 9/28/17 at 12:15 PM. He was asked about the police involvement in Patient #2's physical hold on 7/10/17. He stated he believed 3 police officers were involved during the physical hold, and was unable to state whether they had hands on Patient #2. He stated the BHC staff could call the police directly, but it was more typical for the staff to call the hospital security officers, who would call in the city police for reinforcement as needed. He stated the facility's security department was staffed by off-duty city police officers and was unable to state whether the officers present were on-duty hospital security officers or city police officers. He confirmed the restraint documentation did not include the names of the officers or the number of officers present during the physical hold. The RN was asked if an incident report was completed due to the involvement of the police. He stated an incident report was not completed. The Security Supervisor was interviewed on 9/28/17 at 12:50 PM. He stated the hospital had 2 security officers on duty between 11:00 AM and 3:00 AM, with 1 officer on duty from 3:00 AM to 11:00 AM. He stated 1 officer was on duty during the time of Patient #2's physical hold from 10:15 AM to 10:45 AM, and the other 2 officers present were city police. He stated the facility staff have the option of calling 911 for police assistance, or calling hospital security, and hospital security may call city police for back up if necessary. He stated hospital security officers and city police officers may or may not be directly involved in a physical hold. He confirmed the officers did not document their involvement in Patient #2's physical hold on 7/10/17. Patient #2's record did not include documentation of the interventions used during a physical hold.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27086 Based on review of medical records, hospital policy, and staff interview, it was determined the hospital failed to ensure each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient was renewed as authorized by hospital policy for 2 of 4 patients who were restrained (#3 and #4) and whose medical records were reviewed. This resulted in unauthorized restraint use. Findings include: The hospital policy Restraint/Seclusion, dated [DATE], was reviewed. The policy included, but was not limited to, the following information: - Duration of order for restraint use must not exceed twenty-four (24) hours for the initial order . - If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day . The policy was not followed. Examples include: 1. Patient #3 was a [AGE] year old female who was admitted to the hospital on [DATE]. Restraint orders were reviewed from [DATE] through [DATE]. Restraint orders included, but were not limited to, the following dates and times: - [DATE] 12:05 AM (Initial) - [DATE] 11:42 AM (renewal) - [DATE] 2:30 PM (renewal) There were no documented restraint orders on [DATE]. Medical record documentation indicated Patient #3 was restrained continously from [DATE] through [DATE]. The ACNO was interviewed on [DATE] at 10:09 AM. She reviewed Patient #3's medical record and confirmed Patient #3 continued in restraints on [DATE] without a renewal order for [DATE]. Restraint orders were not renewed in accordance with hospital policy. 00023 2. Patient #4 was a [AGE] year old male who was admitted to the hospital on [DATE] and died on [DATE] at 7:00 PM. Patient #4's medical record documented an order for bilateral wrist restraints in the ICU on [DATE]. The order was dated [DATE] at 3:30 PM and stated Utilize restraints for the next 24 hours (not to exceed 24 hours). The medical record documented Patient #4 remained in restraints until his death. The order for wrist restraints was renewed on [DATE] at 6:38 PM, 27 hours after the initial restraint order. Patient 4's medical record was reviewed with the ACNO on [DATE] beginning at 10:05 PM. She confirmed the restraint order was not reviewed within the 24 hours prescribed by the order and hospital policy. Patient #4's restraint order was not renewed in accordance with hospital policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27086 Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure there was medical record documentation of the condition or symptom(s) that warranted the use of restraints for 2 of 4 patients (#1 and #3) whose medical records were reviewed. This resulted in a lack of clarity as to whether the least restrictive restraints were utilized. Findings include: Patient #3 was a [AGE] year old female who was admitted to the hospital on 12/26/16 for care in the ICU related to vascular disease, necrotric muscle, and related complications. Physician documentation included restraint orders, dated 1/25/16 6:30 AM, for 4 point soft restraints for 24 hours for pulling at line(s). There was no documentation that explained how pulling at lines justified leg restraints. Review of nursing notes documentation for 1/25/16 did not include an explanation as to why it was necessary to restrain Patient #3's legs. The ACNO and Director of Respiratory/ICU were interviewed together on 2/02/16 at 10:23 AM. The Director of Respiratory/ICU explained the reason Patient #3 needed leg restraints was because she had a large groin wound with a wound vac and leg movement was interfering with her medical care. The ACNO and the Director of Respiratory/ICU confirmed documentation did not clearly explain the reason for the leg restraints. The hospital policy Restraint/Seclusion, dated 11/23/15, was reviewed. The policy did not specifically address the requirement to document the patient's condition or symptom(s) that warranted the use of restraints. The policy was limited to the following documentation requirements: The medical record contains documentation of: a. Assessment of risk for restraint or seclusion b. Restraint or seclusion alternatives employed c. Determination of effectiveness/ineffectiveness of restraint or seclusion alternatives d. Second tier review of need for restraint or seclusion e. Order for restraint or seclusion and any renewal orders for restraint or seclusion f. Restraint or seclusion application/initiation g. Family notification of restraint or seclusion use h. Patient and family education regarding restraint or seclusion use i. Assessment of the patient in restraint or seclusion j. Monitoring of the patient in restraint or seclusion k. Medical and behavioral evaluation for restraint or seclusion management of violent or self-destructive behavior l. Modifications of the plan of care m. Physician notification of changes in patient condition n. Restraint or seclusion removal/termination o. Document requirements related to deaths of patients . Patient #3's medical record did not include clear documentation as to the patient's condition or symptoms that warranted the use of leg restraints. 00023 2. Patient #1 was a [AGE] year old female who was admitted to the hospital on 1/20/16 after a 35 foot fall. She suffered an open fracture of her right femur and fractures of her right elbow, jaw, face, right hip, and pelvis. A ventilator flow sheet stated Patient #1 was intubated at 1:20 PM on 1/20/16. A nursing progress note, dated 1/20/16 at 1:06 PM, stated soft restraints were applied on all 4 extremities. Another nursing progress note by another RN, titled Restraints Evaluation/2nd Tier Review and dated 1/20/16 at 1:09 PM, stated Patient #1 had restraints applied to both upper extremities and to her left lower extremity. Nursing progress notes documented Patient #1 remained restrained until 8:40 PM on 1/20/16. None of the progress notes documented the symptoms that required the use of restraints. A nursing progress note, dated 1/20/16 at 1:07 PM, stated Behavior - Attempts to remove device. The note did not state which device Patient #1 was trying to remove or how she could use her right arm or leg to remove a device given the nature of her fractures. The ED Director reviewed Patient #1's medical record on 2/02/16 beginning at 9:30 AM. He agreed the specific symptoms that required the use of restraints were not documented. The symptoms that warranted the use of restraints for Patient #1 were not documented.

33951 Based on observation, review of patient rights information, review of medical records and hospital policies, and patient and staff interview, it was determined the hospital failed to ensure patients' rights were protected and promoted. This resulted in the failure of the hospital to ensure each patient received care in a safe setting, and restraints were used safely and appropriately by qualified staff to protect the patient or others from harm. Findings include: 1. Refer to A117 as it relates to the failure of the hospital to ensure all patient were informed of their rights. 2. Refer to A118 as it relates to the failure of the hospital to ensure all patient were informed of whom to contact to file a grievance. 3. Refer to A144 as it relates to the failure of the hospital to ensure care was provided to patients in a safe setting. 4. Refer to A167 as it relates to the failure of the hospital to ensure the use of restraints was implemented in accordance with safe and appropriate techniques as determined by hospital policy. 5. Refer to A168 as it relates to the failure of the hospital to ensure restraints were implemented in accordance with current, clear, and complete orders of physicians or other LIPs who were authorized to order restraints. 6. Refer to A171 as it relates to the failure of the hospital to ensure orders for restraints used to manage violent or self-destructive behavior were renewed in accordance with hospital policy. 7. Refer to A175 as it relates to the failure of the hospital to ensure the condition of patients who were restrained was monitored by trained staff. 8. Refer to A178 as it relates to the failure of the hospital to ensure a face-to-face meeting by a physician or LIP was conducted within 1 hour of the application of restraints used to manage violent or self-destructive behavior. 9. Refer to A194 as it relates to the failure of the hospital to ensure security staff had education, training, and demonstrated knowledge to manage violent or aggressive patients. The cumulative effects of these negative systemic practices seriously impeded the ability of the hospital to protect patient rights and provide services in a safe setting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 00023 Based on observation, review of patient rights information, and staff and patient interview, it was determined the hospital failed to ensure 3 of 4 current patients (#11, #12, and #13), who were interviewed, were informed of their rights. This prevented patients from exercising their rights. Findings include: 1. Patients were not aware of their rights. Examples include: a. Patient #11 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. She was a current patient who was admitted on [DATE]. She stated she was not given a copy of the patient rights and had not been informed of her rights by staff. b. Patient #12 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. He was a current patient who was admitted on [DATE]. He stated he was not given a copy of the patient rights and had not been informed of his rights by staff. c. Patient #13 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. He was a current patient who was admitted on [DATE]. He stated he was not given a copy of the patient rights and had not been informed of his rights by staff. Patients were not informed of their rights. 2. The 3 current patients noted above each had a folder that contained information from the hospital but did not contain a copy of patient rights. The Unit Secretary was interviewed on 11/18/15 beginning at 12:15 PM. She had folders of patient information she was preparing at the nursing station on the Medical/Oncology Unit. She stated the folders included a brochure outlining patient rights. The folders she was preparing did not include a copy of patient rights. She went into a back room and retrieved a box of patient rights brochures and placed them in the folders. The rights brochures were not in the folders in the rooms of the above patients. The Nursing Director of the Medical/Oncology Unit was interviewed on 11/18/15 beginning at 2:05 PM. He stated the hospital did not use the patient rights brochures any more. He presented a bound patient handbook and stated the hospital kept one in each patient room. He took the surveyor into an empty room and there was a 3 ring binder in a drawer. This was different from the handbook presented earlier. The binder contained approximately fifty pages of material including the rights. Staff members were not clear about a consistent method of informing patients of their rights. If booklets were placed in patient rooms, patients were not aware of this. The hospital failed to ensure patients were informed of their rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 00023 Based on staff and patient interview, it was determined the hospital failed to ensure 3 of 4 current patients (#11, #12, and #13), who were interviewed, were informed of whom to contact to file a grievance. This prevented patients from exercising their rights and prevented the hospital from identifying care issues. Findings include: 1. Patients were not aware of whom to contact to file a grievance, as follows: a. Patient #11 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. She was a current patient who was admitted on [DATE]. She stated she had not been given a copy of the patient rights, including her right to file grievances. She also stated she had not been informed of whom she could contact to file a grievance. b. Patient #12 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. He was a current patient who was admitted on [DATE]. He stated he had not been given a copy of the patient rights, including his right to file grievances. He also stated he had not been informed of whom he could contact to file a grievance. c. Patient #13 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. He was a current patient who was admitted on [DATE]. He stated he had not been given a copy of the patient rights, including his right to file grievances. He also stated he had not been informed of whom he could contact to file a grievance. The Nursing Director of the Medical/Oncology Unit was interviewed on 11/18/15 beginning at 2:05 PM. He stated the hospital kept bound patient handbooks in rooms. He took the surveyor into an empty room and there was a 3 ring binder in a drawer. The binder contained approximately fifty pages of material including the rights. The Director looked at the binder but was not immediately able to find the grievance information. He eventually located it on page 12. Patients were not informed of where to find grievance information, including who to contact to file a grievance. Additionally, the information in the patient room handbooks was not readily identifiable. Patients were not informed of their right to file grievances, including whom to contact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on medical record review, staff interview and review of hospital policies, it was determined the hospital failed to provide a safe environment for 1 of 2 patients (#3) who were restrained for violent or self destructive behavior and whose records were reviewed. This failed practice had the potential to result in negative patient outcomes and interfere with the safety of all patients. Findings include: 1. Patient #3 was a [AGE] year old male admitted to the hospital on 10/16/15, with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE]. The hospital failed to ensure policies were followed to provide for Patient #3's safety. Examples include: a. The hospital's policy #491, Code 5 - Request for Assistance, effective 3/14/12, stated Upon Code 5 notification, all available personnel will report to the area. The charge nurse/clinical team leader, department director or house supervisor will act as Code 5 leader and assume responsibility for evaluating the need for assistance. The Code 5 leader will inform those present of the situation and identify those needed to assist. Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated Code 5 (all available male assistance/security) called in response to patient's escalating aggression and threat to self and staff. The note further stated Officers restrained patient with bed sheets for patient's and staff's safety. There was no documentation in Patient #3's record stating how the security officers were informed or directed, or who acted as the Code 5 leader. Patient #3's record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, and he was released from the sheet restraints placed by the officers. During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record. She stated it was not the hospital's practice to restrain patients with sheets. The Director of ICU was interviewed on 11/19/15 at 11:15 AM. He stated he was the chair of the Restraint Committee for the hospital. When asked if the hospital used sheets to restrain patients, he stated No, never. A hospital security office was interviewed on 11/19/15 at 8:40 AM. He stated security officers responded to Code 5 situations. He stated in most cases the nurse in charge deferred to the security officers in situations where a patient was exhibiting aggressive behavior and required restraint. He described sheet restraints as rolled sheets applied over the patient's chest and/or legs, tied to one side of the bed and held down by a security officer on the other side of the bed. He reviewed Patient #3's record and stated he did not believe the officers stayed with him for the 1 hour and 50 minutes he was in sheet restraints and stated they probably tied the sheets to both sides of the bed. It was unclear how the sheet would be quickly released in case of an emergency. Patient #3 was restrained with sheets applied by the hospital's security officers. b. The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, stated An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release. Additionally, it stated When a LIP/physician is not available to issue a restraint or seclusion order, an RN with demonstrated competence may initiate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated. Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM, at the time sheet restraints were applied. The note stated MD contacted and orders received to give IM Geodon 20 mg now and notify him of effectiveness. A Nurses' Note dated 10/16/15 at 9:53 PM, stated Patient #3's physician was notified of his behavior. The note documented the physician instructed the nurse to administer Geodon and call back it if did not work, to discuss restraints. However, sheet restraints were in place. Patient #3's record did not include a physician's order for the sheet restraints applied on 10/16/15 at 9:45 PM, and removed 1 hour and 50 minutes later. During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed there was not a physician's order for the sheet restraints. Patient #3 was placed in restraints without a physician's order. c. The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, included a section titled Second Tier of Review which stated A member of nursing administration/management (e.g., nursing supervisor, manager/director, CNO, etc.) will review the need for restraint or seclusion with the RN who has determined that the patient requires restraint or seclusion. The second tier of review will occur with the initial application or restraint or seclusion. Patient #3's record did not include documentation of a Second Tier of Review during the 1 hour and 50 minutes he was restrained with sheets. During an interview on 11/19/15 at 11:15 AM, the Director of ICU, who is the chair of the Restraint Committee, reviewed Patient #3's record and confirmed there was no Second Tier of Review after sheet restraints were applied. Patient #3's need for restraint was not reviewed, to determine if policies were followed and restraints were appropriate. d. The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, stated A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation .to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. Patient #3's record did not include documentation of a face-to-face evaluation by a physician or other trained professional within 1 hour of the placement of restraints for violent/self destructive behavior, to complete a physical and behavorial evaluation, assess the safety of the patient, and determine the need to continue or terminate the restraint. During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed there was no documentation of a face-to-face evaluation by a physician or other trained professional within 1 hour of the implementation of restraints. Patient #3 did not receive a face-to-face evaluation after being restrained. e. The Director of ICU was interviewed on 11/19/15 at 11:15 AM. He stated he was the chair of the Restraint Committee for the hospital. He stated the hospital's unit Directors were members of the Restraint Committee which met monthly. He stated at each meeting he asked the Directors if they were aware of any problems on their units related to restraints, then gave each Director the names of patients on their unit who were restrained within the last month. They returned to their units to complete audits of restraint records. He stated the hospital had an audit tool and it was the responsibility of each Director to monitor and audit restraint records on their unit. Documentation of an audit of Patient #3's restraint record was requested. On 11/19/15 at 11:50 AM, the Director of Risk Management stated he spoke to the Unit Director who stated no audit of Patient #3's restraint record was completed. Therefore, there was no evaluation of the appropriateness of the restraint and the safety of the patient. Minutes of the Restraint Committee monthly meetings in 2015 were requested. In a letter faxed to surveyors on 11/20/15, the Director of Risk Management stated In response to your request for restraint committee minutes; please be advised the committee did not meet in 2015, therefore there are no minutes. The hospital failed to review restraint records to ensure the safety of patients was not jeopardized.

33951 Based on patient record review, policy review and staff interview, it was determined the hospital failed to ensure the use of restraints was implemented in accordance with safe and appropriate techniques as determined by hospital policy for 1 of 2 patients (#3) who were restrained for violent or self destructive behavior and whose records were reviewed. This resulted in an inability of the hospital to ensure restraints were implemented in a safe and effective manner. The findings include: 1. The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, included a section titled Second Tier of Review which stated A member of nursing administration/management (e.g., nursing supervisor, manager/director, CNO, etc.) will review the need for restraint or seclusion with the RN who has determined that the patient requires restraint or seclusion. The second tier of review will occur with the initial application of restraint or seclusion. Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated all available male assistance/security officers were called due to his escalating aggression. The note further stated Officers restrained patient with bed sheets for patient's and staff's safety. Patient #3's record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, he was released from the sheet restraints placed by the officers. Patient #3's record did not include documentation of a Second Tier of Review during the 1 hour and 50 minutes he was restrained with sheets. During an interview on 11/19/15 at 11:15 AM, the Director of ICU, who is the chair of the Restraint Committee, reviewed Patient #3's record and confirmed there was no Second Tier of Review after sheet restraints were applied. Patient #3's need for restraint was not reviewed per hospital policy. 2. Refer to A168 as it relates to the failure of the hospital to ensure restraints were implemented in accordance with current, clear, and complete orders of physicians or other LIPs who were authorized to order restraints. 3. Refer to A171 as it refers to the failure of the hospital to ensure orders for restraint used to manage violent or self-destructive behavior were renewed every 4 hours in accordance with hospital policy. 4. Refer to A175 as it relates to the failure of the hospital to ensure the condition of patients who were restrained was monitored by trained staff. 5. Refer to A178 as it relates to the failure of the hospital to ensure a face-to-face meeting by a physician or LIP was conducted within 1 hour of the application of restraints used to manage violent or self-destructive behavior. The hospital failed to ensure policies related to safe and appropriate use of restraints were followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on medical record review, policy review, and staff interview, it was determined the use of restraints was not implemented in accordance with current, clear, and complete orders of physicians or other LIPs for 1 of 2 patients (#3) who were restrained for violent of self destructive behavior and whose records were reviewed. This resulted in missing or incomplete orders and restraint use that was not consistent with the orders of a physician or other LIP. This had the potential to result in unsafe care of restrained patients. Findings include: The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, stated An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release. Additionally, it stated When a LIP/physician is not available to issue a restraint or seclusion order, an RN with demonstrated competence may initiate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated. Patient #3 was a [AGE] year old male admitted to the hospital on 10/16/15, with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE]. Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated all available male assistance/security officers were called due to Patient #3's escalating aggression. The note further stated Officers restrained patient with bed sheets for patient's and staff's safety. MD contacted and orders received to give IM Geodon 20 mg now and notify him of effectiveness. A Nurses' Note dated 10/16/15 at 9:53 PM stated Patient #3's physician was notified of his behavior. The note documented the physician instructed the nurse to administer Geodon and call back it if did not work, to discuss restraints. Patient #3's record included a physician's order for bilateral soft wrist restraints, dated 10/16/15 at 11:04 PM. His record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, he was released from the sheet restraints placed by the officers and placed in bilateral upper extremity soft restraints. Patient #3's record did not include a physician's order for the sheet restraints applied on 10/16/15 at 9:45 PM, and removed 1 hour and 50 minutes later. During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed there was not a physician's order for the sheet restraints. Patient #3 was placed in restraints without a physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure orders for restraint used to manage violent or self-destructive behavior were renewed every 4 hours for 1 of 2 patients (#3) who were restrained for more than 4 hours to manage violent or self-destructive behavior and whose records were reviewed. This resulted in lack of oversight by a physician or qualified LIP and had the potential to interfere with patient safety. Findings include: The hospital's policy #391, Patient Restraint/Seclusion, effective [DATE], included guidelines for restraints for violent or self-destruction behavior. It stated physician orders for restraints must not exceed 4 hours for adults 18 and older. Patient #3 was a [AGE] year old male admitted to the hospital on [DATE], with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE]. Patient #3's record included a physician's order for bilateral soft wrist restraints, dated [DATE] at 11:04 PM. Patient #3's record included a restraint monitor note dated [DATE] at 11:35 PM. The note stated bilateral soft wrist restraints were implemented due to violent/self destructive behavior. Nurses' Notes in Patient #3's clinical record dated [DATE] at 2:00 AM, 3:52 AM, 5:30 AM, 7:37 AM, 8:10 AM, 8:28 AM, and 10:00 AM, documented restraints were in place due to violent/self destructive behavior. A Nurses' Note dated [DATE] at 11:00 AM stated Patient #3's restraints were removed. Patient #3's record included a physician's order for bilateral soft wrist restraints, dated [DATE] at 11:04 PM. The order expired at 3:04 AM on [DATE]. His record did not include physician orders for restraints used from 3:04 to 11:00 AM on [DATE]. During an interview on [DATE] at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed the physician's restraint order was not renewed every 4 hours. Orders for restraints used to manage Patient #3's violent or self-destructive behavior were not renewed at a minimum of every 4 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure the condition of patients who were restrained was monitored by trained staff for 1 of 2 patient (#3) who were restrained for violent or self destructive behavior and whose records were reviewed. This resulted in a lack of oversight and had the potential to interfere with patient safety. Findings include: The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, included a section on monitoring patients in restraint. It stated An RN will assess the patient at least every 2 hours. The policy stated the assessment would include signs of injury associated with the restraint, including circulation of affected extremities, respiratory and cardiac status, psychological status, needs for range of motion, hydration and nutritional needs, hygiene and elimination needs, and consideration of less restrictive alternatives to restraint. Patient #3 was a [AGE] year old male admitted to the hospital on 10/16/15, with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE]. Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated all available male assistance/security officers were called due to his escalating aggression. The note further stated Officers restrained patient with bed sheets for patient's and staff's safety. Patient #3's record included a physician's order for bilateral soft wrist restraints, dated 10/16/15 at 11:04 PM. His record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, he was released from the sheet restraints placed by the officers and placed in bilateral upper extremity soft restraints due to violent/self destructive behavior. Patient #3's record did not include documentation of an RN assessment during the 1 hour and 50 minutes he was restrained by sheets. Patient #3's record included a Restraints Monitor note dated 10/17/15 at 2:00 AM, 2 hours and 25 minutes after his bilateral upper extremity soft restraints were applied. However, the entry did not include an assessment of his status and needs, or consideration of alternatives to restraint. Patient #3's record included an RN assessment related to his restraints dated 10/17/15 at 3:52 AM, 4 hours and 17 minutes after restraints were applied to his upper extremities. Patient #3's record included an RN assessment related to his restraints dated 10/17/15 at 5:30 AM. However, the next RN assessment related to restraints was documented at 8:10 AM, 2 hours and 40 minutes after the previous assessment. An additional RN assessment related to restraints was documented at 11:00 AM, 2 hours and 50 minutes after the previous assessment. The restraints were discontinued at that time. During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed his status and needs related to restraints were not assessed by an RN every 2 hours. Patient #3's condition was not monitored frequently while he was in restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure a face-to-face meeting by a physician or LIP was conducted within 1 hour of the application of behavioral restraints for 1 of 2 patients (#3) who were restrained to manage violent or self-destructive behavior and whose records were reviewed. This prevented the hospital from evaluating the causes and appropriateness of the need for restraint. Findings include: The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, stated A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation .to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. Patient #3 was a [AGE] year old male admitted to the hospital on 10/16/15, with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE]. Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated all available male assistance/security officers were called due to Patient #3's escalating aggression. The note further stated Officers restrained patient with bed sheets for patient's and staff's safety. Patient #3's record included a physician's order for bilateral soft wrist restraints dated 10/16/15 at 11:04 PM. His record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, he was released from the sheet restraints placed by the officers and placed in bilateral upper extremity soft restraints due to violent/self destructive behavior. A Nurses' Note date 10/17/15 at 11:00 AM stated his wrist restraints were removed. Patient #3 was in sheet restraints for 1 hour and 50 minutes. He was in soft wrist restraints for 11 hours and 25 minutes. However, Patient #3's record did not include documentation of a face-to-face evaluation by a physician or other trained professional within 1 hour of the placement of restraints for violent/self destructive behavior. During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed there was no documentation of a face-to-face evaluation by a physician or other trained professional within 1 hour of the implementation of restraints. Patient #3 did not receive a face-to-face evaluation after being restrained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33951 Based on review of restraint education information, medical record review, and staff interview, it was determined the hospital failed to ensure security officers had education, training, and demonstrated knowledge to manage patients exhibiting out-of-control and/or aggressive behavior. This resulted in inappropriate use of restraint to manage the aggressive behavior of 1 of 2 patients (#3) who were restrained to protect the safety of self and others. This failure placed all patients experiencing behavioral and psychiatric challenges at risk of physical and/or mental harm. Findings include: Patient #3's record documented he was a [AGE] year old male admitted to the hospital on 10/16/15, with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE]. Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated all available male assistance/security officers were called due to Patient #3's escalating aggression. The note further stated Officers restrained patient with bed sheets for patient's and staff's safety. Patient #3's record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, and he was released from the sheet restraints placed by the officers. During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record. She stated it was not the hospital's practice to restrain patients with sheets. The Director of ICU was interviewed on 11/19/15 at 11:15 AM. He stated he was the chair of the Restraint Committee for the hospital. When asked if the hospital used sheets to restrain patients, he stated No, never. The hospital utilized off duty Police Officers as hospital security officers. Training records for 3 Security Officers scheduled for duty on 11/19/15 were requested, including records for the Security Officer who restrained Patient #3 noted above. The hospital provided documents titled Idaho Peace Officer Standards and Training, dated 1/01/15, for all 3 Security Officers. The documents included a record of training such as firearms training, stalking investigations, and arrest techniques. No training specific to hospital duties, including hospital restraint training, was included in training reports. The Director of Risk Management was interviewed on 11/19/15 beginning at 12:00 noon. He stated there was no record of hospital training for Security Officers, including restraint training. The hospital used a system for the management of behavior called Non Violent Crisis Intervention (NVCI). The on duty Security Officer was interviewed on 11/19/15 beginning at 8:40 AM. He stated Security Officers participated in the placement of restraints for patients with violent or self destructive behavior. The Security Officer stated he had not received restraint training at the hospital. He stated he did not know what behavior management system the hospital used. He stated he did not know what the acronym NVCI stood for. He stated he did not use the hospital's behavior management system. He stated, if Security Officers responded to a call regarding patients' acting out, then the nurses deferred to the officers to help things calm down. Staff members who restrained patients were not trained by the hospital. 00023

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28544 Based on record review and staff interview, it was determined the hospital failed to ensure an RN supervised and evaluated the nursing care for 1 of 3 obstetrical patients (#4) whose ED records were reviewed. This resulted in inadequate assessment and nursing care for an obstetrical patient who left the facility AMA. Findings include: 1. Patient #4 was a [AGE] year old pregnant female in her third trimester admitted to the ED on 7/14/13 at 3:02 AM. An ED triage note entered 7/14/13 at 3:17 AM, documented Patient #4's height, weight, and current medications she was taking. The triage note did not include vital signs or indicate an assessment had been completed. The entry did not include Patient #4's transfer to the OB unit for a MSE as per the facility policy. A preprinted order sheet titled ORDERS FOR OUTPATIENT VISIT, LABOR and DELIVERY, documented verbal orders had been received on 7/14/13 at 3:45 AM. The orders, although signed by a nurse, were not authenticated by a physician. The order sheet indicated the reason for Patient #4's visit as convulsions. Also included on the sheet was an order to Evaluate patient including: Fetal Heart monitoring, U/A Urine Culture if indicated. The order sheet had another section, also dated 7/14/13 at 3:45 AM, which stated Transfer to ED. Patient #4's record contained a fetal heart monitor strip which documented her uterine contractions and fetal heart pattern from 3:40 AM to 3:53 AM. An Ante/[NAME] Flowsheet, dated 7/14/13 at 3:45 AM and 3:53 AM, documented Report to (obstetrician) that (Patient #4) brought from ER with c/o convulsions. Pt states had diarrhea all night. . orders rcvd (received) to transfer pt back to ER for evaluation. The flowsheet did not indicate an RN assessment had been performed while in the OB unit. An ED nursing entry at 6:03 AM, documented Patient #4 left the ED against medical advice, and stated she was leaving the ED due to the long waiting time. The record did not include evidence of assessment related to her presenting complaint of convulsions. A nursing assessment and vital signs were not found in Patient #4's record. Patient #4's record included a sheet titled CODING SUMMARY, which included diagnoses of EPILEPSY COMP PREG/CHILDBIRTH, ANTEPARTUM. The sheet also included her discharge disposition of Against Medical Advice. In a report titled ER DOCUMENTATION, dated 7/14/13 at 5:43 AM, the ED physician documented Patient #4 had left before he had been able to examine or speak with her. During an interview on 8/08/13 at 11:00 AM, the ED physician who was working on 7/14/13 at the time Patient #4 had come to the ED reviewed her record. He stated Patient #4 had been taken to L&D for an MSE and when cleared was brought back to the ED. He stated he was busy with multiple traumas, but had looked at Patient #4's presenting complaint on the ED board and had entered orders on the computer before seeing her. He stated he later canceled the orders as she had left AMA. During an interview on 8/08/13 beginning at 10:35 AM, the Director of the ED reviewed Patient #4's medical record. The ED Director stated there was an algorithm the ED staff followed. He stated a patient in her third trimester of pregnancy would be sent immediately to L&D for assessment of the pregnancy and fetal well being. After determining a patient was stable in that respect, the patient would be returned to ED for an assessment of further medical conditions. The ED Director was unable to determine Patient #4 had vital signs taken or had been assessed by an RN in the ED or the OB units. The hospital failed to ensure an RN had supervised and evaluated the nursing care for Patient #4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32213 Based on staff interview, review of medical records, and review of policies, it was determined medical record entries were incomplete for 5 of 48 patients (#4, #19, #26, #40, #42) whose medical records were reviewed. This resulted in a lack of clarity related to patient care and the inability of the hospital to determine whether care had been provided. Findings include: The Physician Orders policy, effective [DATE], stated Verbal/telephone orders are to be authenticated by the ordering medical staff member. In addition, the policy stated that medication orders should include the date and time of the order and the signature of the person ordering the medication. The hospital failed to adhere to the policy as follows: 1. Patient #42 was a [AGE] year old female admitted to the hospital through the ED on [DATE] for treatment of injuries sustained in a motor vehicle accident. She was discharged from the hospital on [DATE]. Her medical record contained the following incomplete documentation: a. A verbal order from the physician for Lortab Elixir, a narcotic pain medication, was documented by an LPN on a Physician's Orders form on [DATE] at 10:11 AM. The LPN signed off the order at 10:25 AM. The order had not been authenticated by a physician. The CNO reviewed the record and was interviewed on [DATE] at 4:10 PM. She confirmed the verbal order had not been authenticated by the ordering physician per hospital policy. b. A PHYSICIAN'S PREPRINTED ORDERS titled POST ANESTHESIA contained orders for pain medication, nausea medication, oxygen therapy, seizure medications, hypotension medications and IV fluids to be given if needed during post-anesthesia recovery. The orders contained an electronic signature of the anesthesiologist on [DATE] at 7:48 AM, two days after Patient #42 was discharged from the hospital. The CNO reviewed the record and was interviewed on [DATE] at 4:10 PM. She stated the preprinted orders should have been signed, dated, and timed by the anesthesia provider during the time Patient #42 was in recovery. She confirmed the orders had not been authenticated during Patient #42's admission in accordance with hospital policy. Patient #42's record contained incomplete orders. 2. Patient #19 was a 6 year old female admitted to the hospital on [DATE] for surgery after a dog bit her face. She was discharged [DATE]. Her medical record contained the following: a. PHYSICIAN'S PREPRINTED ORDERS titled DISCHARGE ORDERS contained orders for medication and when to make a follow-up appointment. The orders were signed by the physician on [DATE] but were not timed. The ACNO reviewed the record and was interviewed on [DATE] at 2:20 PM. She confirmed the orders were not timed in accordance with hospital policy. b. A PHYSICIAN'S PREPRINTED ORDERS titled POST ANESTHESIA contained orders for pain medication, nausea medication, oxygen therapy, seizure medications, hypotension medications and IV fluids to be given if needed during post-anesthesia recovery. The orders contained an electronic signature of the anesthesiologist on [DATE] at 4:01 PM, 3 days after Patient #19 was discharged from the hospital. The ACNO reviewed the record and was interviewed on [DATE] at 2:20 PM. She stated the preprinted orders should have been signed, dated, and timed by the anesthesia provider during the time Patient #19 was in recovery. She confirmed the orders had not been authenticated during Patient #19's admission in accordance with hospital policy. Patient #19's record contained incomplete orders. 28544 3. Patient #40 was a [AGE] year old male admitted to the hospital on [DATE] for chest pain. He expired on [DATE]. a. A form, titled RECORD OF DEATH, indicating Patient #40 expired [DATE] at 2:18 PM, required a physician signature, and was not signed by the attending physician. The remaining areas on the form were complete and had been signed by the RN who provided care to Patient #40 upon his passing. The Director of ICU was interviewed on [DATE] beginning at 9:45 AM. After reviewing Patient #40's record, he confirmed the form had not been signed by the attending physician. b. A PHYSICIAN'S PREPRINTED ORDERS titled RESTRAINTS FOR NON-VIOLENT BEHAVIOR-INITIAL ORDER contained orders for restraint use on upper and lower extremities for a 24 hour period beginning [DATE] at 00:20 AM. The order contained an electronic signature of the attending physician on [DATE] at 11:07 AM, 2 days after Patient #40 had expired. The Director of ICU was interviewed on [DATE] beginning at 9:45 AM. After reviewing Patient #40's record, he confirmed the form had not been signed by a physician at the time restraints had been initiated. Patient #40's record contained incomplete orders. 4. Patient #4 was a [AGE] year old female admitted to the ED on [DATE] at 3:02 AM with an admission complaint of convulsions. A preprinted order sheet titled ORDERS FOR OUTPATIENT VISIT, LABOR and DELIVERY, documented verbal orders had been received on [DATE] at 3:45 AM. The orders, although signed by a nurse, were not authenticated by a physician. The order sheet indicated the reason for Patient #4's visit as convulsions. Also included on the sheet was an order of Evaluate patient including: Fetal Heart monitoring, U/A Urine Culture if indicated. The order sheet had another section, also dated [DATE] at 3:45 AM, which stated Transfer to ED. During an interview on [DATE] beginning at 10:35 AM, the Director of the ED reviewed Patient #4's medical record and confirmed the order had not been authenticated in accordance with the hospital policy. Patient #4's record contained incomplete orders. 32844 5. Patient #26 was a [AGE] year old male admitted to the hospital on [DATE] for chest pain. He was discharged on [DATE]. His medical record contained the following incomplete documentation: a. A verbal telephone order from the physician for NPO(nothing by mouth), was documented by an RN on a Physician's Orders form on [DATE] at 11:00 AM. The RN signed off the order at 12:41 PM. The order had not been authenticated by a physician. b. A verbal telephone order from the physician for increase IV fluids to 250 ml/hr and 1 inch Nitropaste to chest now, was documented by an RN on a Physician's Orders form on [DATE] at 12:12 PM. The RN signed off the order at 12:41 PM. The order had not been authenticated by a physician. c. A verbal telephone order from the physician for Type and Cross 2 units PRBC's(packed red blood cells) and STAT (immediately) abdominal CT (computed tomography scan) without contrast now, rule out bleed, was documented by an RN on a Physician's Orders form on [DATE] at 7:40 PM. The RN signed off the order at 7:46 PM. The order had not been authenticated by a physician. d. A verbal telephone order from the physician for abdominal/pelvis CT with contrast now, was documented by an RN on a Physician's Orders form on [DATE] at 8:17 PM. The RN signed off the order at 9:13 PM. The order had not been authenticated by a physician. The Director of ICU was interviewed on [DATE] beginning at 2:30 PM. After reviewing Patient #26's physician's orders, he confirmed the forms had not been signed by the physician. Patient #26's record contained incomplete orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 00023 Based on staff interview and review of medical records and credential files, it was determined the hospital failed to ensure physical therapy services were provided by therapists under the orders of the physician who was responsible for the care of the patients. This affected the care of 2 of 3 patients (#3 and #24), who were receiving wound care by the physical therapist and whose medical records were reviewed, and had the potential to affect the care of all wound care patients. This resulted in the potential for persons to order medical treatment without the consent of the of the governing body. Findings include: 1. Patient #24's medical record documented a [AGE] year old male who was admitted to the hospital on 8/5/13 and was currently a patient as of 8/06/13. His diagnoses included lymphoma and a bowel infection. The HISTORY AND PHYSICAL, dated 8/05/13, stated Patient #24 had an abdominal wound from a previous surgery. An order, dated 8/05/13 stated Wound care for Abd wound. No further orders for wound care were present in the record. Patient #24's wound care was observed on 8/06/13 beginning at 2:05 PM. Patient #24 had an open abdominal wound that measured approximately 5 inches by 3.5 inches. The Wound Care Therapist, a physical therapist, cleansed the wound with saline and applied a calcium alginate dressing with silver impregnated in it. The Wound Care Therapist was interviewed on 8/06/13 beginning at 2:50 PM. He stated he determined the wound care treatment for patients and did not require orders or co-signatures by a physician for these treatments. The physical therapist provided treatment without physician orders. 2. Patient #3's medical record documented a [AGE] year old female who was admitted to the hospital on 8/01/13 for acute encephalopathy with delirium and decubitus ulcers on her buttocks. ADMISSION ORDERS, dated 8/01/13 at 7:00 PM, called for a wound care consultation for Patient #3's sacral decubitus ulcers. No further wound care orders were present in the medical record. A Wound Care Initial Evaluation, dated 8/01/13 at 6:00 PM by the Wound Care Therapist, stated Patient #3 had an Unstageable pressure ulcer on her SACRAL/BUTTOCKS area with serous drainage. The evaluation stated the therapist used a Melgisorb AG dressing, a special absorbent dressing impregnated with silver ions, to treat the wound. The evaluation stated the therapist would visit Patient #3 at 1-3 day intervals to treat the wound. A Wound Care Follow-up Treatment note, dated 8/02/13 at 6:00 PM by the Wound Care Therapist, stated he again saw Patient #3 and again applied a Melgisorb AG dressing. A PATIENT ASSESSMENT by the Wound Care Therapist, dated 8/03/13, stated the Melgisorb dressings were not lasting due to Patient #3 being incontinent of stool. The note stated the therapist recommended nursing remove the dressings, perform routine skin cares and apply Criticaid moisture barrier to the affected area 2-3 times a shift and as needed. A visit by the Wound Care Therapist was documented on 8/04/13 at 7:22 PM. A description of the wound and care provided by the therapist was not documented. A final note by the Wound Care Therapist, dated 8/05/13 at 6:00 PM, stated Patient #3's RN called him and informed him the RN had removed a gauze dressing and replaced it with Mepilex Border (a self-adherent soft silicone dressing). The note stated the therapist planned to leave the dressing in place for now. It also stated he supplied Patient #3's nurse with EXU-DRY Dressings, a specific type of wound dressing. The Wound Care Therapist was interviewed on 8/06/13 beginning at 2:50 PM. He confirmed there were no physician orders for Patient #3's wound care treatment. The physical therapist provided treatment without physician orders. 3. The ACNO was interviewed regarding wound care on 8/06/13 beginning at 3:45 PM. She stated the hospital did not have policies that defined the roles of wound care therapists in relation to writing orders, determining the treatment of wounds, and physician responsibilities for the oversight of wound care. She stated the Wound Care Therapist did not have privileges which authorized them to determine and order wound care treatment. The hospital allowed the physical therapist to treat patients without physician orders.

27570 Based on observation and interview, the facility failed to assure that Alcohol Based Hand Rub (ABHR) dispensers were installed as required. Failure to keep an ABHR away from an ignition source could result in a dispenser fire. This deficient practice affected one of four smoke compartments on the 5th floor, staff, and 12 patients on the dates of the survey. The facility has the capacity for 292 nursing beds with a census of 196 the day of survey. Findings include: Observation on 08/06/13 at 9:45 a.m., revealed that an ABHR dispenser was adjacent to an ignition source (light switch) in the E.I.R.M.C. 5th floor nourishment room. Interview with the Director of Plant Operations on 08/06/13 at 9:45 a.m., revealed that the facility was not aware that the ABHR dispenser was located next to an ignition source in this room. The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27931 Based on review of policies and grievance documentation and staff interview, it was determined the hospital failed to ensure the Behavioral Health Center established and adhered to a process for prompt resolution of grievances for 16 of 17 BHC patients (#3 - #18) who submitted grievances between 5/01/13 and 1/08/13. This failure resulted in a lack of documentation of grievances including the issue to be addressed, the investigation, and resolution letter provided to the complainant. Findings include: 1. The grievance policy for the BHC was requested. The BHC - PATIENT GRIEVANCE policy, dated 6/14/11, was provided and reviewed. The policy did not contain guidance for the prompt resolution of grievances as follows: a. The BHC - PATIENT GRIEVANCE policy did not define a complaint or a grievance. The hospital's grievance policy was requested and compared to the BHC grievance policy. The hospital policy, Patient Complaint & Grievance Management, dated 7/19/12, provided a definition of a complaint and a grievance. According to the policy a complaint, is a concern represented by a patient or patient's representative that can be addressed or resolved promptly by staff members who are present at the time of the complaint. 'Staff present' includes those individuals close to the complaint situation or who can quickly be at the patient's location (i.e. nursing, clinical ancillary staff, risk management, administration, nursing director/manager, etc.) to resolve the patient's complaint. Generally and it should be the objective, that complaints should be resolved timely while the patient is still receiving care at the facility. The hospital's policy defined a grievance as a written or verbal complaint (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 representative, regarding the patient's care .A written complaint is always considered a grievance, whether from an inpatient, outpatient, released or discharged patient or their representative .A verbal complaint is a grievance if it cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it requires investigation, and/or if it requires further actions for resolution. The policy stated, This policy and procedure is applicable to all hospital departments, services, and contract employees. b. The BHC - PATIENT GRIEVANCE policy stated, After attempts to resolve the complaint with the involved staff have been exhausted, the patient may file a grievance by completing the Patient Grievance Form. However, according to the hospital policy, Patient Complaint & Grievance Management, if a complaint is not resolved it is, by definition, a grievance. c. The BHC - PATIENT GRIEVANCE policy stated that each patient would be informed of the process to resolve a complaint and the review process for grievances. The policy did not outline the procedure staff were to use to resolve a complaint or review a grievance. The hospital policy, Patient Complaint & Grievance Management, provided guidance to be followed by staff members upon the receipt of a complaint. The policy also stated that grievances would be investigated. d. The BHC - PATIENT GRIEVANCE policy did not define time frames for acknowledgement of, or response to, a grievance. The hospital policy, Patient Complaint & Grievance Management, stated a written initial letter must be provided to complainant within 7 days after receipt of the Grievance. This letter will provide the name of the hospital, contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion. If the grievance is not resolved with in the 7 days a letter of notification will be sent to the complainant. The letter will indicate the time period for resolution, with the goal of completion within two weeks after the 7 day letter. The Executive Director of the BHC was interviewed on 1/09/12 at 2:50 PM. She stated the BHC - PATIENT GRIEVANCE policy was the policy referred to at the BHC. She confirmed that prior to 1/09/13 she was not aware of the hospital's grievance policy or procedure. She acknowledged the current process to manage complaints and grievances was not adequate and lacked the necessary guidance of the hospital policy. The policy did not contain guidance for the prompt resolution of grievances. 2. Staff involved in the grievance process at the BHC were interviewed. Understanding of the process to promptly resolved grievances was not consistent as follows: The Executive Director of the BHC was interviewed on 1/08/13 at 11:15 AM. She stated that the Grievance Officer was responsible for initially handling complaints and grievances at BHC. She stated that any written concern was considered a grievance. She explained that patients had access to a Patient/Resident Grievance Form. She explained that once a patient documented the concern on the grievance form, the form was reviewed by the Grievance Officer. She stated that the Grievance Officer spoke with the patient and other parties involved to resolve the issue. The Executive Director of the BHC stated that if the concern was resolved the Grievance Officer documented this on the form, otherwise the Grievance Officer would document that it was unresolved and sent to the appropriate manager. She stated if the concern was not resolved with the manager's involvement, she would become involved. She stated if the concern was not resolved at her level it would be sent to her supervisor and risk management. She confirmed that each step of the process was to be documented. She stated that the BHC did receive complaints from discharged patients and family members. She stated she did not document these concerns or handle them according to the hospital's grievance policy. She confirmed the complaints and grievances were not tracked. The Grievance Officer was interviewed on 1/08/13 at 10:50 AM. She stated she was not aware there was a difference between a complaint and a grievance. She was asked to explain when a concern would be considered a grievance. She stated if I feel like it's a grievance or if she was not able to resolve the issue then it was a grievance. She stated she collected the Patient/Resident Grievance Form(s) a couple of times a week. She explained she would then triage the concerns or comments and that she handled the minor issues. She stated that sometimes patients used the form for other things besides communicating a concern. The Grievance Officer stated her first step was to speak directly with the patient to better understand the exact nature of the concern. She stated if possible she would resolve the concern at that point and if she was not able to resolve the concern she would forward it on to the appropriate manager. She stated that occasionally a patient was not able to communicate clearly due to mental or emotional issues. She explained that in these cases she would speak with staff members and/or try to speak with the patient at a later time. She stated that when the grievance was handled by the manager the form was to be returned to her and filed. The Grievance Officer explained that she did not receive training when she was assigned this position. She stated that she was unaware of a policy related to complaints or grievances. Understanding of the process to promptly resolved grievances was not consistent. 3. Information related to grievances submitted at the BHC was reviewed. A process for the prompt resolution of grievances was not used in the following examples: 00023 a. Patient #3's medical record documented a [AGE] year old male who was admitted to the hospital's BHC from 6/15/12 to 6/28/12. His PSYCH EVALUATION, dated 6/16/12, stated his diagnoses included mood disorder and polysubstance abuse. The evaluation stated Patient #3 had been abusing over the counter cough medication. A form labeled NURSING PLAN OF CARE FOR USE OF RESTRAINT/SECLUSION, dated 6/17/12 at 11:26 PM, indicated Patient #3 threw a chair and threatened staff with pieces of the broken chair. He was subsequently restrained for 20 minutes. As a result of the incident, he was banned from admission and treatment to the BHC. Patient #3's psychiatrist was interviewed on 1/09/13 beginning at 10:35 AM. He stated Patient #3 was discharged home on 6/28/12. He stated around the middle of July 2012, Patient #3 again became suicidal. He stated he directed Patient #3's guardian to bring the patient to the BHC for treatment. He stated when Patient #3 arrived at the BHC, his guardian was told Patient #3 had been banned from admission to the BHC. The patient had to seek treatment at another hospital. The psychiatrist stated he encouraged Patient #3's guardian to talk with the hospital's CEO about his concerns. The CEO was interviewed on 1/09/13 beginning at 1:50 PM. He stated Patient #3's guardian complained to him after the BHC refused to admit the patient. The CEO stated he did not refer this to the hospital's grievance team. Subsequently, the grievance was not investigated. The grievance by Patient #3's guardian was not logged and was not investigated. 32213 b. Patient #4 submitted a Patient/Resident Grievance Form on 5/10/12. The concern was about other patients singing religious songs during a group activity that she did not feel were appropriate in the hospital setting. Patient #4 also stated the policy was not to promote religion. The Grievance Officer documented that she spoke to Patient #4 about the BHC policy, noted the issue was resolved and signed the form but did not date it. Patient #4 signed the form on 5/18/12, eight days after the form was submitted. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #4's grievance form. She confirmed there was no documentation to indicate a letter had been sent in response to this grievance. c. Patient #7 submitted three Patient/Resident Grievance Form(s) related to an incident that took place on 5/19/2012. One form was submitted on 5/23/12 and two were submitted on 5/24/12. The forms documented that Patient #7 thought she had been discharged and called family to pick her up, but was told she could not be discharged because the physician was on vacation. Patient #7 was very upset about this and called for the physician to be fired. On the form dated 5/23/12 Patient #7 wrote that she did not turn in the form on the day of the incident Because I was concerned about staff retaliation . The Grievance Officer documented on the grievance form from 5/23/12, patient too psychotic to interview .verbally assaultive. The Grievance Officer signed the form but did not date it. There was no documentation of whether the issue was investigated or resolved. The forms from 5/24/12 had no documentation from the Grievance Officer. The Executive Director of the BHC was interviewed at 11:15 AM on 1/8/13. She reviewed the grievance forms for Patient #7. She stated that the forms were not adequately completed. She confirmed the forms did not contain documentation of an investigation of the concern or a written response to the patient and that there was no documentation at all to the grievance forms dated 5/24/12. She stated that if Patient #7 was psychotic at the time the Grievance Officer attempted to discuss the issue with Patient #7, there should be more documentation stating why Patient #7 was unable to discuss these concerns. She stated she expected there to be documentation that the Grievance Officer attempted to follow up with Patient #7 at another time. d. Patient #8 submitted the following concerns Patient/Resident Grievance Form(s) on 5/29/12, 6/18/12, and 12/28/12: i. The concern on 5/29/12 was related to a staff member telling Patient #8 that her opinion did not matter. The Grievance Officer documented that she referred the complaint to a manager and signed the form but did not date it. Documentation from a manager indicated the staff member was spoken to about working with patients and avoiding conflict. The manager signed the form but did not date it. The issue was documented as resolved and Patient #8 signed the form but did not date it. ii. The concern on 6/18/12 was related to confronting a staff member about a comment the staff member made. Patient #8 also documented that she was sick of his attitude, infractions, and not listening (to) us. The Grievance Officer documented that she referred the concern to a manager on 6/20/12 (two days after it was submitted) because it was a staff issue, and signed the form. There was further documentation the staff member was being instructed on alternatives to control the class, but this documentation was not signed or dated. The issue was documented as resolved and Patient #8 signed the form but did not date it. iii. The concern on 12/28/12 was related to Patient #8 feeling like a staff member hates her because she did not attend school. The Grievance Officer documented that when Patient #8 stated her emotions altered her perception of the staff member's attitude towards her. The concern was documented as resolved and the Grievance Officer signed the form on 12/31/12 (three days after it was submitted). Patient #8 also signed the form but did not date it. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #8's grievance forms. She confirmed there was no documentation to indicate when the grievance was resolved (for the 5/29/12 and 6/18/12 grievances) or that letters had been sent in response to any of the grievances. She stated she believed the manager provided the additional documentation to the 6/18/12 grievance but confirmed this documentation was not signed/dated. e. Patient #18 submitted the following concerns on Patient/Resident Grievance Form(s) on 7/14/12 and 10/04/12: i. The concern submitted on 7/14/12 was related to Patient #18's dislike of a staff member's actions and the way the staff member treated others. The Grievance Officer documented the issue was referred to a manager and signed the form on 7/18/12 (four days after it was submitted.) The concern was marked as unresolved and Patient #18 signed the form but did not date it. There was no documentation of a manger's involvement with this issue. ii. The concern submitted on 10/05/12 was related to Patient #18 feeling like she couldn't process with staff without getting yelled at. The Grievance Officer documented the concern was referred to a manager because it involved a staff member. The Grievance Officer signed the form on 10/12/12 (seven days after the grievance was submitted) . The grievance was documented as unresolved and Patient #18 signed the form on 10/12/12. There was no documentation to indicate a manager's involvement, that the grievance was resolved and a written notice of response provided to Patient #18. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance documentation for Patient #18. She stated it was her expectation that the manager speak with the patient and the staff member. She confirmed that there was no documentation of the manager's involvement in resolving either of these concerns. She stated it was possible the manager documented something in Patient #18's chart, but based on the documentation on the grievance forms it could not be determined the grievances were thoroughly reviewed and resolved. She also confirmed that there was no documentation to indicate a letter had been sent in response to the grievances. f. Patient #13 submitted the following concerns on Patient/Resident Grievance Form(s) on 6/02/12, 6/05/12, and 7/15/12: i. The concern submitted on 6/02/12 was related to a staff member and a peer using a word that Patient #13 found offensive. The Grievance Officer documented the issue was referred to manager because it involved staff. The Grievance Officer signed the form but did not date it. There was no documentation to indicate whether the issue was resolved or not. There was no documentation to indicate a manager was involved with this issue. ii. The concern submitted on 6/05/12 was related to a staff member always giving people infractions . and the difficulty of this staff member's class. The Grievance officer documented the issue was referred to manager because it involved staff. The Grievance Officer signed the form but did not date it. There was no documentation to indicate whether the issue was resolved or not. There was no documentation to indicate a manager was involved with this issue. iii. The concern submitted on 7/15/12 was related to a staff member acting like a child . Patient #13 also stated the staff member had fallen asleep on the job and was only doing the job to pay for school. The Grievance officer documented the issue was referred to manager because it involved staff. The Grievance Officer signed the form on 7/18/12 (three days after it was submitted) and marked the grievance as unresolved. There was no documentation to indicate whether the issue was ultimately resolved or not. There was no documentation to indicate a manager was involved with this issue. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance forms for Patient #13. She stated that she did not know if any of the grievances were reviewed by a manager as there was no documentation of this on any grievance form. She confirmed there was no date to indicate when the Grievance Officer reviewed the grievance forms from 6/02/12 and 6/05/12. She also confirmed that there was no documentation to indicate a letter had been sent in response to the grievances. g. Patient #14 submitted a concern on the Patient/Resident Grievance Form on 10/05/12 related to a staff member being irritable towards others. The Grievance Officer documented the concern was referred to a manager because it involved a staff member. The Grievance Officer signed the form on 10/12/12 (seven days after the grievance was submitted) and marked the concern as unresolved. There was documentation that this concern was discussed with the staff member, but there was no signature or date indicating who spoke with the staff or when. Patient #14 signed the form on 10/12/12. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance form for Patient #14 and stated she believed the unidentified documentation was from the manager. She confirmed there was no documentation to indicate a letter had been sent in response to this grievance. h. Patient #11 submitted two Patient/Resident Grievance Form(s) on 6/18/12 related to a staff member giving infractions unnecessarily. The Grievance Officer documented on each form that the concern was referred to a manager because it involved a staff member. The Grievance Officer signed the forms on 6/20/12 (two days after they were submitted.) There was no documentation on either form to indicate a manager was involved in this issue. There was no documentation on either form to indicate if the issue was resolved or unresolved. Patient #11 signed both forms on 7/29/12. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #11's grievance forms. She stated that she did not know if this complaint was reviewed by a manager as there was no documentation from the manager on the forms. She stated the form appeared to have been signed by Patient #11 when the grievance was resolved but confirmed this was difficult to determine. She also confirmed that there was no documentation to indicate a letter had been sent in response to this grievance. i. Patient #15 submitted a Patient/Resident Grievance Form on 10/22/12. The concern was related to a comment a staff member made to Patient #15. Patient #15 requested a meeting with staff members to resolve this issue. The Grievance Officer documented the concern was referred to a manager per Patient #15's request. The Grievance Officer signed the form on 10/23/12. The concern was documented as unresolved. There was no documentation to indicate a manager had been involved in the issue or a meeting with staff had taken place. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #15's grievance form. She stated that she did not know if this complaint was reviewed by a manager as there was no documentation from the manager on the form. She stated she assumed the meeting was set up and stated that perhaps there was documentation of this in Patient #15's medical record. She agreed that it was preferable to have all of the documentation regarding any investigation and resolution to a grievance in one location. She confirmed there was no documentation to indicate a letter was sent in response to this grievance. j. Patient #16 submitted a Patient/Resident Grievance Form on 6/17/12. The concern was that a staff member changed a planned activity to a different activity. The Grievance Officer documented the issue had been referred to a manager because it involved a staff member. The Grievance Officer signed the form on 6/18/12 (one day after the grievance was submitted.) There was no documentation to indicate a manager had been involved in the resolution of this concern. There was no documentation to indicate the issue was resolved or unresolved. Patient #16 signed the form but did not date it. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #16's grievance form. She stated that she did not know if this complaint was reviewed by a manager as there was no documentation from the manager on the form. She confirmed there was no documentation to indicate a letter was sent in response to this grievance. k. Patient #17 submitted a Patient/Resident Grievance Form on 6/18/12. The concern was related to a staff member. The Grievance Officer documented the concern was referred to a manager and signed the form on 6/20/12 (two days after it was submitted). There was no documentation to indicate a manager had been involved in the resolution of this concern. There was no documentation to indicate the issue was resolved or unresolved. Patient #17 signed the form on 7/29/12. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #17's grievance form. She stated that she did not know if this complaint was reviewed by a manager as there was no documentation of this on the form. She stated the form appeared to have been signed by Patient #17 when the grievance was resolved but confirmed this was difficult to determine. She also confirmed that there was no documentation to indicate a letter had been sent in response to this grievance. l. Patient #9 submitted 16 Patient/Resident Grievance Form(s) dated from 9/12/12 to 9/16/12. There were multiple nonspecific concerns on each page, some dealing with people watching him, conditions in his room, the food, and the number of patients the facility had at a given time. There were also references to his grievances not being addressed, no one listening to him, issues with staff and his rights being violated. Only one page contained documentation that the grievance(s) had been acknowledged. At the bottom of the page was a note dated 6/18/12 documenting Patient #9 was transferred to a state hospital and diagnosed with paranoid schizophrenia. There was no signature. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance forms for Patient #9. She confirmed there was no response from the Grievance Officer on any of the forms. She stated that it was the BHC's policy that if the patient was too agitated to be interviewed about the concerns on the form, then the interview was to be postponed until the patient was feeling better. She stated her expectation would have been for the Grievance Officer to speak to Patient #9 at some point during his stay or document on the forms why she could not. She confirmed there was no documentation to indicate the Grievance Officer had acknowledged the concerns. m. Patient #12 submitted a Patient/Resident Grievance Form on 10/29/12 related to the temperature of her room. There was documentation on the form the issue was referred to a manager. There was no signature for this documentation and no date for when the issue was referred to the manager. There was documentation on the form from the manager that the temperature was in normal ranges, the policy on bringing blankets from home was reviewed and the manager had spoken with other patients about the temperature. The manager signed the form on 11/05/12 (seven days after the grievance was submitted.) On the line for Patient Signature was written discharged . The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #12's grievance form. She stated the manager had probably interviewed Patient #12 before discharge but did not document the encounter until 11/05/12. She confirmed that there was no documentation to indicate the manager had spoken with Patient #12 or that a letter had been sent in response to the grievance. n. Patient #6 submitted the following concerns on Patient/Resident Grievance Form(s) on 5/27/12, 5/29/12 and 10/28/12: i. The concern submitted on 5/27/12 was related to Patient #6 wanting blue Powerade once a day. There was no documentation from the Grievance Officer on this form. ii. Three Patient/Resident Grievance Form(s) were submitted on 5/29/12. The concerns were related to being able to wear a watch, a glass ring being tampered with and ten dollars missing from her wallet. Only one form (from 5/27/12 and 5/29/12) contained documentation from the Grievance Officer. The Grievance Officer addressed the missing money and suggested double check inventory on discharge (and) file complaint (at) that time if appropriate . The Grievance Officer documented she would notify Patient #6's physician regarding the request for blue Powerade. The Grievance Officer documented the ring had been inventoried and was not accessible to Patient #6. In addition, the Grievance Officer documented she would follow up on the rules regarding watches. The issues were documented as resolved and signed by the Grievance Officer and Patient #6 on 5/29/12. iii. The concern submitted on 10/28/12 was regarding ten dollars missing from Patient #6's wallet. There was no documentation on the form from the Grievance Officer. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance forms submitted by Patient #6. She stated the actions of the Grievance Officer were not well documented. She stated that instead of waiting until discharge to see if money had been removed from Patient #6's wallet, something more immediate should have been done. She stated she expected a staff member to check the wallet contents against the list of inventoried items documented when Patient #6 was admitted to the facility. She stated there should have been documentation on each separate Patient/Resident Grievance Form. She confirmed there was no documentation of a written response to the grievances. o. Patient #10 submitted Patient/Resident Grievance Form(s) on 6/04/12 and 6/20/12 as follows: i. The concern submitted on 6/20/12 was related to a female patient lying about a male patient. The Grievance Officer documented on the form that this was written as a warning to staff that a female patient was trying to frame a male patient to get him removed from the unit. The issue was documented as resolved, the Grievance Officer and Patient # 10 signed the form on 6/20/12. ii. The concern submitted on 6/04/12 was a staff member giving patients infractions unnecessarily. The Grievance Officer documented the issue was sent to a manager because it involved a staff member and signed the form but did not date it. There was no documentation to indicate if the issue was resolved or unresolved. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance forms submitted by Patient #10. She confirmed there was no documentation to indicate the manager was involved in the resolution of the complaint submitted on 6/04/12. She confirmed there was no documentation that a letter of resolution was written in response to the grievances. p. Patient #5 submitted the following concerns on Patient/Resident Grievance Form(s) on 12/21/12 and 12/30/12: i. The concern submitted on 12/21/12 was related to a staff member speaking to her in a sarcastic tone when she was upset. The Grievance Officer documented that the she discussed with Patient #5 how her approach contributed to the staff member speaking the way he did. The Grievance Officer also discussed with Patient #5 alternate methods of having her needs met. The issue was documented as resolved and signed by the Grievance Officer on 12/31/12 (ten days after it was submitted.) The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance documentation for Patient #5. She confirmed that there was no documentation that the staff member in question was spoken to, only that Patient #5 needed to alter her reactions. She confirmed there was no documentation that a written response was provided to Patient #5. ii. The concern submitted on 12/30/12 was about two staff members making Patient #5 taste their breath. There was documentation on the form that Patient #5 acknowledged this was a joke. There was no signature or date for the documentation. The Grievance Officer was interviewed on 1/08/13 at 10:50 AM. She confirmed that documentation submitted on the Patient/Resident Grievance Form was not always

27931 Based on interview and review of grievance documentation and policies, it was determined the governing body failed to ensure the effective operation of the grievance process at the BHC. This impacted 16 of 17 BHC patients (#3 - #18) who submitted grievances between 5/01/12 and 1/08/13 and had the potential to impact all patients who received care at the BHC. This resulted in the lack of the documentation of grievances, the investigation of grievances, and the resolution of the grievance process. Findings include: 1. The grievance policy for the BHC was requested. The BHC - PATIENT GRIEVANCE policy, dated 6/14/11, was provided and reviewed. The policy did not contain guidance for the prompt resolution of grievances as follows: a. The BHC - PATIENT GRIEVANCE policy did not define a complaint or a grievance. The hospital's grievance policy was requested and compared to the BHC grievance policy. The hospital policy, Patient Complaint & Grievance Management, dated 7/19/12, provided a definition of a complaint and a grievance. According to the policy a complaint, is a concern represented by a patient or patient's representative that can be addressed or resolved promptly by staff members who are present at the time of the complaint. 'Staff present' includes those individuals close to the complaint situation or who can quickly be at the patient's location (i.e. nursing, clinical ancillary staff, risk management, administration, nursing director/manager, etc.) to resolve the patient's complaint. Generally and it should be the objective, that complaints should be resolved timely while the patient is still receiving care at the facility. The hospital's policy defined a grievance as a written or verbal complaint (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 representative, regarding the patient's care .A written complaint is always considered a grievance, whether from an inpatient, outpatient, released or discharged patient or their representative .A verbal complaint is a grievance if it cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it requires investigation, and/or if it requires further actions for resolution. The policy stated, This policy and procedure is applicable to all hospital departments, services, and contract employees. b. The BHC - PATIENT GRIEVANCE policy stated, After attempts to resolve the complaint with the involved staff have been exhausted, the patient may file a grievance by completing the Patient Grievance Form. However, according to the hospital policy, Patient Complaint & Grievance Management, if a complaint is not resolved it is, by definition, a grievance. c. The BHC - PATIENT GRIEVANCE policy stated that each patient would be informed of the process to resolve a complaint and the review process for grievances. The policy did not outline the procedure staff were to use to resolve a complaint or review a grievance. The hospital policy, Patient Complaint & Grievance Management, provided guidance to be followed by staff members upon the receipt of a complaint. The policy also stated that grievances would be investigated. d. The BHC - PATIENT GRIEVANCE policy did not define time frames for acknowledgement of, or response to, a grievance. The hospital policy, Patient Complaint & Grievance Management, stated a written initial letter must be provided to complainant within 7 days after receipt of the Grievance. This letter will provide the name of the hospital, contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion. If the grievance is not resolved with in the 7 days a letter of notification will be sent to the complainant. The letter will indicate the time period for resolution, with the goal of completion within two weeks after the 7 day letter. The Executive Director of the BHC was interviewed on 1/09/12 at 2:50 PM. She stated the BHC - PATIENT GRIEVANCE policy was the policy referred to at the BHC. She confirmed that prior to 1/09/13 she was not aware of the hospital's grievance policy or procedure. She acknowledged the current process to manage complaints and grievances was not adequate and lacked the necessary guidance of the hospital policy. The policy did not contain guidance for the prompt resolution of grievances. 2. Staff involved in the grievance process at the BHC were interviewed. Understanding of the process to promptly resolved grievances was not consistent as follows: The Executive Director of the BHC was interviewed on 1/08/13 at 11:15 AM. She stated that the Grievance Officer was responsible for initially handling complaints and grievances at BHC. She stated that any written concern was considered a grievance. She explained that patients had access to a Patient/Resident Grievance Form. She explained that once a patient documented the concern on the grievance form, the form was reviewed by the Grievance Officer. She stated that the Grievance Officer spoke with the patient and other parties involved to resolve the issue. The Executive Director of the BHC stated that if the concern was resolved the Grievance Officer documented this on the form, otherwise the Grievance Officer would document that it was unresolved and sent to the appropriate manager. She stated if the concern was not resolved with the manager's involvement, she would become involved. She stated if the concern was not resolved at her level it would be sent to her supervisor and risk management. She confirmed that each step of the process was to be documented. She stated that the BHC did receive complaints from discharged patients and family members. She stated she did not document these concerns or handle them according to the hospital's grievance policy. She confirmed the complaints and grievances were not tracked. The Grievance Officer was interviewed on 1/08/13 at 10:50 AM. She stated she was not aware there was a difference between a complaint and a grievance. She was asked to explain when a concern would be considered a grievance. She stated if I feel like it's a grievance or if she was not able to resolve the issue then it was a grievance. She stated she collected the Patient/Resident Grievance Form(s) a couple of times a week. She explained she would then triage the concerns or comments and that she handled the minor issues. She stated that sometimes patients used the form for other things besides communicating a concern. The Grievance Officer stated her first step was to speak directly with the patient to better understand the exact nature of the concern. She stated if possible she would resolve the concern at that point and if she was not able to resolve the concern she would forward it on to the appropriate manager. She stated that occasionally a patient was not able to communicate clearly due to mental or emotional issues. She explained that in these cases she would speak with staff members and/or try to speak with the patient at a later time. She stated that when the grievance was handled by the manager the form was to be returned to her and filed. The Grievance Officer explained that she did not receive training when she was assigned this position. She stated that she was unaware of a policy related to complaints or grievances. Understanding of the process to promptly resolved grievances was not consistent. 3. Patients #3 - #18 submitted a total of 41 grievances between 5/01/12 and 1/08/13 as follow: * Patient #3 ' s parent complained to the CEO after being informed upon arrival at the BHC on approximately 7/20/12, that his son was banned from admission to the BHC. * Patient #4 submitted a Patient/Resident Grievance Form on 5/10/12. * Patient #5 submitted concerns on Patient/Resident Grievance Form(s) on 12/21/12 and 12/30/12. * Patient #6 submitted concerns on three Patient/Resident Grievance Form(s) dated 5/27/12, 5/29/12 and 10/28/12: * Patient #7 submitted three Patient/Resident Grievance Form(s) related to an incident that took place on 5/19/2012. One form was submitted on 5/23/12 and two were submitted on 5/24/12. * Patient #8 submitted three Patient/Resident Grievance Form(s) dated 5/29/12, 6/18/12, and 12/28/12. * Patient #9 submitted 16 Patient/Resident Grievance Form(s) dated from 9/12/12 to 9/16/12. * Patient #10 submitted Patient/Resident Grievance Form(s) on 6/04/12 and 6/20/12. * Patient #11 submitted two Patient/Resident Grievance Form(s) on 6/18/12. * Patient #12 submitted a Patient/Resident Grievance Form on 10/29/12. * Patient #13 submitted concerns on Patient/Resident Grievance Form(s) on 6/02/12, 6/05/12, and 7/15/12. * Patient #14 submitted a concern on the Patient/Resident Grievance Form on 10/05/12. * Patient #15 submitted a Patient/Resident Grievance Form on 10/22/12. * Patient #16 submitted a Patient/Resident Grievance Form on 6/17/12. * Patient #17 submitted a Patient/Resident Grievance Form on 6/18/12. * Patient #18 submitted concerns on Patient/Resident Grievance Form(s) on 7/14/12 and 10/04/12. Information related to these grievances was reviewed. There was no documentation that the BHC identified the concerns as grievances and responded to them as grievances. 4. The Executive Director of Risk Management was interviewed on 1/08/13 at 3:30 PM. He stated that he believed that the BHC was processing and tracking grievances in accordance with the hospital's policy. He stated he was not aware of the process used at the BHC and confirmed that the Executive Director of BHC was not involved in the hospital's grievance committee. 5. The Chief Operating Officer was interviewed on 1/09/13 at 11:40 AM. She confirmed that the Executive Director of BHC reported up to her. She stated the hospital considered the BHC a free-standing facility. She confirmed that she met monthly with the Executive Director of BHC and BHC managers. She stated that grievance issues were handled by the Executive Director of Risk Management. She stated the BHC should be using the same process to manage grievances as the hospital. The governing body did not ensure an effective grievance process was utilized at the BHC.

27931 Based on interview and review of patient rights information and facility policies, it was determined the facility failed to establish a clearly explained process for patients at the BHC to submit grievances. This failure had the potential to result in patients and/or their representatives not having concerns addressed. Findings include: 1. A pamphlet titled, YOUR PATIENT RIGHTS & RESPONSIBILITIES, undated, was reviewed. One section of this pamphlet addressed complaint and grievance resolution. The pamphlet directed patients to let your caregiver know of any concerns you have .Our goal is to respond to your concern in a timely manner and with an appropriate and clear resolution. The pamphlet listed staff members capable of responding to complaints/grievances, including physicians, department managers/directors, and charge nurses. In addition, patients were provided with the accrediting organization and state agency contact information. On 1/08/13 at 1:55 PM the Executive Director of Risk Management presented an updated version of the patient rights pamphlet. The Executive Director of BHC was present during this interview and confirmed that the new pamphlet was not part of the admission paperwork given to patients or their representatives as of 1/09/13. The Executive Director of Risk Management stated the new pamphlet contained minor changes that were updated toward the end of the summer or the beginning of the fall of 2012. The new pamphlet contained additional information regarding complaints and grievances. The pamphlet stated that The patient and his or her family have the right to have complaints reviewed by the hospital. In addition to the staff members listed above, and outside entities to report concerns to, this pamphlet provided the contact information of the Executive Director of Risk Management. The Executive Director of the BHC was interviewed on 11/08/13 at 11:15 AM. She stated BHC could be a little more definitive about the grievance process. It's vague. She agreed that because the process is vague it could be difficult for a patient to understand. Patient rights information did not clearly outline the process of submitting a grievance. 2. The grievance policy for the BHC was requested. The BHC - PATIENT GRIEVANCE policy, dated 6/14/11, was provided and reviewed. The policy stated, A grievance procedure is available to all patients to systematically address unresolved patient complaints. All patients will be informed of their right to initiate a grievance and educated of the grievance procedure within 24 hours after their admission, unless impractical because of the patient's medical or emotional status. The policy explained that if attempts to resolve a complaint with involved staff were exhausted, the patient may file a grievance by completing the Patient Grievance Form. The policy did not address the submission of a verbal grievance. The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She stated patients were given the pamphlet containing information about grievances and complaints on admission to the BHC. She stated sometimes patients are unable to process this information at the time of admission due to an altered mental or emotional state. She stated the staff was inconsistent in ensuring patients were informed of the grievance process. The BHC policy does not address the procedure for the submission of a verbal grievance.

27931 Based on review of policies and interview it was determined the facility failed to ensure time frames for investigation and response to grievances were established for the BHC. This directly impacted 16 of 17 BHC patients (#3 - #18) who submitted grievances between 5/01/12 and 1/08/13, and had the potential to impact all patients who received care at the BHC. This failure had the potential to result in delayed and unsatisfactory responses from the facility to the complainants. Findings include: The patient grievance policy was requested. The BHC - PATIENT GRIEVANCE policy, dated 6/14/11, was provided and reviewed. The BHC - PATIENT GRIEVANCE policy did not define time frames for acknowledgement of or response to a grievance. The hospital's grievance policy was requested and compared to the BHC grievance policy. The hospital policy, Patient Complaint & Grievance Management, dated 7/19/12, stated a written initial letter must be provided to complainant within 7 days after receipt of the Grievance. This letter will provide the name of the hospital, contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion. If the grievance is not resolved with in the 7 days a letter of notification will be sent to the complainant. The letter will indicate the time period for resolution, with the goal of completion within two weeks after the 7 day letter. The policy also stated, This policy and procedure is applicable to all hospital departments, services, and contract employees. Patients #3 - #18 submitted a total of 41 grievances between 5/01/12 and 1/08/13 as follow: * Patient #3 ' s parent complained to the CEO after being informed upon arrival at the BHC on approximately 7/20/12, that his son was banned from admission to the BHC. * Patient #4 submitted a Patient/Resident Grievance Form on 5/10/12. * Patient #5 submitted concerns on Patient/Resident Grievance Form(s) on 12/21/12 and 12/30/12. * Patient #6 submitted concerns on three Patient/Resident Grievance Form(s) dated 5/27/12, 5/29/12 and 10/28/12: * Patient #7 submitted three Patient/Resident Grievance Form(s) related to an incident that took place on 5/19/2012. One form was submitted on 5/23/12 and two were submitted on 5/24/12. * Patient #8 submitted three Patient/Resident Grievance Form(s) dated 5/29/12, 6/18/12, and 12/28/12. * Patient #9 submitted 16 Patient/Resident Grievance Form(s) dated from 9/12/12 to 9/16/12. * Patient #10 submitted Patient/Resident Grievance Form(s) on 6/04/12 and 6/20/12. * Patient #11 submitted two Patient/Resident Grievance Form(s) on 6/18/12. * Patient #12 submitted a Patient/Resident Grievance Form on 10/29/12. * Patient #13 submitted concerns on Patient/Resident Grievance Form(s) on 6/02/12, 6/05/12, and 7/15/12. * Patient #14 submitted a concern on the Patient/Resident Grievance Form on 10/05/12. * Patient #15 submitted a Patient/Resident Grievance Form on 10/22/12. * Patient #16 submitted a Patient/Resident Grievance Form on 6/17/12. * Patient #17 submitted a Patient/Resident Grievance Form on 6/18/12. * Patient #18 submitted concerns on Patient/Resident Grievance Form(s) on 7/14/12 and 10/04/12. Information related to these grievances was reviewed. There was no documentation that the BHC identified the concerns as grievances or provided a response in any specific time frame. The Executive Director of the BHC was interviewed on 1/09/12 at 2:50 PM. She confirmed the BHC - PATIENT GRIEVANCE policy was the policy referred to at the BHC. She stated that prior to 1/09/13 she was not aware of the hospital's grievance policy or procedure. She acknowledged that the current process to manage complaints and grievances was not adequate and the BHC policy lacked the time frame guidance found in the hospital policy. The grievance process at the BHC did not include time frames for the investigation and response to grievances.

27931 Based on review of grievance documentation and policies and staff interview, it was determined the facility failed to ensure the BHC responded to grievances with a written notice. This directly impacted 16 of 17 BHC patients (#3 - #18) who submitted grievances between 5/01/12 and 1/08/13, and had the potential to impact all patients who received care at the BHC. This resulted in lack of clarity related to the steps taken to investigate the grievance and resolution of the investigation process. Findings include: The patient grievance policy was requested. The BHC - PATIENT GRIEVANCE policy, dated 6/14/11 was provided and reviewed. The BHC - PATIENT GRIEVANCE policy did not address providing a written notice to the patient with the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion. The hospital's grievance policy was requested and compared to the BHC grievance policy. The hospital policy, Patient Complaint & Grievance Management, dated 7/19/12, stated a written initial letter must be provided to complainant within 7 days after receipt of the Grievance. This letter will provide the name of the hospital, contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion. If the grievance is not resolved with in the 7 days a letter of notification will be sent to the complainant. The letter will indicate the time period for resolution, with the goal of completion within two weeks after the 7 day letter. The policy also stated, This policy and procedure is applicable to all hospital departments, services, and contract employees. Patients #3 - #18 submitted a total of 41 grievances between 5/01/12 and 1/08/13 as follow: * Patient #3 ' s parent complained to the CEO after being informed upon arrival at the BHC on approximately 7/20/12, that his son was banned from admission to the BHC. * Patient #4 submitted a Patient/Resident Grievance Form on 5/10/12. * Patient #5 submitted concerns on Patient/Resident Grievance Form(s) on 12/21/12 and 12/30/12. * Patient #6 submitted concerns on three Patient/Resident Grievance Form(s) dated 5/27/12, 5/29/12 and 10/28/12: * Patient #7 submitted three Patient/Resident Grievance Form(s) related to an incident that took place on 5/19/2012. One form was submitted on 5/23/12 and two were submitted on 5/24/12. * Patient #8 submitted three Patient/Resident Grievance Form(s) dated 5/29/12, 6/18/12, and 12/28/12. * Patient #9 submitted 16 Patient/Resident Grievance Form(s) dated from 9/12/12 to 9/16/12. * Patient #10 submitted Patient/Resident Grievance Form(s) on 6/04/12 and 6/20/12. * Patient #11 submitted two Patient/Resident Grievance Form(s) on 6/18/12. * Patient #12 submitted a Patient/Resident Grievance Form on 10/29/12. * Patient #13 submitted concerns on Patient/Resident Grievance Form(s) on 6/02/12, 6/05/12, and 7/15/12. * Patient #14 submitted a concern on the Patient/Resident Grievance Form on 10/05/12. * Patient #15 submitted a Patient/Resident Grievance Form on 10/22/12. * Patient #16 submitted a Patient/Resident Grievance Form on 6/17/12. * Patient #17 submitted a Patient/Resident Grievance Form on 6/18/12. * Patient #18 submitted concerns on Patient/Resident Grievance Form(s) on 7/14/12 and 10/04/12. Information related to these grievances was reviewed. There was no documentation that the BHC identified the concerns as grievances and provided a response with the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion. The Executive Director of the BHC was interviewed on 1/08/13 at 11:15 AM. She stated if the concern was not resolved with the manager's involvement, she would become involved. She stated if the concern was not resolved at her level it would be sent to her supervisor and risk management. She stated written responses to grievances came from the Executive Director of Risk Management's office. She explained that she was often able to resolve issues over the phone, however this was not documented. The Executive Director of the BHC was interviewed on 1/09/12 at 2:50 PM. She stated the BHC - PATIENT GRIEVANCE policy was the policy referred to at the BHC. She confirmed that prior to 1/09/13 she was not aware of the hospital's grievance policy or procedure. She acknowledged that the current process to manage complaints and grievances was not adequate. Patients did not receive written responses to grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 00023 Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure the right to be involved in care planning and treatment and the right to request treatment was afforded to 1 of 6 psychiatric patients (Patient #3) whose medical records were reviewed. This prevented patients from making informed decisions about their care. Findings include: Patient #3's medical record documented a [AGE] year old male who was admitted to the hospital's BHC from 6/15/12 to 6/28/12. His PSYCH EVALUATION, dated 6/16/12, stated his diagnoses included mood disorder and polysubstance abuse. The evaluation stated Patient #3 had been abusing over-the-counter cough medication. The section of the evaluation labeled VIOLENCE stated Patient #3's .chart documents multiple previous suicide attempts including cutting, hanging, overdosing and huffing chlorine gas. The patient also has a history of self-cutting that is not motivated by suicidal intent. No mention of violence to others was documented. Patient #3's medical record documented he was placed in 4 point restraints. A CONTINUOUS MONITORING AND CARE OF PATIENT IN RESTRAINT/SECLUSION form, dated 6/17/12 at 10:50 PM, indicated he was restrained from 10:15 PM until 10:35 PM. His behavior was listed as calm at 10:15 PM, 10:30 PM, and 10:35 PM. The form stated he was calm and apologized for his actions. It stated he denied a desire to assault staff. The NURSING PLAN OF CARE FOR USE OF RESTRAINT/SECLUSION, dated 6/17/12 at 11:26 PM, stated Patient #3 .was calm up to throwing chair and threatening staff with piece of broken chair. A form labeled DEBRIEFING WITH STAFF, dated 6/17/12 at 11:31 PM, stated Patient #3 .called girlfriend-told her he was going to throw chair through window and assault staff in order to get IM medication, [patient's] girlfriend called staff, [patient] carried out plan. The form stated this was Patient #3's first time for assaultive behavior and said he would not do it again. No documentation was present that staff asked Patient #3 what motivated his outburst. No documentation was present that other incidents occurred during the other 13 days of Patient #3's hospitalization . No physician progress note mentioned the incident. The discharge summary did not mention the incident. Patient #3's psychiatrist was interviewed on 1/09/13 beginning at 10:35 AM. He stated he had assumed Patient #3's care from the on-call psychiatrist on 6/18/12, the day following the incident. He stated he was still Patient #3's psychiatrist. He stated Patient #3 was discharged home on 6/28/12. He stated around the middle of July, 2012, Patient #3 again became suicidal. He stated he spoke with Patient #3's guardian and told the guardian to bring Patient #3 to the BHC where he would be admitted directly to the hospital. He stated he telephoned the BHC with orders to admit Patient #3. He stated he was then told Patient #3 had been banned from admission to the BHC and would not be admitted for treatment. The psychiatrist stated the guardian then called him and stated he was at BHC with Patient #3. The guardian told the psychiatrist BHC would not admit Patient #3. The psychiatrist stated he then arranged for Patient #3 to be admitted to a hospital approximately 52 miles away. The psychiatrist stated he had not been consulted prior to BHC's refusal to admit Patient #3. The psychiatrist stated Patient #3 was still banned from admission to BHC as of 1/09/13. Patient #3 was admitted to the Emergency Department at Eastern Idaho Regional Medical Center 7 times from August through December 2012. He was stabilized in the Emergency Department and/or subsequently admitted to a medical floor for psychiatric complaints and medical stabilization. Patient #3's presenting complaints and disposition included: A. 8/07/12 to 8/08/12-overdose on cold medication. Patient #3 was transferred to the other hospital for psychiatric treatment. B. 8/16/12-depression and suicidal ideation. Patient #3 was transferred to the other hospital for psychiatric treatment. C. 10/10/12-depression and suicidal ideation. Patient #3 was transferred to the other hospital for psychiatric treatment. D. 10/20/12 to 10/21/12-drug overdose. Patient #3 was discharged to home. E. 12/02/12-depression and suicidal ideation. Patient #3 was discharged to home. F. 12/21/12 to 12/22/12-drug overdose. Patient #3 was admitted for medical stabilization and then transferred to the other hospital for psychiatric treatment. G. 12/26/12 to 12/29/12-drug overdose. Patient #3 was admitted for medical stabilization and then transferred to the other hospital for psychiatric treatment. The Executive Director of the BHC was interviewed on 1/08/13 beginning at 2:10 PM. She stated Eastern Idaho Regional Medical Center refused to consider Patient #3 appropriate for admission for psychiatric treatment. She stated she thought Patient #3's guardian had been verbally notified of that decision but had not been notified in writing. She did not know when he had been verbally informed. She stated there was no policy or procedure that outlined a process to ban patients from treatment at the BHC. She stated she there was no documentation which explained how the decision to ban Patient #3 from the BHC was made. The decision to ban Patient #3 from admission to the BHC was not discussed with him and his guardian before a final decision was made. This prevented Patient #3 and his guardian from being involved in planning for his care and treatment and from being able to request treatment. The decision was not shared with Patient #3 and his guardian prior to them presenting to the BHC for admission of Patient #3 in a crisis situation.