University of Kansas Health System - St Francis Campus

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 47234 Based on policy review, record review, document review, and interview, the Hospital failed to review an allegation of sexual assault immediately as required per policy for 1 (Patient 1) of 2 patients reviewed. This deficient practice has the potential to place patients or representatives at risk for unresolved grievances and complaints and systemic issues that could lead to harm and other adverse outcomes. Findings Include: Review of hospital policy titled, “117-ADM [Administration] Complaints and Grievances - RM [Risk Management] - [Above Named Hospital],” dated 03/28/18, showed, “ ...Investigate and respond to patient and/or family/representative complaints and grievances, including but not limited to quality of care ...Patient Grievance - A grievance is defined as ANY of the following: ...A patient’s rights complaint by a patient or the patient’s representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS [Centers for Medicare and Medicaid Services] Hospital Conditions of Participation (CoP) ... Grievances about situations that endanger the patient such as abuse or neglect must be reviewed immediately ...The Patient Representative and/or designated person will send a letter of notification to the patient within 7 days of a received grievance ...The Facility Compliance Officer (FCO) will be responsible for addressing grievances involving potential corporate compliance violations or other regulatory violations ... All grievances will have a written response from the patient representative within thirty days of receipt of the grievance depending on the nature of the grievance ...” Review of hospital policy titled, “200-ADM [Administration] Patient Rights and Responsibilities,” dated 04/21/25, showed, “ ...Patient Has The Right ...To personal security and privacy so that ...Patients are free from physical or mental abuse, neglect or harassment ... Patient Grievance Process: ... All formal written or verbal patient grievances will receive a written response from [Above Named Hospital] within 30 days of receipt of grievance ...” Review of hospital policy titled, “158-IPCM [Inpatient Care Management] Abuse, Neglect and Exploitation,” dated 02/21/24, showed, “ ...To assist Health Center staff in identifying possible abuse/neglect/exploitation and outline appropriate actions for investigation and/or reporting ... Adult Abuse - An individual 18 years of age or older alleged to be unable to protect their own interests. Physical, psychological, or sexual acts that jeopardize an individual’s medical care, health status, sense of personhood, right to self-determination, or personal property or income. Failure to provide a safe environment ... Reports of suspected abuse or neglect of residents of medical care facilities, including nursing homes, are to be reported to the Department of Health and Environment ...” Patient 1 Review of Patient 1’s medical record showed a 71-year-old was seen in the emergency department on 03/23/25 at 8:32 AM and admitted with a diagnosis of fecal impaction (hardened stool stuck in the rectum or lower colon due to constipation) and evidence of proctitis (an inflammation of the rectum’s lining). Review of a hospital document titled, “Event Log,” dated 01/01/25 to 05/27/25, showed that Patient 1 filed a grievance with the hospital for alleged sexual abuse on 04/01/25. The document showed, “ ...Report Date; 04/01/25 10:23 [10:23 AM]; Event Date 03/23/2025; [Patient 1] ...Category (s) associated with event or unsafe condition; Patient Security; Patient called grievance line yesterday (3/31/25). Pt [patient] states she was raped while in our ER [Emergency Room]. Pt [Patient] states she went to the ED [Emergency Department] on 3/23/25 to get an enema (a procedure that involves injecting fluid int the rectum to cleanse the colon or lower bowel) due to impaction ...she was raped (anal). Pt [Patient] stated that she screamed “stop” several times when the doctor began the exam, but he would not stop. States he pinned her down with his arm and continued to “jam his finger” into her anus (the opening of the rectum to the outside of the body) ...” During an interview on 05/28/25 at 11:15 AM, Patient 1 stated that during an emergency room visit on 03/23/25 a doctor performed a painful rectal exam without clear consent, despite asking him to stop. Patient 1 stated the risk manager at the hospital was informed of the incident and was told the case would be resolved in 30 days. Patient 1 stated that no mail had been received from the hospital regarding the outcome as of date of interview. During an interview on 05/29/25 at 10:58 AM, Staff H, Risk Manager, stated that policy does not specify a timeframe to report an allegation of sexual assault to the compliance officer. Staff H stated that the surgeon named in the grievance was not interviewed until May 20. Staff H stated that the case was initially handled as an “incident” instead of a grievance, and the patient was informed that a letter would be sent once the investigation was complete. Nearly 60 days passed without a formal letter being sent, including a 30-day extension letter that should have been sent earlier but was not. During an interview on 05/29/25 at 3:38 PM, Staff C, Chief Executive Officer (CEO), stated, “When we receive an allegation of abuse, we follow policy. Any allegation of rape should be taken seriously and handled as a priority.””

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 47234 Based on policy review, record review, document review, and interview, the Hospital failed to provide a patient with a grievance of its written notification of decision, steps taken, and results of the grievance process as required for 1 (Patient 1) of 2 patients reviewed. This deficient practice has the potential to place patients or representatives at risk for unresolved grievances and complaints and systemic issues that could lead to harm and other adverse outcomes. Findings Include: Review of hospital policy titled, “117-ADM [Administration] Complaints and Grievances - RM [Risk Management] - [Above Named Hospital],” dated 03/28/18, showed, “ ...Investigate and respond to patient and/or family/representative complaints and grievances, including but not limited to quality of care ...Patient Grievance - A grievance is defined as ANY of the following: ...A patient’s rights complaint by a patient or the patient’s representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS [Centers for Medicare and Medicaid Services] Hospital Conditions of Participation (CoP) ... Grievances about situations that endanger the patient such as abuse or neglect must be reviewed immediately ...The Patient Representative and/or designated person will send a letter of notification to the patient within 7 days of a received grievance ...The Facility Compliance Officer (FCO) will be responsible for addressing grievances involving potential corporate compliance violations or other regulatory violations ... All grievances will have a written response from the patient representative within thirty days of receipt of the grievance depending on the nature of the grievance. The final written response will include the following information: Name of hospital. Contact person. Steps taken on behalf of the patient to investigate the grievance ...” Review of hospital policy titled, “200-ADM [Administration] Patient Rights and Responsibilities,” dated 4/21/25, showed, “ ...Patient Has The Right ...Patients are free from physical or mental abuse, neglect or harassment ... Patient Grievance Process: ... All formal written or verbal patient grievances will receive a written response from [Above Named Hospital] within 30 days of receipt of grievance ...” Patient 1 Review of Patient 1’s medical record showed a 71-year-old was seen in the emergency department on 03/23/25 at 8:32 AM and admitted with a diagnosis of fecal impaction (hardened stool that stuck in the rectum or lower colon due to constipation) and evidence of proctitis (an inflammation of the rectum’s lining). Review of hospital document titled “Event Log” dated 01/01/25 to 05/27/25, showed that Patient 1 filed a grievance with the hospital for alleged sexual abuse on 04/01/24. The document showed, “ ...Report Date; 04/01/25 10:23 [10:23 AM]; Event Date 03/23/2025; [Patient 1] ...Category (s) associated with event or unsafe condition; Patient Security; Patient called grievance line yesterday (3/31/25). Pt [patient] states she was raped while in our ER [Emergency Room]. Pt [Patient] states she went to the ED [Emergency Department] on 3/23/25 to get an enema (a procedure that involves injecting fluid int the rectum to cleanse the colon or lower bowel) due to impaction ...she was raped (anal). Pt [Patient] stated that she screamed “stop” several times when the doctor began the exam, but he would not stop. States he pinned her down with his arm and continued to “jam his finger” into her anus (the opening of the rectum to the outside of the body) ...” During an interview on 05/28/25 at 11:15 AM, Patient 1 stated that during an emergency room visit on 03/23/25 a doctor performed a painful rectal exam without clear consent, despite asking him to stop. Patient 1 stated the risk manager at the hospital was informed of the incident and was told the case would be resolved in 30 days. Patient 1 stated that no mail had been received from the hospital regarding the outcome as of date of interview. During an interview on 05/29/25 at 10:58 AM Staff H, Risk Manager, stated that Patient 1’s allegation of sexual assault was initially handled as an incident, and the patient was informed that a letter would be sent once the investigation was complete. Staff H stated that nearly 60 days passed without a formal letter being sent, including a 30-day extension letter that should have been sent earlier but was not. Review of Patient 1’s medical record or hospital documents failed to show that Patient 1 was provided with a written response from the patient representative within thirty days of receipt of the grievance with name of hospital, contact person and steps taken on behalf of the patient to investigate the grievance in accordance with hospital policy.”

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 40633 Based on review of the Emergency Preparedness Plan (EPP), supporting documents, and an interview conducted on 01/03/2025, the Hospital failed to comply with the requirements for developing and implementing emergency preparedness policies and procedures as outlined in §482.15(b). Specifically, the facility did not establish clear safeguards for backup generators, including details on their capacity to provide sufficient power to critical areas during power outages. Additionally, there were no detailed policies specifying when, where, or how patient relocation or evacuation would occur if backup power systems failed or became overwhelmed. The facility ’ s emergency preparedness policies lacked any protocols regarding the necessary steps to notify authorities having jurisdiction (AHJ), including the State Surveying Agency and Licensing Agency, upon the activation of the emergency preparedness plan. The failure to notify these authorities in a timely manner in the event of an emergency could result in non-compliance with regulatory requirements and hinder the appropriate response and oversight from relevant agencies. The regulations require that healthcare facilities include specific procedures not only for backup power systems but also for communicating with regulatory authorities when emergencies arise. The absence of such policies presents a risk that the facility may not meet compliance requirements and may experience delays in the oversight and support necessary for effective emergency response. Findings Include: A review of the agency’s Emergency Preparedness Program (EPP), last reviewed in 2024, revealed the absence of policies or procedures detailing the safeguards for backup power systems, their operational capacity, and the critical areas of the facility that rely on power during emergencies. Additionally, there were no procedures addressing what should be done if backup power systems fail or are insufficient to meet the needs of the facility. Furthermore, the plan lacked any explicit protocols for when and how to notify authorities having jurisdiction (AHJ), such as the State Surveying Agency and Licensing Agency, upon the activation of the emergency preparedness plan. The following policies were supplied for review: Title: 200-EOC Continuity of Operations Plan - UKHSSFC Policy Number: 200 - EOC This policy outlines the hospital ’ s continuity of operations plan, addressing the protection of essential functions during and after a disaster. It focuses on maintaining operational capabilities despite emergencies and ensuring recovery in cases of prolonged disruption. Title: 138-EOC Loss of Normal Electrical Power - UKHSSFC Policy Number: 138 - EOC This policy describes the steps to take in the event of a loss of normal electrical power, including the activation of emergency backup generators and managing critical systems to ensure patient safety. Despite these detailed policies, both documents lacked the required sections for notifying the appropriate authorities, such as the State Surveying Agency and Licensing Agency, when the emergency preparedness plan is activated. Additionally, the policies did not contain clear guidelines or protocols for ensuring that essential functions, such as patient relocation or evacuation in case of power failure, would be carried out promptly. There were also no defined timeframes for initiating evacuations or relocations or for informing the authorities regarding the emergency. During an interview on 01/03/2025, between 3:00 PM and 8:00 PM, the Emergency Operations Manager confirmed that the emergency preparedness policies did not include instructions for notifying the appropriate regulatory agencies, such as the State Surveying Agency and Licensing Agency, when the emergency preparedness plan was activated. The Emergency Operations Manager also acknowledged the lack of documented procedures outlining who would be responsible for initiating patient evacuation or relocation if backup power systems failed. The Emergency Operations Manager confirmed that these key components were missing from the most recent review of the Emergency Preparedness Program and noted that no formal action had been taken to address these gaps in the facility’s preparedness plans. This lack of clear procedures for communication with authorities could result in delays in reporting critical incidents and affect the facility ’ s ability to comply with regulatory expectations in an emergency situation.”