Clearsky Rehabilitation Hospital of Elwood St Jos

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47233 Based on policy review, record review, and interview, the Hospital failed to ensure it met the requirements for Patient Rights Condition of Participation when the hospital failed to protect and promote each patient’s rights and failed to provide care in a safe setting. Findings Include: 1. The hospital failed to follow its grievance process policy, failed to classify an allegation of abuse as a grievance, and failed to provide the patient and or patient representative with a letter of decision in a timely manner. (Refer to Tag A0118) 2. The hospital failed to ensure the patients’ right to receive care in a safe setting as required for 2 of 4 sampled patients (Patient 2, and 4). (Refer to Tag A0144) 3. The hospital failed to ensure that 1 of 4 sampled patients were free from all forms of abuse and harassment. (Refer to Tag A0145)”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 47233 Based on policy review, document review, and interview, the Hospital failed to ensure that an allegation of sexual assault was classified as a grievance and responded to within seven (7) days of receipt. The hospital failed to follow its grievance resolution policy for notification and timely resolution as required for 1 of 4 sampled patients (Patient 1). This deficient practice places any patient at risk for not having an allegation of abuse or neglect thoroughly investigated and resolved. Findings Include: Review of a policy titled, “Complaints and Grievances,” dated 07/2024 showed, “ ...It is the policy of the [Hospital] to encourage inpatients, family members, and other visitors to share their concerns and complaints... Grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient ...that is not resolved promptly by staff present or that requires further investigation ...A grievance is also any complaint verbal or written regarding abuse or neglect of a patient ...A written response to the formal grievance will be provided to the patient on average within 7 days of receipt ...The response will include the completion date of the investigation ...If the grievance is not resolved within 7 days, then a letter will be sent out addressing the investigation is ongoing and will be resolved within 30 days ...” Review of a hospital policy titled, “Reporting Abuse and Neglect,” dated 07/2024 showed, “It is the policy of the Rehab Hospital that all employees are knowledgeable of the state requirement to identify and report suspected incidences of abuse, neglect, and exploitation ... When a report is made the Rehab Hospital will investigate and report the actions taken and conclusions reached within five days of the discovery of the incident. The findings will be provided to the Quality Council for review and action ...” Patient 1 Review of Patient 1’s medical record showed a 43-year-old admitted on 09/13/24 at 1:55 PM with a chief complaint of cerebral infarction (an occurrence when blood flow to the brain is blocked, causing brain tissue to die) due to unspecified occlusion (blockage) or stenosis (narrowing) of the left middle cerebral artery. Past medical history included hypertension (elevated blood pressure), previous cerebrovascular accidents (CVAs) with residual left hemiplegia (paralysis or weakness on one side of the body), methamphetamine abuse, and medical noncompliance. The medical record showed Patient 1 had difficulty speaking but was able to express needs by written communication. Review of a document titled, “Facility Report” dated 10/08/24 showed that Patient 1 made a complaint of alleged sexual abuse by an agency staff member on 09/24/24 and 09/25/24. The report showed, “ ...Date of Incident (on or about): 9/24/2024 9/25/2024 ... Patient, [Patient 1], communicates via written communication. [Patient 1] wrote on white board that a tall, light skinned, bald male with glasses came in to her hospital room and was removing her brief and stuck his finger in her vagina. [Patient 1] informs staff member that this occurred on 2 separate [sic] nights and 2 incidents within each of those nights. A calendar was given to the patient to point to which dates it occurred. Patient points to the night of 9/24/24 and the night of 9/25/24. Patient writes that staff member had on maroon scrubs. Patient writes that staff member was not a [Hospital] employee, rather was an agency staff member. Patient claims there were no other witnesses. Patient wrote that staff member said “I will be back” ...” Review of a document titled, “Event Log” showed that on 09/24/2024 a “Safety Event” occurred to Patient 1 showing, “ ...KS Level of Event Possible grounds for disciplinary action by the appropriate licensing agency ...” The log failed to show the date the safety event was entered onto the log. Review of a document titled, “2024 Grievance Log” showed that Patient 1’s grievance of alleged sexual assault was not documented as received until 11/20/24 (57 days after patient reported event). The log showed, “Date Grievance Received ...11/20/2024 ...Patient Name ...[Patient 1] ... Grievance Summary ...Patient had complaint of sexual allegations against an agency staff male ... Date Final Letter sent ...11/20/2024 ...” Review of a grievance resolution letter to Patient 1, dated 11/20/24 showed, “ ...Upon reporting this event in September an investigation was initiated which was completed on September 30, 2024. We investigated the staff that were on site the nights that you identified and determined that the person matching your description was an agency staff. We reported your concerns to the agency that employees him and have requested that he not return to our facility. We have also filed a police report and continue to cooperate fully with their investigation. I want to apologize that we did not respond in writing to you after the investigation concluded with the results ...” During an interview on 12/17/24 at 9:06 AM, Staff H, Registered Nurse (RN) stated that Staff L, Certified Nurse Aide (CNA) [alleged perpetrator] had worked a total of 5 shifts at the hospital including 9/16/24; 9/18/24/; 9/24/24; 9/25/24 and 9/26/24. Staff H, RN, stated that during the event investigation the hospital did not interview additional patients to inquire if they had interactions with Staff L, CNA. Staff H stated, “ ...this event was not reported to [state licensing agency] ...” During an interview on 12/17/24 at 11:32 AM, Staff D, Nurse Practitioner (NP) stated, “with suspected abuse we have to notify the police and then get their recommendations.” Staff D went on to state, “ ...I spoke to [Patient 1] a little bit, it is kind of difficult to communicate with her ...we followed protocol and contacted the police. They suggested since it had been so long since the incident a SANE [Sexual assault Nurse Exam] was not recommended ...” Staff D stated that he spoke to the patient the next day after reporting with another physician, emotional support was offered, but no exam completed. During an interview on 12/17/24 at 2:07 PM Staff G, RN stated, “ ...we put the wrong date on the grievance letter it should have been October 7th ...once we got the subpoena in November, we decided to make this a grievance ...we stopped investigating once law enforcement showed up and took it from there ...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47233 Based on policy review, document review, record review, surveillance video review, and interview, the Hospital failed to ensure nursing staff followed the Fall Risk policy and procedures and failed to follow fall prevention guidelines for high fall risk patients as stated in their policy for 2 of 4 Patients (Patients 2 and 4). Findings Include: Review of a policy titled, “Fall Prevention,” dated 04/2024, showed, “Purpose: To provide guidelines and processes that identify patients who are at risk for falls, maintain the personal safety of all patients at risk, provide a systematic method of screening, planning, treating, and communicating the fall risk to all appropriate staff ...The Morse Fall Scale will be utilized to determine if there are existing (intrinsic/psychological) factors that may affect the patient’s fall risk. All patients are screened for fall risk to determine a risk score and then proceed to implement the appropriate interventions, based on the patient’s level of risk. All patients are formally screened for fall risk ...at the time of admission ...Re-screen for fall risk: ... every shift and as needed with a significant change in physical or mental status ... After an actual fall ... 4. Assign a risk category based on the patient score from Morse Fall Scale Scoring tool: o Less than 15 = Minimal Risk o 15 to 45 = Fall Risk Level I (Moderate) o Greater than 45 = Fall Risk Level II (High) ... 7. Included in training only Post Fall Management: o Assess for injuries (i.e., abrasion, contusion, laceration, fracture, head injury). Obtain and record vital signs (including supine, sit, and stand). Assess for change in range of motion. Notify parties regarding fall incident: ...Attending physician (provide nursing assessment and obtain additional medical directions or orders) ...All patient care team members (alert and continue to monitor for injuries/change in condition post fall) ...Clinical manager/supervisor or designee on-duty. Record circumstances of fall in medical record. Initiate pharmacy medication review. Obtain orders. Consider additional High-Risk interventions. Medical record documentation should include a description of the event that occurred and actions taken...” Patient 2 Review of Patient 2’s medical record showed a 52-year-old admitted on 06/25/24 at 3:21 PM, with a diagnosis of cerebral infarction (an occurrence when blood flow to the brain is blocked, causing brain tissue to die) due to unspecified occlusion (blockage) or stenosis (narrowing) of the left middle cerebral artery. Past medical history included hypertension (elevated blood pressure) and hyperlipidemia (high levels of lipids (fats) in the blood). Review of the hospitals “Event Log” showed that Patient 2 had an unwitnessed fall that occurred on 06/26/24. Review of Patient 2’s medical record and document titled, “Falls Information,” showed that the patient was a high risk for falls on 06/25/24 (prior to the date of incident) with a Morse Fall Risk score of 40. Review of a document titled, “Progress Notes” dated 06/26/2024 at 9:50 AM showed, “I was at the nurses station when I heard the door slam to patient room. I went to assess the situation with one of the PCT [Patient Care Technician]. Patient came out of bathroom on his own and reports he was light headed and fell. Patient was sitting on the floor behind the door when I walked in...” Review of the medical record failed to show Patient 2 was assessed for injuries, assessed for change in range of motion, that all patient care team members were notified, that clinical manager was notified, that a pharmacy medication review was initiated, nor additional high-risk fall interventions implemented per policy after Patient 2 fell. Review of Patient 2’s Morse Fall Risk assessments showed that hospital nursing staff failed to input that the patient had a history of falls when conducting the fall risk assessment on 07/07/24 and 07/08/24. This failure resulted in an inaccurate fall risk as “moderate” instead of “high”. Review of the medical record failed to show a properly documented Morse Fall Risk Score with High Fall Risk Interventions implemented after Patient 2 had fallen on 06/26/24. Last documented Morse Fall Risk assessment for Patient 2 was conducted on 07/08/24 at 8:00 AM. Patient 2 discharged on 07/09/2024 at 8:58 AM. Patient 4 Review of Patient 4’s medical record showed a 91-year-old admitted on 09/10/24 at 4:40 PM with a diagnosis of impaired mobility secondary to orthostatic hypotension (a drop in blood pressure when changing positions), falls, and cognitive impairment. Past medical history included hypertension (elevated blood pressure) and gastroesophageal reflux disease (acid reflux of the esophagus). Patient 4 discharged on 09/20/2024 at 11:58 AM. Review of the hospitals “Event Log” showed that Patient 4 had an unwitnessed fall that occurred on 09/13/24. Review of a “Progress Note” dated 09/13/24 at 7:53 PM showed that Patient 4 was found laying on the floor by a patient care technician after a fall alarm sounded. Patient 4 had reported that she hit the back of her head on the floor and complained of left shoulder pain. The physician was informed that Patient 4 was on heparin (blood thinner medication) and orders for neurological checks were given. Review of a document titled, “Orders” dated 09/14/24 at 6:08 AM showed, “Order: Neurological Checks ...Order Details: 9/14/24 6:08:00 AM, q4hr [every 4 hours], Stop date 9/15/24 8:00:00 AM, post fall ...” Review of the medical record failed to show neurological checks were completed as ordered on 09/13/24 at 7:53 PM. Review of the medical record failed to show neurological checks were completed as ordered on 09/14/24 at 6:08 AM. During an interview on 12/18/24 at 8:59 AM Staff A, RN stated, “ ...we assess the patient and call the provider and get orders we do not automatically start neuro checks on unwitnessed falls ...” During an interview on 12/19/24 at 9:28 AM Staff A, RN stated, “ ...For the first 24 hours all patients are high fall risk, until therapy evaluates the patient ...””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47233 Based on interview, record review, document review, and policy review, the Hospital failed to ensure that patients were free from abuse, mistreatment, neglect, and exploitation when they failed to ensure thorough investigations of all allegations of abuse and failed to show evidence that patients were protected during their investigation for 1 of 4 patients (Patient 1). Findings Include: Review of a document titled, “Patient Rights and Responsibilities” dated 11/2020 showed, “ ...The rights of every patient, or his or her designated representative ...include, but are not limited to: ... 27. the right to be free from all forms of abuse and harassment; including the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation ...29. the right to receive care in a safe setting ...” Patient 1 Review of Patient 1’s medical record showed a 43-year-old admitted on 09/13/24 at 1:55 PM with a chief complaint of cerebral infarction (an occurrence when blood flow to the brain is blocked, causing brain tissue to die) due to unspecified occlusion (blockage) or stenosis (narrowing) of the left middle cerebral artery. Past medical history included hypertension (elevated blood pressure), previous cerebrovascular accidents (CVAs) with residual left hemiplegia (paralysis or weakness on one side of the body), methamphetamine abuse, and medical noncompliance. The medical record showed Patient 1 had difficulty speaking but was able to express needs by written communication. Review of a document titled, “Facility Report,” dated 10/08/24, showed that Patient 1 made a complaint of alleged sexual abuse from an agency staff member on 09/24/24 and 09/25/24. The report showed, “ ...Date of Incident (on or about): 9/24/2024 9/25/2024 ... Patient, [Patient 1], communicates via written communication. [Patient 1] wrote on white board that a tall, light skinned, bald male with glasses came in to her hospital room and was removing her brief and stuck his finger in her vagina. [Patient 1] informs staff member that this occurred on 2 separate [sic] nights and 2 incidents within each of those nights. A calendar was given to the patient to point to which dates it occurred. Patient points to the night of 9/24/24 and the night of 9/25/24. Patient writes that staff member had on maroon scrubs. Patient writes that staff member was not a [Hospital] employee, rather was an agency staff member. Patient claims there were no other witnesses. Patient wrote that staff member said “I will be back” ...” Review of a document titled, “Event Log,” showed that on 09/24/2024 a “Safety Event” occurred to Patient 1 showing “ ...KS Level of Event Possible grounds for disciplinary action by the appropriate licensing agency ...” Review of a document titled, “2024 Grievance Log” showed that Patient 1’s grievance of alleged sexual assault was not documented as received until 11/20/24 (57 days after patient reported event). The log showed, “Date Grievance Received ...11/20/2024 ...Patient Name ...[Patient 1] ... Grievance Summary ...Patient had complaint of sexual allegations against an agency staff male. Appropriate licensing agency and local law enforcement contacted for further investigation ...Actions taken to resolve ...DPO [Director Patient Outcomes] and DTO [Director Therapy Operations] visited with patient and investigated sexual allegations. Provider Notified. Law Enforcement notified. [Employer] notified and staff member placed on Do Not Return List/Supsended [sic] ... Date Final Letter sent ... 11/20/2024 ...” The safety event was not reported to the state licensing agency as stated in the document. Review of a grievance resolution letter to Patient 1, dated 11/20/24 showed, “ ...Upon reporting this event in September an investigation was initiated which was completed on September 30, 2024. We investigated the staff that were on site the nights that you identified and determined that the person matching your description was an agency staff. We reported your concerns to the agency that employees him and have requested that he not return to our facility. We have also filed a police report and continue to cooperate fully with their investigation. I want to apologize that we did not respond in writing to you after the investigation concluded with the results ...” During an interview on 12/17/24 at 9:06 AM, Staff H, Registered Nurse (RN) stated that Staff L, Certified Nurse Aide (CNA) [alleged perpetrator] had worked a total of 5 shifts at the hospital including 9/16/24; 9/18/24/; 9/24/24; 9/25/24 and 9/26/24. Staff H, RN, stated that during the event investigation the hospital did not interview additional patients to inquire if they had interactions with Staff L, CNA. Staff H stated, “ ...this event was not reported to [state licensing agency] ...” During an interview on 12/17/24 at 11:32 AM, Staff D, Nurse Practitioner (NP) stated, “with suspected abuse we have to notify the police and then get their recommendations.” Staff D went on to state, “ ...I spoke to [Patient 1] a little bit, it is kind of difficult to communicate with her ...we followed protocol and contacted the police. They suggested since it had been so long since the incident a SANE [Sexual assault Nurse Exam] was not recommended ...” Staff D stated that he spoke to the patient the next day after reporting with another physician, emotional support was offered, but no exam completed. During an interview on 12/17/24 at 2:07 PM Staff G, RN stated, “ ...we put the wrong date on the grievance letter it should have been October 7th ...once we got the subpoena in November, we decided to make this a grievance ...we stopped investigating once law enforcement showed up and took it from there ...””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47234 Based on policy review, record review, and interview, the Hospital failed to ensure it informed each patient, or when appropriate, the patient’s representative of the patient’s rights, in advance of furnishing or discontinuing patient care for 1 of 3 sampled patients (Patient 1) This deficient practice places any patient at risk of not understanding their individual rights as required per regulation requirements 42 CFR §482.13(a)(1). Findings Include: Review of Hospital Policy titled “Provision of Patient Rights” no date showed “Policy: All staff members will observe the rights of each patient. All patients will be informed of their rights and responsibilities as part of their orientation to the rehabilitation program. Procedure: 1. The rehabilitation nurse or social worker/case manager will review the Patient’s Rights and Responsibilities document with the patient or family member at the time of admission. The staff member reviewing the rights of the patient will document in the medical record that the rights were reviewed and with whom. 2. The patient/family member will be given a copy of the Patient Rights and Responsibilities.” Patient 1 Review of Patient 1’s medical record showed a 82-year-old female admitted on 01/05/24 at 9:38 PM with a diagnosis of severe sepsis (infection that causes organ damage) secondary to Klebsiella (bacteria) pneumonia, Urinary Tract Infection (UTI), acute renal failure (when kidneys suddenly can’t filter waste from the blood) requiring dialysis (treatment for people who kidneys are failing) in the setting of chronic kidney disease related to absence of kidney. Patient 1 had a past medical history uncontrolled diabetes mellitus with hyperglycemia (too much sugar in the blood). Review of Patient 1’s medical record failed to show a signed Patient Rights. During an interview on 02/08/24 at 9:22 AM Staff A, Director of Nursing (DON) stated, “Patient Rights are done the next business day. Patient 1 did not get patient rights since she came in on a Friday and left on a Sunday.” During an interview on 02/08/24 at 1:25 PM Staff B, Director of Marketing and Business Development stated, “When the patient arrives to the hospital, they sign consent to treat by the nursing department. Admissions has them sign Patient Rights, sometimes it’s the same day but most of the time it’s the next day. If patient arrives over the weekend, it’s the next business day.””