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Based on interviews and record reviews, the facility failed to ensure that staff followed the facility patient complaint/grievance policy and procedure in a timely manner for one of one patients. (Patient #1).

This had the potential to affect any patient and/or patient's representative who filed a complaint/grievance.

Findings included:

Interview on 02/09/16 with the complainant/patient #1's mother revealed but was not limited to the following: " _____ was admitted to the facility on 01/21/16 and remains as an inpatient at the facility as of this date. The complainant stated she informed the facility nursing staff on 01/30/16 and again on 01/31/16 that her eight year old son smelled of urine. On 01/30/16, she asked her son if he urinated in his bed and he confirmed to her that he did. She asked him if he changed his clothes and he told her he did not change his clothes. She stated her son was completely potty trained and did not have toileting accidents. She informed the facility nursing staff of her concerns on both dates and was told by the nursing staff that was part of her son needing to get used to his medications. On 01/31/16, she asked to speak to a supervisor or someone she could file a complaint with and was told her message would be relayed and someone would call her. She stated she filed a complaint with the state on 02/04/16 because she had not received a return phone call from the facility regarding her concerns as of that date."

Interview on 02/09/16 at 11:00 AM with the Nurse Supervisor for the Child and Adolescent Unit revealed that she believed she was informed about the complainant's concerns last Wednesday (02/03/16) and she contacted her by phone and left a voice mail. She stated she spoke with the complainant on Friday (02/05/16) regarding her concerns. She confirmed that as of 02/09/16, she has not documented her interactions with the parent as a grievance/complaint.

Interview on 02/09/16 at 3:36 PM with the facility Patient Advocate revealed she was made aware of this complainant's concerns on 02/05/16 by the Nurse Supervisor for the Child and Adolescent Unit. She confirmed that she has been unable to speak with the complainant as of 02/09/16. She confirmed that she had not documented the complainant's concerns as a complaint/grievance as of this date.

Record review on 02/09/16 of the facility Patient Advocacy/Conflict & Grievance Resolution Policy and Procedure, last revised April 13, 2015, revealed but was not limited to the following: " it is the responsibility of each staff member to respond in a timely manner to any concern or complaint voiced by the patient and their families no matter how trivial the complaint may appear to be. For the purpose of this policy, a grievance is defined as a "patient grievance" when a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when complaint is not resolved at the time of the complaint by staff present). The staff member receiving the complaint should notify his/her supervisor when the issue cannot be immediately resolved. The staff member receiving a verbal or written complaint will attempt to solve the concern immediately. If not, they will then contact the Supervisor/Charge Nurse, etc. This process should take no more than 24 hours to resolve the complaint. If the concern cannot be resolved at this level, the Patient Advocate will facilitate the investigation and resolution of the grievance through a complete investigation by the appropriate department head."

Based on interviews and record reviews, the facility failed to ensure the nursing progress notes contained information for revisions in the treatment plan for one of one patients (Patient #1) when Patient #1 began experiencing bedwetting/toileting accidents.

This presented a risk that the treatment plan may not accurately reflect the patient's need for treatment

Findings. included:

Interview on 02/09/16 with the complainant/patient #1's mother revealed but was not limited to the following: " _____ was admitted to the facility on 01/21/16 and remains as an inpatient at the facility as of this date. The complainant stated she informed the facility nursing staff on 01/30/16 and again on 01/31/16 that her eight year old son smelled of urine. On 01/30/16, she asked her son if he urinated in his bed and he confirmed to her that he did. She asked him if he changed his clothes and he told her he did not change his clothes. She stated her son was completely potty trained and did not have toileting accidents. She informed the facility nursing staff of her concerns on both dates and was told by the nursing staff that was part of her son's body needing to get used to his medications."

Interview on 02/09/16 at 11:32 AM with Registered Nurse #2 who served as charge nurse on the Patient #1's Unit revealed but was not limited to the following: " one morning or so, he (Patient #1) was wet when he got up in the morning. He would tell staff and they would assist him with bathing and changing clothes."

Interview on 02/09/16 with Mental Health Technician (MHT) #1 who provided care to Patient #1 revealed but was not limited to the following: " _____ (Patient #1) comes and tells me when he wet the bed. I helped him strip his bed and then he takes a shower independently. This happened at least twice a week during the first week of his admission."

Interview on 02/09/16 at 11:58 AM with Patient #1's facility Psychiatrist revealed but was not limited to the following: " We have had difficulty stabilizing ______ (Patient #1). He had an acute medication shortly after his admission." He confirmed that Patient #1 began experiencing toileting accidents shortly after admission and that information should have been documented by the nursing staff. He stated that bedwetting and urinary leaking during the day are side effects of one of his medications. He stated that if nursing staff had informed Patient #1's mother that his bedwetting/toileting accidents were "part of his body needing to get used to his medications", that was a "poor response and not acceptable."

Record review on 02/09/16 of Patient #1's nursing documentation revealed that he was documented as independent in toileting throughout his admission. There was no nursing documentation regarding his bedwetting/toileting accidents.

Record review on 02/09/16 of Patient #1's Master Treatment Plan, opened on 01/21/16 and reviewed on 01/28/16 revealed the following problems: aggressive/assaultive behavior and sexualized behavior. Patient #1's Master Treatment Plan was not updated to reflect Patient #1's bedwetting/toileting accidents.

Record review of Treatment Planning Policy and Procedure, last reviewed January 2015, revealed but was not limited to the following: " Master Treatment Plan in Acute/Partial Hospitalization Program will be updated at least every 7 days in the treatment team meeting. The Master Treatment Plan will include the long and short term goals the patient must achieve to attain, maintain, and or re-establish emotional and/or physical health as well as maximize growth and development."