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Based on a review of medical records, facility documentation and interview with facility staff (EMP), it was determined that the facility failed to provide timely referral of patient concerns, failed to complete portions of the grievance form accurately, and failed to accurately log grievance into the Grievance log for two of two medical record reviewed (MR1 and MR16).

Findings include:

Review on May 4, 2018, of facility policy, Patient and Family Grievances /The Role of the Patient Advocate, dated 4/15, revealed, "... Procedure: ... 5.3 Patient/Family Grievance Forms are made available to patients to encourage their report of concerns while a patient in this facility. The staff member receiving a verbal grievance must instruct the patient to fill out the Patient/Family Grievance Form or assist the patient in completing the form. The form will be immediately given to the Patient Advocate (Monday through Friday), the House Supervisor (evenings, nights and weekends or the Administrator on Duty ... 5.5 The grievance will be logged into the Grievance log by the Patient Advocate or designee. 5.6 Time Frame: The staff person responding to the grievance should speak with the patient or patient's representative within 24 hours of the receipt of the complaint to clarify the issue and inform the patient of the time frame for investigation and written response ... . "

Review of MR16's grievance form, "Patient/Family Grievance,"dated February 10, 2018 revealed portions of the form indicating, date and time received, received by, and forwarded to were not completed by staff as required.

Review of facility's Grievance Log revealed no documented evidence that grievance forms related to MR16 dated February 10, 2018 and March 17, 2018 were logged into the Grievance log.

Review of MR1's "Social Service Progress Note," dated 1/16/18, revealed " ... FM (foster mother) expressed concern that pt (patient) wasn't wearing underwear and said she was brushing her teeth with her finger. SW (social worker) confirmed staff does support all pts with ADL's (activities for daily living) and will follow-up with treatment team."

Review of the facility's "Grievance Log" dated January 2018-April 2018, revealed no documented evidence that the quality care concerns FM expressed on 1/16/18 to SW were logged by staff, as required by policy.

Interview with EMP5 on May 4, 2018 between 11:12 AM and 11:22 AM confirmed never receiving any quality care concerns about patient related to MR1.

Interview conducted on May 4, 2018 at approximately 12:00 PM with EMP1 confirmed above grievances related to MR16 were not forwarded to Patient Advocate, were not logged into Grievance Log and there was no documented evidence of staff response to address complaint within the 24 hour time frame. Further confirmed, the staff portion for MR1's grievance form dated February 10, 2018 was not completed as required by staff. EMP1 confirmed never receiving grievance or concerns about patient related to MR1.

Based on review of facility policy and procedures, review of facility documents, review of medical records and interview with staff (EMP), it was determined the facility failed to follow their policy for Medication Errors in four of four medical records reviewed (MR11, MR14, MR15, MR16).

Findings include:

Review on May 4, 2018, of facility policy "Medication Errors," reviewed December 2015 revealed, "Policy ... It is the policy of Fairmount Behavioral Health system to ensure that medication errors are documented and reported with follow-up action taken to protect the patient. Procedure: ... 2.0 The attending physician is notified of the occurrence. 3.0 Documentation in the medical record shall include the following: 3.1 error made; 3.2 any adverse reaction 3.2 date and time of notification of physician and physician response; ... 3.4 nursing follow-up and 3.5 patient response. 4.0 A Medication Variance Report Form is completed including an occurrence report ... ".

Review on May 4, 2018, of MR11 revealed a medication error occurred on November 17, 2017. Further review of MR11 revealed no evidence of the facility's documentation requirements for the medication error or of a completed "Medication Variance Report."

Review on May 4, 2018, of MR14 revealed a medication error occurred on March 7, 2018. Further review of MR14 revealed no evidence of the facility's documentation requirements for the medication error.

Review on May 4, 2018, of MR15 revealed a medication error occurred on January 14, 2018. Further review of MR15 revealed no evidence of the facility's documentation requirements for the medication error or of a completed "Medication Variance Report."

Review on May 4, 2018, of MR16 revealed a medication error occurred on February 11, 2018. Further review of MR16 revealed no evidence of the facility's documentation requirements for the medication error. Review of facility document "Medication Variance Report" for MR16 revealed the document was not completed for the sections "Possible contributing factor(s)" and "Tools used to decrease frequency of variance."

Interview with EMP2 on May 4, 2018, between 10:50 AM and 11:30 AM confirmed the above findings in MR11, MR14, MR15 and MR16.

Based on review of facility policy, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure Activities for Daily Living (ADLs) information pertaining to the patient's hygienic care was consistently documented in the medical record for one of one medical record reviewed (MR1).


Findings include:


Review on May 4, 2018, of facility policy, "Nursing Standards of Care," dated 1/16, revealed, " ... It is the policy that all patients admitted to ... will have their nursing care delivered in accordance with established standards of care and practice. It is also policy that these standards be written, objective and used in the measurement of quality of care. Procedure: ... 4.C. Activities of Daily Living: Standard of Care: The patient can expect direction, assistance and supervision of their activities of daily living in supporting and promoting patient independent function in this area. Standard of Nursing Practice: The nurse uses the activities of daily living in a good directed way to foster adequate self care and physical and mental well being of clients. Rationale: Nurses are the primary health care providers who interact with the patient on a daily basis regarding activities of daily . ... The Nurse will: ... 4.C.2 Encourage the patient to collaborate in the development of a self-care plan to reach the highest level of self-care possible. ... Outcome criteria: By the end of the acute phase the patient will be able to: ... 4.C.1.B Maintain hygiene with minimal assistance ...."


Review on May 4, 2018, of facility document, "Continuing Care/Discharge Planning," revealed the admission date as: 1/11/18, and the discharge date as 3/23/18.


Review on May 4, 2018, of MR1's, "Comprehensive Assessment Tool Nursing Assessment," dated January 12, 2018, revealed, " ... IV. Functional Screening: A. Self-care: Hygiene: ... Needs assistance with: bathing, dressing, laundry, oral hygiene ... ."


Review of MR1, "Nurse Progress Note," dated January 12, 2018 through March 23, 2018, revealed no documented evidence of hygienic care and education being provided, as per policy, with the exception of the following dates: January 29, 2018, February 13, 2018, and March 18, 2018. Further revealed, no documented evidence ADLs were completed except for the following dates: January 12, 2018, January 29, 2018, January 30, 2018, February 13, 2018, and March 18, 2018.


Interview on May 4, 2018 between 10:57 AM and 11:08 AM with EMP confirmed patient related to MR1 required assistance with ADLs. Further confirmed staff is required to document on ADLs daily.