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Based on review of the hospital policy and grievance log, the hospital staff failed to identify and follow the grievance policy for 1 of 2 reviewed grievance (Patient #2).

The findings included:

Hospital Patient Complaint and Grievance Management Policy dated 11/02/2023 revealed "PURPOSE This policy sets forth the procedure for appropriately identifying and promptly resolving patient and/or patient representative complaints and grievances and requires each patient and/or patient representative be informed about how to file a grievance ...GRIEVANCES Complaints meeting any of the following criteria are considered a grievance and require a written response ...2. Complaints regarding patient's care or with the allegation of abuse, neglect, patient harm or failure of the hospital to comply with one or more CoPs, or other CMS requirements ..."

Review on 11/05/2025 of the Grievance Log for the past 6 months failed to reveal documentation of Patient #2 for the 08/18/2025 through 08/29/2025 admission included on the log.

Closed medical record review on 11/04/2025 revealed Patient #2 was a 17-year-old-female who presented as an Involuntary Commitment (legal obligation for hospital admission process) to the hospital on 08/18/2025 for Suicidal Ideation (feelings of harm to self). Review revealed 3 of 11 days with documentation to note on 08/20/2025 at 1209 hygiene "Independent", on 08/21/2025 at 0745 "face washed, brushed teeth", on 08/26/2025 at 1127 the Registered Nurse (RN) noted "Pt presents calm and cooperative ...bathroom door locked." on 08/28/2025 at 0815 "face washed". ... On 08/28/2025 at 2105 the RN noted " ...Patient was irritable ...Patient was asked to sit in hallway so that her roommate could shower and patient refused .... Writer told patient that she should give her roommate the same privacy that she is given to complete hygiene time. SW (Social Worker) came to speak with patient, and she was able to get out of room for roommate to shower ..." Record review revealed the nursing staff were monitoring Patient #2 for signs and symptoms of purging associated with medication noncompliance in the setting of the Behavioral Health Unit (BHU). Record review revealed on 08/29/2025 at 1635 Patient #2 was discharged to the prior living (Named) Group home with a staff member with a documented 09/02/2025 scheduled follow up appointment.

Interview on 11/05/2025 at 0845 with the Hospital Leadership: Assistant Vice President (AVP), Director of Nursing, Director of Inpatient Therapy, Administrative Supervisor, Accreditation Coordinator, Quality, Nurse Manager revealed the reviewed video of the hallway on the BHU was only accessible for 15 days unless the facility staff saved a specific incident. As per AVP, the leadership was notified of the allegation of sexual inappropriate touch by a Health Care Technician toward a patient during a shower. If an event was found to be substantiated the video would have been saved by the facility. The hospital was notified on 09/04/2025 at 1000 by way of a County Detective appearance to the facility. The hospital completed the investigation on 09/10/2025 with the conclusion of unsubstantiated allegation. On 09/15/2025 the hospital was notified by the Health Care Registry that they would not investigate. The hospital system automatically taped over the timed video as per usual process. Interview with the Hospital Leadership found the allegation of a Patient Care Technician having inappropriate sexual contact with Patient #2 to be unsubstantiated. Interview revealed that the Hospital Leadership had investigated the allegation, however did not process the reported incident as a Grievance as per policy.

Interview on 11/05/2025 at approximately 0850 with the RN Administrative Supervisor revealed the BHU adolescents were provided hygiene time at 0800 at time of wake up, on Saturday/Sunday shower time was 1600 and Monday through Friday 1430 was shower time. Interview revealed a Patient Care Technician would remain on the hallway outside of patient rooms to monitor for patient safety during shower time.

Interview on 11/05/2025 at 1655 with the Central Division Grievance Coordinator revealed a work history in the role for 8 years at the facility. Interview revealed that the notification of the alleged abuse of Patient #2 should have been processed as a formal grievance as per policy. Interview revealed the hospital staff did not process and follow the policy as expected.
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