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Based on policy review, document reviews, and staff interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to ensure patient rights were protected based on the lack of a prompt resolution of patient grievances; not informing patients in writing of the results of grievance investigations; not ensuring a safe environment; and not following its policy on abuse prevention. These failures had the potential to affect the resolution of patient concerns and patient safety for the current 24 inpatients on the Adult Treatment Center (ATC) East Unit and any future patient admitted to the unit.

Findings Include:

1. The hospital failed to implement its grievance process by failing to investigate grievances and document the investigation for 13 of 26 grievances listed on the grievance log from 04/01/21 to 10/04/21. (See findings in A0118).

2. The hospital failed to ensure the patient was provided written notice of the hospital's decision for three patients (Patients 4, 6, and 10) of three grievances reviewed for documentation of a resolution letter. (See findings in A0123).

3. The hospital failed to ensure patients received care in a safe setting by having three trees in the outdoor area used by patients that provided a risk for patient and/or staff injury. (See findings in A0144).

4. The hospital failed to ensure the hospital's policy on abuse and neglect was implemented following an allegation of rape. (See findings in A0145).

Based on policy review, document review, and interviews, the hospital failed to implement its grievance process by failing to document the investigation for 13 of 26 grievances involving six patients (Patients 4, 6, 10, 11, 12, and 13) listed on the grievance log from 04/01/21 to 10/04/21. This failure had the potential to affect the resolution of patient concerns for the current 24 inpatients on the Adult Treatment Center (ATC) East Unit and any future patient admitted to the unit.

Findings Include:

Review of the policy titled, "Patient Grievance - Suggestion Process," dated 02/27/20, indicated a grievance was defined as a "written concern or objection from an inpatient or his/her representative expressing dissatisfaction with patient care, quality, delivery of care, or any problem with patient related services; B. A verbal or written concern or objection from a discharged patient or his/her representative; . . . D. The concern or objection cannot be effectively followed up to resolution by "staff present" within twenty-four hours and while the patient is still at LSH; E. A verbal concern which is placed in writing immediately by the patient or the staff receiving the information and acting at the patient's request becomes a formal complaint; F. Follow-up or investigation will require more than one day and may require, under usual circumstances, up to fourteen days (unusual circumstances may require longer investigation and/or resolution); G. A written response is required; H. A written notice of "action in progress" is required within seven days of the LSH program's receipt of the grievance, which must advise the patient or representative of the following: 1. The steps being taken to investigate the complaint, 2. The approximate date of completion of the process, and 3. The name (or title) and telephone number of the LSH Customer Services Specialist. I. A final written response is required when the investigation is completed and/or a decision is made. . ." There was no documentation of the requirements to be included in the final resolution letter. The policy did not allow for a grievance to submitted verbally by an inpatient.

1. Review of a grievance submitted by Patient 4 on 09/20/21 indicated Patient 4 "would like to address the nature of my concern about leaving this place and taking a ride back home to my dad who is my guardian. Please understand I need to address some things about here and when I leave where I will stay. . ." The grievance was received by Patients' Rights Officer (PRO) who referred it to a Psychologist. The "Staff action" documented by Registered Nurse (RN) 2 on 09/24/21 indicated RN 2 discussed with Patient 4 the following, "When you are ready to discharge we will work on getting your belongings from your home in [name of city] with your dads [sic] help. When you will be discharged will be up to doctor and the treatment team. If you have questions about your discharge and where we are put in a request to [name of Licensed Bachelor Social Worker (LBSW)] instead of a grievance." There was no documentation of what the other "things about here" were that was stated in Patient 4's grievance. There was no documentation of an investigation that included documentation by LBSW regarding Patient 4's concerns about discharge.

During an interview on 10/05/21 at 1:10 PM, the PRO stated he/she did not speak with Patient 4 regarding his grievance. The PRO stated the grievances "go right in the box [on the unit] and I pick them up out the box." The PRO stated when the response was received "in the box" yesterday he/she reviewed the documentation and considered the grievance was closed.

During an interview on 10/05/21 at 1:25 PM, the Psychologist stated Patient 4 is a "delusional patient" and has sent in multiple grievances about the same issues. The Psychologist stated Patient 4 was concerned about getting his/her property from his fathers' home when discharged from the hospital. The Psychologist stated there was a previous grievance and that he/she had met with Patient 4 and the unit leader RN 2. The Psychologist stated he/she asked RN 2 to meet with Patient 4 about this issue, since it was the same issue, and RN 2 agreed. Psychologist stated there is a place to put that he/she reassigned the grievance to RN 2, but Psychologist didn't think about documenting that. Psychologist confirmed the grievance had no documentation of the previous investigation/discussions that were conducted.

2. Review of a grievance presented by Patient 10 on 04/20/21 indicated, "Medication staff wanting to argue with me. Telling me what time did I tell you? Instead of just telling me. I was asking her about breakfast. I told her I always had a schedule." Review of the section "What would you like to have done about this?" indicated Patient 10 documented, "Have Med staff talked to. Have them have more patience with people, clients, residents. In the meantime I will make a schedule about the times." Review of RN 2's action indicated the grievance was discussed with the patient and involved staff. There was no documentation of the discussion conducted with the medication nurse and/or a written statement by the medication nurse.

During an interview on 10/05/21 at 1:58 PM, the PRO confirmed there was no documentation of the discussion that was conducted by RN 2 with the medication nurse.

3. Review of a grievance submitted by Patient 6 on 06/19/21 indicated, "[Mental Health Developmental Disability Technician (MHDD)] 4 called me names, threatened, and insulted me." The grievance was dated as received by the PRO on 08/19/21 (two months after it was submitted) and referred the grievance to Risk Management on 08/25/21. Review of a document titled, "Referral Staff action/response" completed by the Assistant Risk Manager (ARM) on 08/25/21 showed, "thank you for reporting this incident. Risk Management will have this investigated." There was no documentation of an investigation that included documentation by the PRO or ARM regarding Patient 6's concerns about MHDD 4 calling him/her names, threatening, and insulting him/her. There was no documentation showing Patient 6's response to staff's action/decision.

Review of a document, attached to the grievance completed by Patient 6, titled, "Professional Practices Peer Review/Analysis Worksheet," showed the ARM attempted to reach MHDD 4 on 08/25/21 to ask questions, but MHDD 4 was currently in a class on campus. The document indicated there was "no violation" by MHDD 4. Under the section of the form "Recommendation(s) to minimize future occurrences" showed, "unable to prove." The document was signed by the ARM on 08/25/21 and the Director of Nursing (DON) on 08/31/21. The was no documentation of an investigation or interview with the patient or any of the staff on duty at the time of the alleged incident. There were no other attempts to contact MHDD 4 documented

4. Review of the grievance log (an ongoing list containing the name of the patient, a description of the grievance, date the grievance was submitted and the date the grievance was received by the PRO) during the period from 04/01/21 to 10/04/21 indicated the following:

a. A grievance submitted on 06/09/21 by Patient 11 was not received until 08/19/21.
b. A grievance submitted by Patient 6 on 06/19/21 and 06/21/21, in addition to two other grievances with the date indicated as "UKN" (meaning unknown), were not received until 08/19/21.
c. Two grievances with "UKN" [meaning unknown date] were not received until 08/19/21. A grievance submitted on 06/19/21 by Patient 11 and Patient 12 was not received until 08/19/21.
d. A grievance submitted by Patient 12 on 06/19/21 and another grievance with date "UKN" were not received until 08/19/21
e. Two grievances submitted by Patient 13 with "UKN" documented as the date of grievance were not received until 08/19/21.
f. A grievance submitted by Patient 4 with "UKN" in the column titled "date of grievance" was not received until 09/09/21.

During an interview on 10/06/21 at 1:58 PM, the Assistant Superintendent (ASUP) stated that the PRO was the designated staff member to review patient grievances. ASUP stated the PRO picks up grievances filed by staff/patients from the grievance box located on the ATC East Unit. ASUP stated the PRO position had been vacant for approximately 60 days during the time the above grievances were submitted. The ASUP confirmed that during this time there was not a specific person designated to fulfill the duties of the PRO.

Based on policy review, document review, and interviews, the hospital failed to ensure the patient was provided written notice of the hospital's decision that contained 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 for three patients (Patients 4, 6, and 10) of three grievances reviewed for documentation of a resolution letter. This failure had the potential to affect the current 24 inpatients on the Adult Treatment Center (ATC) East Unit and any future patient admitted to the unit.

Findings Include:

Review of the policy titled "Patient Grievance - Suggestion Process," effective 02/27/20, indicated a grievance was defined as a "written concern or objection from an inpatient or his/her representative expressing dissatisfaction with patient care, quality, delivery of care, or any problem with patient related services . . . G. A written response is required; H. A written notice of "action in progress" is required within seven days of the LSH program's receipt of the grievance, which must advise the patient or representative of the following: 1. The steps being taken to investigate the complaint, 2. The approximate date of completion of the process, and 3. The name (or title) and telephone number of the LSH Customer Services Specialist. I. A final written response is required when the investigation is completed and/or a decision is made. . . II. Action by [name of hospital] Customer Services Department: . . .K. Sends final memo/letter of resolution, with copy of grievance form, to inpatient by campus mail and to discharged patient, family or outside representative through U.S. [United States] mail at last known address. . ." There was no documentation of the requirements to be included in the final resolution letter.

1. Review of a grievance submitted by Patient 4 on 09/20/21 indicated Patient 4 "would like to address the nature of my concern about leaving this place and taking a ride back home to my dad who is my guardian. Please understand I need to address some things about here and when I leave where I will stay. . ." Review of a letter titled, "Response to Patient Suggestion/Grievance" dated 10/05/21, addressed to Patient 4, and written by the Patients' Rights Officer (PRO) indicated the letter did not include 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.

During an interview on 10/05/21 at 1:10 PM, the PRO confirmed the resolution letter sent to Patient 4 did not include all elements required by the regulations.

2. Review of a grievance presented by Patient 10 on 04/20/21 indicated, "Medication staff wanting to argue with me. Telling me what time did I tell you? Instead of just telling me. I was asking her about breakfast. I told her I always had a schedule." Review of the section titled, "What would you like to have done about this?" indicated Patient 10 documented, "Have Med staff talked to. Have them have more patience with people, clients, residents. In the meantime I will make a schedule about the times." Review of the documentation presented by the PRO indicated no documentation of a resolution letter sent to Patient 10.

During an interview on 10/05/21 at 1:58 PM, the PRO stated a resolution letter was not sent to Patient 10, because he was discharged before the response was presented to him/her. The PRO confirmed a letter was not mailed to Patient 10 as required by hospital policy.

3. Review of a grievance submitted by Patient 6 on 06/19/21 showed, "[Mental Health Developmental Disability Technician (MHDD)] 4 called me names, threatened, and insulted me." The grievance was received by the PRO on 08/19/21 and referred to Risk Management on 08/25/21. Review of a letter attached to the grievance titled, "Response to Patient Suggestion/Grievance" dated 08/25/21, addressed to Patient 6, and written by the PRO, indicated the letter did not include 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.

During an interview on 10/06/21 at 1:58 PM, the Assistant Superintendent confirmed the resolution letter sent to Patient 6 did not include all required elements of grievance regulations.

Based on observation, medical record review, policy review, and interviews, the hospital failed to ensure patients received care in a safe setting by having three trees in the outdoor area used by patients on the Adult Treatment Center (ATC) East unit that provided a risk for patient and/or staff injury. This failure had the potential to place the current 24 inpatients and all staff working on the ATC East unit as well as any future patient admitted to the unit at risk for injury.

Findings Include:

Review of the undated "Patient Bill of Rights" indicated ". . . Every patient being treated in any treatment facility, in addition to all other rights preserved by the Care and Treatment Act for Mentally Ill Persons, shall have the following rights: . . . 17. To receive care in a safe setting. . ."

Observation on 10/04/21 at 10:30 AM of the outdoor area of the ATC East unit used by patients revealed three trees with low-lying branches (approximately three feet to four feet from the ground) and a moveable wooden bench.

Review of Patient 1's electronic medical record, located under the "General" tab under the "Orders" tab, indicated a physician order dated 05/24/21 at 12:13 PM that read, "No outside breaks - throwing rocks, breaking tree branches, and trying to hit people."

Further review showed Patient 1 was placed on elopement precautions every 15 minutes on 08/17/21 at 12:43 PM through 08/20/21 at 4:54 PM due to climbing the fence and pushing through staff to get to the door leading off unit.

During an interview on 10/05/21 at 3:05 PM, Mental Health Developmental Disability Technician (MHDD) 3 indicated he had observed Patient 1 rip a branch off the tree and try to hit staff with the branch.

During an interview on 10/04/21 at 10:30 AM, Administrative Program Director (APD) acknowledged the low-lying branches of the three trees in the outdoor area of the ATC East unit. APD stated they had never had issues with patients trying to climb the trees.

Based on medical record review, policy review, and staff interview, the hospital failed to ensure the hospital's policy on abuse and neglect was implemented by failing to remove the alleged staff perpetrator from direct patient care until an investigation was completed and by failure of the physician to conduct a physical examination of the patient after an allegation of rape was received for one of two patient records reviewed (Patient 9) with an allegation of rape. This failure had the potential to affect the current 24 inpatients and any future patient admitted to the Adult Treatment Center (ATC) East unit.

Findings Include:

Review of the policy titled "Abuse, Neglect or Exploitation of residents or Patients," dated 09/03/19, indicated, ". . . Residents/patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation (ANE). . . All allegations, observations, or suspected cases of ANE that occur on Larned State Hospital (LSH) campus shall be investigated by the hospital. . . II. Action by Chief Nursing Officer (CNO)/Assistant Director of Nursing (ADON)/Unit Leader/Shift Leader: A. Immediately removes the staff or other person identified as the alleged perpetrator of the ANE from the treatment area. . . If there is any likelihood that the staff member poses a risk to the safety and well-being of patient(s)/resident(s), the responding supervisor shall instruct the staff member to immediately clock-out and report to Human Resources. . . Action by Medical Staff/OD [on-call doctor] Medical Staff: A. Assesses resident/patient (and the resident/patient suspected of being the perpetrator) for any physical or emotional injury, provides medical treatment if necessary, and documents the findings in the resident/patient's medical record."

Review of Patient 9's electronic medical record (EMR), navigated by the Release of Information Specialist (RIS), indicated a note dated 05/13/21 at 8:53 AM, documented by Mental Health Developmental Disability Technician (MHDD) 1, located under the "Document" tab, indicated Patient 9 screamed "rape" and alleged MHDD 2 raped him/her.

Review of documentation by Physician (MD) 1 dated 05/13/21 at 8:24 AM showed, he was summoned to ATC [ATC East Unit] due to a [patient's] claim of being raped on the morning of 05/13/21. . . Pt [patient] is psychotic, disorganized & [and] broken English/speech, [patient] says [patient] ate a banana, and other words we couldn't understand. When asked to explain how [patient] got raped? [patient] [patient] [sic] slapped both hands together, layed [sic] supine on his bed, and talking gibberish, and pointed at MHDD, who reported that [Patient 9's name] asked [MHDD] to bring [patient] Wheelchair, [MHDD] stepped in the room to get the chair, and the pt [patient] claimed "rape." [Patient] reportedly has been on 1:1 all night, and another sitter from 0600 [6:00 AM] to 0645 [6:45 AM] . . . After questioning staff who was on 1:1 and RN on the unit, we concluded that the rape claim is not credible and no transfer to [name of acute care hospital] necessary at this time." There was no documentation that a physical exam was performed by MD 1.

Review of an email from the Administrative Program Director for Psychiatric Services Program (APD) dated 05/13/21 at 3:43 PM, in response to an email from the Assistant Risk Manager (ARM), indicated MHDD 2 "is an escort and was moved off East [meaning ATC East unit] until the case is done."

Review of the "Investigative Report," completed on 05/14/21, indicated Registered Nurse (RN) 1 heard Patient 9 yelling "rape" on the morning of 05/13/21 at approximately 6:30 AM while receiving report from the off-going RN. Further review indicated RN 1 had MHDD 1 take over one-to-one (1:1) observation of Patient 9 and had MHDD 2 (alleged perpetrator) take over patient location checks from MHDD 1. RN 1 then removed MHDD 2 from the ATC East unit per the direction of the unit leader RN 2.

Review of an email from the Administrator on 05/14/21 at 3:26 AM to the APD indicated "Due to the allegation, was [patient] sent for a rape kit? . . ."

During an interview on 10/05/21 at 9:50 AM, the APD stated MHDD 2 was not immediately removed from patient care after the allegation of rape was made. APD stated MHDD 2 was removed from ATC East shortly after the allegation was made, but MHDD 2 was assigned as an escort and continued to work with patients throughout the time that the investigation was conducted.

During an interview on 10/06/21 at 8:30 AM, MD 1 stated that he asked Patient 9 questions about the alleged rape the morning of 05/13/21. MD 1 stated that he did not conduct a physical exam. MD 1 stated that the patient would have needed to be sent out to be examined and obtain a rape kit. MD 1 stated Patient 9 was not sent out because the claim was not credible. MD 1 stated he is aware that the hospital states the patient is to receive a physical and emotional examine when there is an allegation of rape.