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Based on facility medical record reviews, facility logs, policy and procedures and interviews, it was determined that the facility failed to ensure that patient's rights were promoted and protected for one patient (P) (P#1) of four sampled patients. P#1's family representative reported that P#1 was possibly sexually abused while admitted to the facility's behavioral health center. The facility failed to provide P#1's family representative with an explanation of Patient Rights including how to file a complaint or grievance; failed to enter the allegation into the grievance log; and failed to provide follow up communication to P#1's family representative.

Findings include:

Cross Refer to A0118 as it relates to the facility's failure to provide information to P#1's family representative of the complaint and grievance process.

Cross Refer to A0121 as it relates to the facility's failure to provide an explanation to P#1's family representative of the complaint and grievance process.

Cross Refer to A0123 as it relates to the facility's failure to provide P#1's family representative with written notification of the facility's investigation.

Based on review of medical records, policy and procedures, complaint and grievance log and interviews it was determined that the facility failed to implement a process for the investigation of grievances and provide each patient/representative with information on the grievance process for one (P#1) of four sampled patients when P#1's family representative did not receive written or verbal explanation of how to report complaints and grievances.

A review of P#1's medical record failed to reveal documentation that P#1's family representative had received written information on Patient's Rights including the process for filing a grievance.

Continued review of the record revealed a nursing note dated 8/22/23 by RN BB at 4:19 p.m. revealed that P#1's family representative reported that she believed something of sexual nature may have happened to P#1 at the facility because she (P#1) was making sexually explicit comments, had become uncomfortable around men, and refused to remove her pants for hygiene purposes. RN BB notified the Charge Nurse, RN DD. RN DD notified the House Supervisor, (HS) EE and hospitalist, MD HH. The legal department was notified by HS EE and MD HH.

A review of three additional medical records (P#2, P#3, P#4) revealed that all included an acknowledgement of the receipt of the Patient's Rights and Responsibilities.

A review of the "Customer Complaints and Grievances" policy, Policy #AHF AD-04-005, effective 12/1990, last revised 5/2023 revealed the purpose is to provide a mechanism and procedures to respond, review, and resolve patient concerns/complaints and grievances as required by the Centers for Medicare and Medicaid Services (CMS) and other Regulatory Agencies, including but not limited to complaints alleging any action prohibited by the Affordable Care Act and its implementing regulations. Policy.
During the admission process, patients and/or their representatives are given a patient information guide which addresses the manner in which concerns/complaints and/or /grievances may be voiced. The handbook also provides the name and number of the following agencies the customer may contact should they feel their concerns/complaints and/or grievances are not being properly addressed.


A review of the "Patient Rights/Responsibilities" policy, Policy #AHF AD04-001, last revised 5/2023 revealed that upon admission as an inpatient to any Atrium Health Floyd facility (Atrium Health Floyd Medical Center, Atrium Health Floyd Behavioral Health, and others) all patients are provided a written listing of their patient rights/responsibilities and Atrium Health Floyd's commitment to comply with the Federal non-discrimination laws and regulations. The patient rights/responsibilities are listed in the patient information handbook provided to all patients who are admitted as inpatients. Patient Rights. 4. A patient or when appropriate, the patient's representative has the right to receive information regarding their patient rights, the complaint/grievance mechanisms and to be informed of the facility rules and regulations that apply to their conduct as the earliest possible time in the course of their care. 25. A patient has the right to receive care in a safe setting. A safe setting includes environmental safety, infection control, security, protection of emotional health and safety. This includes respect, dignity, and comfort, as well as physical safety. 26. A patient has the right to be free from all forms of abuse or harassment. This includes abuse, neglect, or harassment from staff, other patients, and visitors. 29. A patient, and when appropriate, the patient's representative has the right to have any concerns, complaints, and grievances addressed. Sharing concerns, complaints and grievances will not compromise a patient's care, treatment, or services.

A review of the facility's grievance and complaint log dated June 2023 through September 2023 failed to reveal that a grievance was reported by or on behalf of P#1.

During a telephone interview with P#1's representative (PD) II on 9/29/23 at 3:30 p.m., PD II explained that when P#1 was admitted, she was not advised of the Patient's Rights and how to file a complaint or grievance with the facility or other agencies. PD II stated that it was not until P#1 was admitted to another behavioral health facility that the admissions clerk advised her of her rights to file a complaint with the State agency. PD II stated that she did file a complaint with the State on 9/15/23 regarding a possible sexual assault at the facility.

Based on review of the facility's complaint and grievance log, incident report, policy and procedures and interviews it was determined that the facility failed to provide the patient and/or family representative with written notice of the results of the facility's investigation for one (P#1) of four sampled patients. On 8/22/23, P#1's family member submitted a verbal grievance of suspected sexual abuse of P#1. The facility concluded their internal investigation on 8/28/23. The facility failed to provide follow up to P#1's family representative of the facility's decision of their completed investigation.

Findings include:

A review of the facility's grievance and complaint log dated June 2023 through September 2023 failed to reveal a grievance reported by or on behalf of P#1.

Review of the facility's incident report #86681, with closed date of 08/28/23 at 9:15 a.m., revealed this incident was reported by Registered Nurse (RN) BB on 8/22/23 at 6:54 p.m. Immediate actions taken include note in chart and supervisor notified. Reported Incident Severity: Severity Level 1-No Harm/Damage. The family member of Patient (P) #1 reported that it was her (family member) belief that something of a sexual nature happened to P#1 while admitted to the behavioral health center. Family member reports that P#1 began making sexually explicit comments and refused to take off her pants for hygiene and bathroom purposes since she was discharged from the facility. Family member reported that P#1 was unusually uncomfortable around men since discharge. P#1 was not alert and oriented and talked in word salad while admitted. The charge nurse was immediately notified of the accusation by RN BB. The house supervisor and the hospitalist were notified by the charge nurse. The legal department was notified by the house supervisor and hospitalist.

A review of an addendum to incident report #86681 dated 9/26/23 from CM CC revealed on August 23, 2023, Clinical Manager CC interviewed teammates Mental Health Tech (MHT) and Registered Nurse (RN) regarding the alleged incident reported by P#1's family. The interview with MHT occurred at 10:20 a.m. and the interview with RN occurred at 10:45 a.m. The information obtained during the interviews is included in the Clinical Manager's follow-up note in the incident report. CM CC and Security Officer (SO) reviewed the camera footage for the timeframe of the patient's admission, 7/28/23 - 8/16/23. At no time was the patient alone with a male patient or staff member where it was not visible. Incident file closed 8/28/23 at 9:15 a.m.

A review of the "Customer Complaints and Grievances" policy, Policy #AHF AD-04-005, effective 12/1990, last revised 5/2023 revealed that all concerns/complaints and/or grievances, if not addressed and resolved quickly at the time they are shared, are to be documented in the Customer Services Event Database for further investigation and follow-up.

Concerns/complaints deemed to be high risk in nature should be referred immediately to the appropriate Vice President or Executive taking administrative call. (Executive staff may be contacted after normal working hours, by dialing the operator ("O"). Follow-up actions are initiated immediately. Concerns/complaints not adequately resolved through the Service Recovery Process should be documented in the RL DATIX Incident - Customer Event Database. The appropriate manager will receive an alert and the entry will be reviewed by the Patient Advocate Coordinator.

Grievances voiced by a patient (or their representative) will be forwarded to the Patient Advocate Coordinator or her designee, who will complete entry into the Customer Service Event Database. The Patient Advocate Coordinator will complete an acknowledgment letter to the individual within 7 working days. The Patient Advocate Coordinator will document all actions taken in regard to the grievance such as discussion with the patient and/or their representative, discussion with the employee(s) or staff involved, as well as actions taken to prevent future occurrences.
For those issues identified as a grievance, once the customer has communicated their concerns, the Grievance Committee will confer and the customer will be sent a written response, within thirty (30) business days from receipt of the grievance. The written follow-up will include the steps taken on behalf of the customer related to the investigation, the results of the follow-up and the date it was completed. The name and phone number of the hospital contact person will also be included. All written correspondence will be coordinated with the Risk Manager, who will review the correspondence prior to mailing it to the individual making the grievance. The Patient Advocate Coordinator will follow up on a regular basis with the customer until the grievance is resolved.

A review of the "Patient Rights/Responsibilities" policy, Policy #AHF AD04-001, last revised 5/2023 revealed that upon admission as an inpatient to any of the facility's all patients are provided a written listing of their patient rights/responsibilities and the facility's commitment to comply with the Federal non-discrimination laws and regulations. The patient rights/responsibilities are listed in the patient information handbook provided to all patients who are admitted as inpatients. Patient Rights. 4. A patient or when appropriate, the patient's representative has the right to receive information regarding their patient rights, the complaint/grievance mechanisms and to be informed of the facility rules and regulations that apply to their conduct as the earliest possible time in the course of their care. 29. A patient, and when appropriate, the patient's representative has the right to have any concerns, complaints, and grievances addressed. Sharing concerns, complaints and grievances will not compromise a patient's care, treatment, or services.

An interview was conducted with the Clinical Manager (CM) CC on 9/26/23 at 9:00 a.m. in the administration conference room at the main hospital. CM CC stated that she did recall P#1 from the two weeks she was a patient on the senior adult care unit at the FBH facility that is located in a separate facility from the main hospital. CM CC stated she first became aware of the possible sexual assault from Vice President of Behavioral Health and Risk Management (VP) FF who advised her that an investigation needs to be conducted. CM CC stated that P#1's room was the first room, closest to the nurses station, down the long hallway and she like to hang-out at the nurses station. She continued to explain that she began her investigation with a chart review, then a video review, and follow-up interviews with staff who were present on the unit. CM CC confirmed that there are cameras in the patient's rooms, with the exception of a direct view into the bathroom, as well as in the hallway. She continued to explain that during her investigation and subsequent review of the video footage from 7/28/23 through 8/16/23 at no time was P#1 alone with a male patient or staff member. CM BB stated that she concluded her investigation that a sexual assault did not occur at the facility, and she sent her report to VP FF.

An interview was conducted with Risk Management Coordinator (RMC) GG on 9/26/23 at 2:50 p.m. in the administration conference room. RMC GG stated that she did recall receiving and reviewing incident report #86681 concerning P#1. She continued to explain that the process and responsibility of Risk Management is to review all incidents related to Quality and/or Risk Management then, if necessary, the incidents are forwarded to the appropriate supervisors for review and action. RMC GG continued to explain that it is the responsibility of the Patient Advocacy Department to generate all follow up letters to patients and/or their representatives. RMC GG confirmed that P#1's daughter did voice her concerns to the nursing staff caring for her mother. She continued to explain that P#1's daughter's concerns could not be resolved immediately and therefore, per the Complaint and Grievance policy, her verbal concerns would be considered a grievance and should have been handled as a grievance. She continued to explain that P#1's daughter's concerns should have been forwarded to the Patient Advocate for documentation and follow up. RMC GG confirmed that in addition to documentation on the incident log that P#1's daughter's concerns should have been entered onto the grievance log for written follow up however her concerns were not documented as a complaint or grievance.

During a telephone interview with the Vice President of Behavioral Health and Risk Management (VP) FF on 9/28/23 at 10:00 a.m., VP FF stated that she is responsible for managing the behavioral health facility that is located in a separate building from the main hospital and she is responsible for overseeing the Risk Management department that is located in the main hospital. She continued to explain that because she reports to the facility's legal department is why staff will refer to her as the legal representative for the facility, however she is not an attorney. VP FF stated that she does recall receiving a phone call from HS EE regarding P#1 and a possible sexual assault that allegedly took place at the behavioral health facility. She continued to explain that during the phone call she advised HS EE that she would forward the matter to CM CC, who is the Clinical Manager (CM), to thoroughly investigate the matter and that CM CC will include her findings in the incident report. VP FF continued to say that she discussed the incident with CM CC and was advised that CM CC interviewed two staff members who work on the unit where P#1 was admitted and review surveillance video for the entire duration of P#1's stay and concluded that at no time was P#1 left alone with any male staff or male patients. She continued to say that she was advised by CM CC that at no time was there any opportunity for a sexual act to occur during P#1's stay at FBH because P#1 required a lot of attention and redirection, and the staff was closely monitoring her care. VP FF continued to explain that once CM CC concluded her internal investigation, she updated the incident report in the facility's system. VP FF stated that she did follow up with CM AA, who is the CM on the unit where P#1 was admitted to in the main hospital, to advise of CM CC's findings and suggested to CM AA to follow up with P#1's daughter. VP FF stated that as of today, 9/28/23, when she spoke to CM AA and asked, if he ever followed up with P#1's daughter regarding the sexual allegation investigation like she advised him to do when the allegation was internally investigated, CM AA advised her that no he did not follow up with P#1's daughter personally however, he asked a nurse (no name given) to follow up with P#1's daughter and to his knowledge the nurse did follow up.

During a telephone interview with P#1's family representative (PD) II on 9/29/23 at 3:30 p.m., PD II confirmed that as of today, 9/29/23, she has not received feedback from the facility regarding her complaint of a possible sexual assault of P#1.