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Based on interview and record review, the facility failed to inform 13 of 13 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13) of the patient's rights to be free from all forms of abuse including financial, emotional and neglect. This failure had the potential to result in patients being unaware of their rights to be free from all forms of abuse.

Findings:

During a concurrent interview and record review on 3/28/22, at 2:55 PM, with Intake Director (ID), the facility's "PATIENT RIGHTS-HOSPITAL WIDE [PRH]" form (undated), was reviewed. The form indicated, "A patient's right shall include. . .12. Receive care in a safe setting, free from verbal or physical abuse or harassment. . . " The form did not include other forms of abuse including: emotional, financial or neglect. ID stated, "We give [PRH form] to patients on admission and patients sign at the back." ID verified the PRH document did not include all forms of abuse. ID stated, "I don't see financial, sexual, emotional, and neglect [on the PRH form given to all patients]."

During a concurrent interview and record review, on 3/28/22, at 3 PM, with Quality Risk Compliance Director (QRCD), facility's PRH form was reviewed. QRCD verified PRH document was missing other forms of abuse including financial, emotional abuse and neglect. QRCD stated, "I know, I already have a draft."

Based on interview and record review, the hospital failed to ensure two of 12 sampled employees (Registered Nurse [RN] 1 and Mental Health Worker [MHW] 1) had a current Cardiopulmonary Resuscitation (CPR is an emergency procedure that can help save a person's life if their breathing or heart stops) certification card. This failure had the potential to result in the staff being unaware of current life-saving measures which could result in adverse consequences to the patients.

Findings:

During a concurrent interview and record review, on 3/29/22, at 1:30 PM, with Human Resources Director (HRD), RN 1's personnel file (PF) was reviewed and indicated RN 1's CPR certification card expired on 11/30/21. HRD verified the finding and stated, "I don't find any current [CPR card] one in her file." No additional information was provided.

During a concurrent interview and record review, on 3/29/22, at 3:30 PM, with HRD, Mental Health Worker (MHW) 1's PF was reviewed and indicated MHW 1's CPR certification card expired on 12/11/21. HRD verified the finding. No additional information was provided.

Based on interview and record review, the facility failed to conduct an annual performance evaluation (APE is a regular assessment and review of an employee's performance based on job responsibilities and expectation) for two of 12 sampled employees (Registered Nurse [RN] 1 and RN 2). This failure had the potential to negatively impact quality of care provided to the patient population due to unqualified staff.

Findings:

During a concurrent interview and record review on 3/29/22, at 2:50 PM, with Human Resources Director (HRD), Registered Nurse (RN) 1's personnel file was reviewed and indicated the most recent APE was completed on 11/20/20. HRD verified there was no APE completed on 10/21 and stated, "We don't have any recent evaluation."

During a concurrent interview and record review, on 3/29/22, at 3 PM, with HRD, RN 2's personnel file was reviewed and indicated the most recent APE was completed on 2/11/20. HRD verified there was no APE completed on 2/21 and 2/22. There was no additional information provided.