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Based on interview and record review, the hospital failed to ensure the extended resolution letter for a grievance was written in the same language in which the grievance was filed for one of three sampled patients (Patient 1). This failure had the potential to result in a violation of the patient's rights by limiting their ability to understand the status of their grievance. creating a risk of violating patients' rights.

Findings:

During a review of the hospital's P&P titled Complaint and Grievance Management dated 2/28/25, the P&P showed the following:

* Grievances: Most grievances can be resolved within seven days. Grievances requiring extensive investigation may need additional time.

* Extended Resolution: If a grievance cannot be resolved, or if the investigation is not completed within seven days, the Patient Advocacy Office will notify the patient or the patient's authorized representative in writing.

During a review of the grievance form for Patient 1 on 11/24/25, the grievance form showed it was written in English on 10/31/25.

During a review of the final resolution letter on 11/24/25, the letter showed it was dated 11/12/25.

During a review of the extended resolution letter on 11/25/25, the letter showed it was dated 10/31/25. However, the letter was written in different language than the original grievance.

During a concurrent interview and record review with the Associate Risk Manager on 11/25/25 at 1210 hours, the Associate Risk Manager stated the extended resolution letter should not have been written in different language.

Based on interview and record review, the hospital failed to ensure the patients received care in a safe environment for one of three sampled patients (Patient 1) as evidenced by:

1. The nursing staff failed to document consistently the effectiveness of intervention and behaviors trends for hypersexuality for Patient 1 as required by the hospital's P&P.

2. The nursing staff failed to measure Patient 1's VS as required by the hospital's P&P.

These failures created the risk of substandard healthcare outcomes to the patients in the hospital.

Findings:

During a review of medical record for Patient 1 starting on 11/24/25, Patient 1's medical record showed Patient 1 was admitted to the hospital on 10/15/25.

1. During a review of the hospital's P&P titled Sexually Inappropriate Behavior/Hypersexuality-Precaution Guidelines dated 8/2/24, the P&P showed the following:

I. Assessment and Interventions

C. For Sexually Inappropriate Behavior, the following interventions shall be implemented:

E. If hypersexual behavior is present, in addition to Sexually Inappropriate Behavior (SIB) interventions, the RN will implement the following Risk Reduction Interventions, the RN will implement the following Risk Reduction Interventions:

1. 1:1 constant nursing observation
2. Seclusion or restraints per MD order, if necessary

II. Communication

B. The RN will evaluate the effectiveness of interventions each shift and any increase or decrease in sexually inappropriate behavior and or hypersexual behavior and communicate these with the MD, nursing staff, and other care team members by way of daily shift reports, during multidisciplinary team meetings and documentation in the EHR.

During a review of the Psych ED Consultation dated 10/16/25 at 2005 hours, the Psych ED Consultation showed Patient 1 was documented as sexually inappropriate to staff and other patients.

During a concurrent interview and record review with Nurse Manager 1 on 11/25/25 at 1037 hours, the Hypersexual Risk Factor documentation for Patient 1 from 10/15/25 to 10/19/25 included:
- Hypersexual Risk Factor Present
- Exposing self/public sexual gestures
- Trying to coerce other into sex activity
- Inappropriate touching of others
- Making unwanted sexual advances

During an interview on 11/25/25 at 1037 hours, with Nurse Manager 1, Nurse Manager 1 stated the interventions for hypersexual behaviors included medications and redirecting Patient 1 to another room.

Further review of Patient 1's medical record failed to show the effectiveness of the interventions and trends of the sexually inappropriate behavior. Nurse Manager 1 verified the above findings.

2. During a review of the hospital's P&P titled Patient Care Documentation Guidelines (Inpatient) dated 2/8/24, the P&P showed to measure vital signs every eight hour minimum as ordered by MD or more frequently if clinically indicated for behavioral health area.

Review of the Vital Signs showed the following:

* On 10/15/25 at 1506 hours, Patient 1's VS were measured.
* On 10/15/25 at 2045 hours, Patient 1's VS were measured.
* On 10/16/25 at 0830 hours, Patient 1's VS were measured.
* On 10/16/25 at 1541 hours, Patient 1's VS were measured.
* On 10/19/25 at 0759 hours, Patient 1's VS were measured.

There were no documented vital signs for 10/17 or 10/18/25.

During a concurrent interview and record review with Nurse Manager 1 on 11/25/25 at 1037 hours, Nurse Manager 1 stated the unit protocol was once daily, nurses typically measured vital signs once per shift. Nurse Manager 1 verified the VS in behavioral health unit was not measured every eight hours as per the hospital's P&P requirement.