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Based on observations, interview and document review, it was determined the facility staff failed to ensure patients and their representatives were provided the contact information to file a complaint or grievance with the state agency (Virginia Department of Health, Office of Licensure and Certification).

The findings included:

A tour of the child unit was conducted on February 4, 2019 at 2:02 p.m. with Staff Members #1, #2 and #6. The observation revealed posted information regarding patient rights and contact information related to filing complaints and grievances. The information did not include the contact information for the state agency.

An interview was conducted on February 4, 2019 at 2:25 p.m. with Staff Member #6 in the presence of Staff Members #1 and #2. The surveyor requested to review the admission information given to the patient's representative. Staff Member #6 provided the admission papers, which included a tri-fold brochure regarding Patient rights, responsibilities and the contact information for filing complaints and grievances. The brochure did not include the contact information for the state agency. Staff Member #6 verified the brochure did not include the state agency's contact information.

The surveyor conducted observations of the facility's adolescent unit on February 4, 2019 at 2:32 p.m. with Staff Member #7. The observation revealed the posted rights information did not include contact information for the state agency. During the review of the admission information Staff Member #7 verified the admission pack did not include contact information for filing a complaint/grievance with the state agency.

Observations and interviews conducted on February 4, 2019 from 2:47 p.m. through 3:50 p.m. on the facility's eating disorder and adult units revealed the same findings.

The surveyor conducted an end of the day interview on February 4, 2019 with Staff Members #1, #2, #4 and #5. The surveyor informed the facility staff of the findings. Staff Member #5 verified the findings and reported the tri-fold brochures were partly a corporation template which had been recently updated. The surveyor requested the facility's policies and procedures for patient rights, and the process for filing a complaint and/or grievance.

On February 5, 2019, Staff Member #4 presented the facility's policies: "Patient Rights", "Human Rights Plan - Part III- Dignity/Grievance Process", "Human Rights Plan - Part III- Complaint and Fair Hearing", and "Human Rights Plan - Part V- Complaint Resolution, Hearing, & Appeal Procedures- General Provisions." Staff Member #4 and the surveyor reviewed the four (4) policies. Staff Member #4 verified the four (4) policies did not address a process for the patient or the patient's representative to file a complaint or grievance with the state agency. Staff Member #4 verified the four (4) policies did not include contact information for the state agency.

The facility did not present additional grievance processes or policies related to the inclusion of the state agency and its contact information prior to exit February 7, 2019.

Based on interview and document review, it was determined the facility's patient advocate failed to provide a response to complainants within the guidelines provided by the Centers for Medicare and Medicaid Services (CMS) (within seven (7) days) for two (2) of three (3) patients included in the survey sample. (Patients #10, and #12)

The findings included:

During the entrance conference held on February 4, 2019 at approximately 1:30 p.m., the surveyor requested the facility's complaint/grievance log for the months of September 2018 through February 1, 2019.

Staff Member #22 provided navigation of the patients' electronic medical record (EMR) review. Staff Member #4 was present during the EMR reviews conducted February 5 and 6 2019.

Patient #10 was admitted voluntarily to the facility on December 7, 2018 for suicidal ideation with a plan. Patient #10 was discharged on December 7, 2018 against medical advice (AMA). Staff Member #4 reported the facility received a letter from the patient's representative regarding an alleged lack of medical care. The surveyor requested to review the complaint investigation documents related to Patient #10. Staff Members #4 presented the documents for review. Staff Member #1, #2 and #3 were present during the interview with Staff Member #4.

A review of the facility's complaint and grievance log on February 6, 2019 with Staff Member #4 revealed Patient #10 had not been included on the log. Staff Member #4 verified the findings. Staff Member #4 reported Patient Advocacy personnel had recently developed a new tool to track complaints. Staff Member #4 verified the facility's response letter to the Complainant was dated and sent after seven (7) days.

The surveyor obtained Patient #12's name from the facility's complaint log. Patient #12's EMR documented the patient's admission November 26, 2018 and discharge as December 8, 2018. The facility received a complaint related to an incident on December 6, 2018 involving staff and Patient #12. The facility received the complaint on December 7, 2018. The response letter to the family was not sent until December 17, 2018. Staff Member #4 verified the response letter to the complainant was not sent within seven (7) days. Staff Member #4 reported the facility was following the requirements for the mental health-reporting agency, which required written notification to the patient or patient's representative within ten (10) days. The surveyor reviewed the CMS guidelines with Staff Member #4, related to notifying the patient or their representative within a seven (7) day timeframe.

On February 5, 2019, Staff Member #4 presented the facility's policy "Human Rights Plan - Part III- Dignity/Grievance Process." The policy read in part "2. Process for Resolution of Patient Complaints: a. The patient's grievance shall be communicated by the Chief Executive Officer to appropriate staff for the purpose of further assessment and problem resolution, depending upon the nature and extent of the complaint." This portion of the policy does not indicate a timeframe for response to the patient or patient representative.

The "Human Rights Plan - Part III- Dignity/Grievance Process" policy further separated process pathways regarding complaints alleging abuse/neglect or exploitation by persons outside of the hospital or a hospital employee. For complaints alleging abuse/neglect or exploitation, the policy read in part "4. ... b. The Chief Nursing Officer shall initiate an impartial investigation within 24 hours of receiving a report of potential abuse or neglect ... 1. The investigator shall make a final report to the Chief Nursing Officer and the investigating authority and to the human rights advocate within 10 working days of appointment ... 4. In all cases, the Chief Nursing Officer shall provide a written decision, including actions taken as a result of the investigation , within seven working days following the completion of the investigation to the patient or the patient's authorized representative ... The decision shall be in writing and in the manner, format and language that is most understood by the patient ..."

The surveyor inquired regarding the total time involved with a ten (10) day period to complete the investigation and an additional seven (7) days regarding written notification of the patient or patient's representative. Staff Member #4 verified the timeframe within the policy. Staff Member #4 reported the facility generally completed the process of investigation and notification within ten (10) days. Staff Member #4 stated, "We will have to update our policies to reflect the CMS guidelines."

Based on interview and document review, it was determined the facility staff failed to modify the patient's plan of care (Recovery Plan) to reflect the use of physical restraints for two (2) of five (5) restrained patients included in the survey sample. (Patients #7 and #8)

The findings included:

Staff Member #22 provided navigation of the patients' electronic medical record (EMR) review. Staff Member #4 was present during the EMR reviews conducted February 5 and 6 2019.

A review of Patient #7's EMR indicated the patient's admission status as a temporary detention order (TDO) on August 9, 2018. Patient #8 changed his/her admission status to voluntary after his/her hearing on August 13, 2018. Patient #7 scheduled discharge was documented for December 12, 2018. Patient #7's EMR indicated the patient was placed in a physical hold on December 10, 2018. A review of Patient #7's "Recovery Plan" did not include a modification to reflect the use of restraints.

During an interview on February 5, 2019 at 8:45 a.m., Staff Member #22 verified Patient #7's "Recovery Plan" was not updated to reflect a restraint had been utilized on December 10, 2018.

A review of Patient #8's EMR indicated the patient's admission status on January 8, 2019 involved a TDO. Patient #8 was discharged from the facility on January 10, 2019 after being committed during a hearing to a different facility. Nursing staff documented Patient #8 was placed in a physical hold (restraint) on January 8, 2019 and January 10, 2019. A review of Patient #8's "Recovery Plan" did not include modification to reflect utilization of restraint.

During an interview on February 6, 2019 at 9:29 a.m. Staff Member #22 verified Patient #8's "Recovery Plan" did not have modification to reflect the utilization of a restraint on January 8, 2019 and January 10, 2019.

On February 6, 2019, Staff Member #4 reviewed the facility's "Restraint" policy with the surveyor. Staff Member #4 verified the facility's policy included the need to modify the patient's "Recovery Plan" once restraints were employed.

Based on interview and document review, it was determined nursing staff failed to obtain a physician's order after restraining one (1) of five (5) restrained patients included in the survey sample (Patient #9).

The findings included:


Staff Member #22 provided navigation of Patient #9's electronic medical record (EMR) review. Staff Member #4 was present during the EMR review conducted February 6, 2019.

A review of Patient #9's EMR documented the patient's date of admission as October 24, 2018. Patient #9's EMR indicated the patient was placed in three (3) separate physical holds on October 31, 2018. Nursing documentation indicated the first physical hold on October 31, 2018 started at 4:55 p.m. and discontinued at 5:20 p.m. with a debriefing. The second documented physical hold started at 5:25 p.m. and discontinued at 5:27 p.m. on October 31, 2018. The third documented physical hold on October 31, 2018 started at 9:40 p.m. and discontinued at 11:00 p.m. with a debriefing.

A review of the physician's order for restraints on October 31, 2018 only revealed two (2) orders with documented physician notification, completed face to face and second tier assessment. A review of Patient #9's EMR did not include a physician's order for placing the patient in a physical hold/restraint from 5:25 p.m. to 5:27 p.m. on October 31, 2018. Patient #9's EMR did not contain the required face to face or the second tier assessment for the restraint utilized from 5:25 p.m. to 5:27 p.m. on October 31, 2018. Staff Member #2 acknowledged if staff discontinued one physical hold at 5:20 p.m., then placed the patient in a second physical hold at 5:25 p.m. on October 31, 2018, a new physician's order was needed for the second physical hold.

During an interview conducted on February 6, 2019 at 10:02 a.m., Staff Member #2 reviewed Patient #9's EMR. Staff Member #2 stated, "A face-to-face and second tier assessment has to be performed for every physical hold." Staff Member #2 reported he/she would check to determine if a paper order was used instead of an electronic physician's order.

On February 6, 2019, Staff Member #4 reviewed the facility's "Restraint" policy with the surveyor. Staff Member #4 verified the facility's policy specified that a new physician's order was needed for each application of a restraint.

On February 7, 2018 at approximately 9:00 a.m., Staff Member #4 reported a paper order was not found for Patient #9's physical hold performed from 5:25 p.m. to 5:27 p.m., on October 31, 2018.

Based on interview and document review, it was determined nursing staff failed to obtain orders for blood glucose monitoring for one (1) of one (1) diabetic patient included in the survey sample (Patient #10).

The findings include:

Staff Member #22 provided navigation of Patient #10's electronic medical record (EMR) review (A diabetic patient). Staff Member #4 was present during the EMR review conducted February 6 2019.

Patient #10's EMR documented his/her facility admission as 2:23 a.m. on December 12, 2018. The admission documents indicated Patient #10 was diagnosed with Type I Diabetes. Intake information gathered from the transferring hospital listed on the facility's "Disposition and Follow-Up" form dated "12/6/18" at 10:12 p.m., which read in part "Spoke to ED [Emergency Department] RN [Registered Nurse]: (symbol for the word no) insulin pump BS [blood sugar] 278 waiting for Lantus med (insulin) to come to floor from pharmacy to give. Informed Adol. [Adolescent] unit of pt.'s latest BS." Patient #10's intake information did not specify whether Patient #10 received the dose of insulin prior to leaving the transferring hospital.

A review of the Intake Nursing entry at 3:12 a.m. on December 7, 2018 included an initial set of vital signs, but did not include a blood glucose level. Nursing documented speaking with Staff Member #23 at 3:13 a.m., and receiving recommendations to admit to the adolescent unit. The intake information did not include orders for glucose monitoring.

A scanned "RN Skin Assessment upon Arrival to the Unit" dated "12/7/18" with a unit arrival time indicated as 3:45 a.m. documented two (2) facility staff performed the skin assessment. Both employees designated their title as "Tech." The "RN Skin Assessment upon Arrival to the Unit" form documented Patient #10 had a "PEX Com (glucose monitoring device)" located on the back of the patient's right arm.

Patient #10's initial nursing assessment summary completed on the adolescent unit December 7, 2018 at 5:00 a.m. documented Patient #10's interaction with staff. A review of the Adolescent Unit nursing documentation from "0500 (5:00 a.m.)" through 0800 did not indicate a conversation with the admitting psychiatrist occurred.

The nursing assessment documented awareness at 6:09 a.m. and that Patient #10 had a history of Diabetes. A review of nursing documentation did not address the patient's diabetes or monitoring of blood glucose levels.

A review of the Physicians Orders" form scanned into Patient #10's EMR revealed the first telephone order was timed at 9:40 a.m. on December 7, 2018. The order read "TO [telephone order] [Staff Member #23's name] transfer Pt [Patient] to [Staff Member #24's name]. The second order on the Physicians Orders" form was dated December 7, 2018 at 9:40 a.m., read in part "TO: [Staff Member #24's name] Discharge pt AMA [against medical advice] to follow up at [Name of a partial hospital program]." The physician order form provided to the surveyor did not address the patient's history of diabetes.

An interview was conducted on February 6, 2019 at 3:14 p.m. with Staff Member #19. Staff Member #19 reported he/she had reviewed Patient #10's EMR. Staff Member #19 reported he/she had cared for Patient #10 on the day shift starting at "7 a." Staff Member #19 remembered Patient #10 as being "anxious, uneasy, and not wanting to be in the hospital." The surveyor asked regarding Patient #10's glucose monitoring. Staff Member #19 stated, "First we need an order placed in [name of charting system] that will show us what we need to do. It populates the time for the medications. That is how it is done." Staff Member #19 reported that without an order the electronic charting system would not trigger times for medications or monitoring like glucose checks or blood pressure checks. Staff Member #19 reported not being aware of the patient's implanted blood glucose scanner. Staff Member #19 stated, "We had not been trained here on how to use the scanning device, there was no order to use the scanning device." Staff Member #19 stated, "Blood sugar checks should be taken on admission, and insulin orders obtained. That did not happen in this case." Staff Member #19 reported the physician was called and the patient's care was transferred to a physician familiar with the patient. Staff Member #19 reported the patient and his/her family member requested to leave and the physician was contacted and provided an "AMA discharge with follow-up."

An interview was conducted on February 6, 2019 at 3:24 p.m. with Staff Member #16. Staff Member #16 explained the intake process. Staff Member #16 reported remembering Patient #10. Staff Member #16 stated, "We received a call looking for a bed for a sixteen (16) year old diabetic. At the time I took the call, the patient's blood sugar was elevated 278. That's too high I reported to the doctor that the patient was medially unstable. I called the hospital and they reported waiting for Lantus insulin from their pharmacy. I called the adolescent unit nurse to make [him/her] aware of the blood sugar and their pending administration of insulin." The surveyor asked if the facility received with the patient information that the Lantus insulin had been administered. Staff Member #16 reported the transferring hospital did not provide documentation of the insulin. Staff Member #16 stated, "We do not allow patients to come until they're stable. The clinicals, labs any testing is supposed to come over before the patient arrives. We gather the appropriate documents to ensure the patient is stable."

An interview was conducted on February 5, 2019 at 5:35 p.m. with Staff Member #13. Staff Member #13 remembered Patient #10 arrived on the adolescent unit early morning December 7, 2018. Staff Member #13 stated, "I had worked over form evening to nights. I was leaving at 3:00 a.m. I started the admission and the consents." Staff Member #13 reported Patient #10's family member was present during his/her part of the admission process. Staff Member #13 reported Patient #10 was "very anxious with distorted thinking." Staff Member #13 reported Patient #10's anxiety increased when he/she realized his/her family member had left the unit. When the surveyor questioned regarding the patient's elevated blood glucose level or if Patient #10 had received insulin prior to arrival. Staff Member #13 stated, "I didn't question the previous information from intake. First, because the patient should be medically stable before they get to the unit. By the time they arrive on the unit, they should have been medically cleared. We don't accept medically fragile patients." Staff Member #13 reported the nurse assigned to medications handles medical issues like medications, glucose monitoring, or following up on blood pressures.

An interview was conducted on February 7, 2019 at 7:46 a.m., with Staff Member #14. Staff Member #14 reported remembering Patient #10. Staff Member #14 reported Patient #10 was admitted to the unit "sometime around 4:00 in the morning." Staff Member #14 remembered Patient #10 had diabetes and a special monitor. Staff Member #14 reported Patient #10's family member explained to the nurses that the patient had "an implanted scanner and how to use it." Staff Member #10 reported Patient #10 was "never at ease, refused food and drink." Staff Member #14 reported patient #10 was focused on calling his/her family member and "wanted to go home." Staff Member #14 stated, "We have special rules regarding using the phone at night, as soon as it was time. We allowed [him/her] to call home." Staff Member #14 stated, "The nurses take care of the medical needs. I manage the milieu. I make sure the patients are contained, the unit is safe. I take vital signs, record meal and snack intake. I'm there to de-escalate when needed."

A telephone interview was conducted on February 7, 2019 at 11:00 a.m., with Staff Member #21. Staff Member #21 reported remembering Patient #10 from December 7, 2018. Staff Member #21 stated, "I remember [him/her] being extremely anxious. I had floated to the adolescent unit that morning and took over the admission." Staff Member #21 reported the other nurse had been scheduled to leave at 3:00 a.m. Staff Member #21 reported Patient #10's family member had written out the patient's insulin instructions. Staff Member #21 stated, "No one mentioned to me the patient had an implanted glucose scanner." Staff Member #21 reported Patient #10 was "anxious, hard to understand, and would not settle down." Staff Member #21 stated, "We try to encourage all new admissions to lay down and try to sleep if only for a few hours. Their day has usually been rough." Staff Member #21 reported Patient #10 would not go to his/her room but "stayed at the nurse's station." Staff Member #21 reported the intake nurse had received initial orders from Staff Member #23 for the patient's admission and medications. Staff Member #21 reported the internal medicine physician generally ordered medications for medical conditions. Staff Member #21 stated, "There were no orders for insulin and no medications administered when I left at the change of shift."

Based on interviews and document review, it was determined nursing and treatment team staff failed to ensure the provision of care as directed by the patient's treatment plan (Recovery Plan) was reviewed daily for five (5) of seven (7) patients included in the survey sample for medical record review. (Patients # 4, #5, #6, #7, and #8.)

The findings included:

Staff Member #22 provided navigation of the patients' electronic medical record (EMR) review. Staff Member #4 was present during the EMR reviews conducted February 5 and 6, 2019.

An interview was conducted during EMR review on February 5, 2019 at approximately 9:19 a.m. with Staff Members #3 and #22. The surveyor inquired regarding patients' care plans. Staff Member #22 reported the facility used the term "Recovery Plan" since it reflected the goal of the hospitalization and the follow-up care. Staff Member #22 reported either nursing or any treatment team member were responsible for daily entries related to the patents' "Recovery Plan." Staff Member #22 explained more than one staff could make a daily entry but, "generally each nursing shift charts to the patient's Recovery Plan."

A review of Patient #4's EMR, a current inpatient, did not have daily documentation addressing his/her "Recovery Plan" for January 19, 2019, January 26, 2019, January 27, 2019, and February 1, 2019.

A review of Patient #5's EMR, a current inpatient, did not have daily documentation addressing his/her "Recovery Plan" for January 30, 2019.

A review of Patient #6's EMR, a current inpatient, did not have daily documentation addressing his/her "Recovery Plan" for January 30, 2019 and February 3, 2019.

Patient #7 was admitted on August 9, 2018 and discharged December 11, 2018. The surveyor and the facility staff agreed to review a preset of specific days during the patient's 130-day stay. The preset dates provided seventy-three (73) days/opportunities to be reviewed. The review revealed for seventeen (17) of the preset dates staff failed to make a daily entry/documentation addressing the patient's "Recovery Plan."

Patient #8 was admitted on January 8, 2019 and discharged January 10, 2019. A review of Patient 8's EMR did not reveal daily documentation addressing the patient's "Recovery Plan" for January 8, 2019 and January 9, 2019.

On February 5, 2019 at 4:09 p.m. during the end of the day meeting, the surveyor informed Staff Members #1, #2, #4 and #22 of the findings and requested the facility's policy. Staff Member #22 reported the findings were mostly from staff who worked as needed (PRN) at the facility. The surveyor inquired regarding training for PRN staff. Staff Member #1 stated, "Documentation is part of the on-boarding process that PRN nurses receive. They know what should be reviewed daily." Staff Member #1 agreed the "Recovery Plan" directs the provision of care for the patient and needed to be reviewed daily.

On February 6, 2019 at approximately 10:00 a.m., Staff Member #2 and the surveyor reviewed the facility's policy titled "Documentation for the Provision Of Care." The policy read in part "Purpose: To establish policies and procedures for the initiation, development, implementation, and review of recovery care plans for each patient at [Name of the facility]. Recovery plans are necessary to guide the multidisciplinary treatment team as they attempt to assist the patient in their recovery and return to a less restrictive treatment environment ... A. Routine/Daily Risk Assessments and Reassessments * The RN [Registered Nurse] shall complete daily ... Update the Recovery Plan ..."

Staff Member #2 acknowledged the nursing staff failed to documented a daily review and/or update of the cited patients' "Recovery Plans."