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Based on hospital policy review, grievance review, and staff interview, it was determined the hospital failed to ensure a clear process for employees to identify, report, track, and respond to patient grievances for 4 of 4 patients (#3, #6, #10, and #11) whose grievances were reviewed. Misidentification of grievances as complaints had the potential to result in missed opportunities for patients' grievances to be entered, tracked, responded to, and reported for follow-up by hospital staff. Findings include:

A hospital policy "Grievance Patient," revised June 2019, stated:

- "If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements."

- "An unresolved written complaint is always considered a grievance. This includes written complaints from an inpatient, a discharged patient, or a patient's representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with CoPs."

- "Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding the patient's care or with an allegation of abuse or neglect, or a failure of the hospital to comply with one or more CoPs or other CMS requirements."

This policy was not followed. Examples include:

1. Patient #3 was a 22 year old female who was admitted to the hospital on 9/10/19, with an admitting diagnosis of depressive disorder. Other diagnoses included history of eating disorder and fibromyalgia. She was a current inpatient at the time of survey.

a. An "Issue Submission Form" was submitted by "[Patient #3] & Father [name]" to the hospital on 9/12/19, and was documented as "This issue is a: Complaint." The form included a section titled "Issue Received via" which stated, "Phone." The form included a section titled "Description of Issue & Resolution," which stated, "I spoke with both [Patient #3] and her father [name]. Both were generally concerned about the lack of professionalism of staff and about the inattention to [Patient #3's] requests (for hot packs, shower, UTI tests etc.) [Patient #3's father] has requested that [Patient #3] see an NP daily and have the same psychiatrist. What would help him is knowing his main points of contact for [Patient #3]. [Patient #3] would like the results of her UTI test and blood work." The form included a section titled "Resolution Date" which stated, "9/16/19," which was 4 days after the grievance submission.

Patient #3's and her father's concerns were not immediately resolved. It was unclear why they were treated as complaints and not as grievances.

b. An "Issue Submission Form" was submitted by "[Patient #3]" to the hospital on 8/30/19, and was documented as "This issue is a: Complaint." The form included a section titled "Issue Received via" which stated, "Letter/Email." The form included a section titled "Description of Issue & Resolution," which stated, "Patient complained about interactions with RN [name] (see attached complaint). I met with [Patient #3] on 8/31/19 and listened to her concerns. I informed [Patient #3] she'd be working with a different nurse that day and let her know I'd also speak with the RN [name]. [Patient #3] found this an acceptable solution and didn't request further action/ follow up. DON [name] followed up with [RN] on 9/03/19 an [sic] provided documentation of coaching conversation (see attached email). No further action required." The form included a section titled "Resolution Date" which stated, "9/04/19," which was 5 days after the grievance submission. Patient #3's handwritten grievance was attached to the form.

Patient #3's concern was submitted in writing and not immediately resolved. It was unclear why it was treated as a complaint and not a grievance.

The Director of Risk Management was interviewed on 9/25/19, beginning at 1:08 PM, and Patient #3's grievances were reviewed in her presence. She confirmed the issues submitted by Patient #3 and her father should have been identified as 2 separate grievances and documented as such. The Director of Risk Management stated the 2 separate grievances should have been investigated and provided resolution letters as to their dispositions. Additionally, she confirmed Patient #3's handwritten complaint should have been identified as a grievance and should have been provided a resolution letter as to its disposition.

Patient #3's concerns were not identified as grievances and not did not have written grievance resolutions.



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2. Patient #6 was a 36 year old female, admitted to the hospital on 7/17/19, with an admitting diagnosis of psychosis. She was discharged on 8/09/19. Her record was reviewed.

A grievance submitted by Patient #6 on 7/20/19, was reviewed. In the box titled "Investigation Results; Corrective Actions" it stated, "Received the attached Grievance/Concern Communication from [Patient #6] dated 7/20/19 at [5:30 AM] and [1:00 PM]. I was out on [Paid Time Off] on 7/23. Upon returning to work, I met with [Patient #6] on 7/24/19." The box detailed a conversation between the Patient Advocate and Patient #6 regarding her concerns, including her statement she was denied the right to make phone calls. It stated the Patient Advocate would take her request to make phone calls to the nursing staff. The form did not include documentation of an investigation into Patient #6's complaints.

The grievance information provided did not include a written response to Patient #6, for her grievance submitted on 7/20/19. The grievance form included an "X" next to the statement, "NOT Classified as a Grievance." The form stated a written response was not required.

The hospital's Patient Advocate was interviewed on 9/26/19 at 8:30 AM. She stated Patient #6's complaint was written and submitted to a hospital staff member on 7/20/19. The staff member was unable to resolve the complaint, and it was forwarded to the Patient Advocate, who received it when she returned to work on 7/24/19. She stated she spoke to Patient #6 on 7/24/19, and communicated with nursing staff regarding phone usage. The Patient Advocate confirmed she did not complete an investigation into Patient #6's complaint that she was denied access to a phone prior to 7/20/19. Additionally, the Patient Advocate stated Patient #6's complaint was not resolved at the time it was submitted and therefore, became a grievance. She stated Patient #6 should have received a written response, detailing an investigation and resolution of the grievance.

3. Patient #10 was a 51 year old female, admitted to the hospital on 8/11/19, with an admitting diagnosis of major depressive disorder. She was discharged on 8/21/19. Her record was reviewed.

A grievance submitted by Patient #10 on 8/16/19, was reviewed. In the box titled "Investigation Results; Corrective Actions" it stated, "[Patient #10] left a vm [voice mail] on Friday 8/16 that stated she is concerned that she has not seen the medical practitioner. I met with [Patient #10] on 8/19 and she stated that she had seen the doctor this morning but that she had been denied seeing a medical practitioner for two days. No further action needed." The form did not include documentation of an investigation into Patient #10's complaint that she was denied a medical practitioner visit for 2 days prior to 8/16/19.

The grievance information provided did not include a written response to Patient #10. The grievance form included an "X" next to the statement, "NOT Classified as a Grievance." The form stated a written response was not required.

The hospital's Patient Advocate was interviewed on 9/26/19 at 8:45 AM. She stated Patient #10's complaint was left on her voice mail after she left the office for the day on Friday, 8/16/19. She stated she received the voice mail on Monday, 8/19/19. The Patient Advocate stated after hearing the voice mail she reviewed Patient #10's medical record and noted she was seen by a PA on 8/17/19, and by an NP on 8/19/19. She stated she spoke to Patient #10 on 8/19/19, and verified she was seen by an NP earlier that day. The Patient Advocate confirmed she did not complete an investigation into Patient #10's complaint that she was denied a medical practitioner visit for 2 days prior to 8/16/19. Additionally, the Patient Advocate stated Patient #10's complaint was not resolved at the time it was submitted and therefore, became a grievance. She stated Patient #10 should have received a written response, detailing an investigation and resolution of the grievance.

Grievances submitted by Patients #6 and #10 were not investigated. The patients did not receive written responses to their grievances, including investigation details, results, and dates of completion.



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4. Patient #11 was a 28 year old male who was admitted to the hospital on 8/18/19, with an admitting diagnosis of major depressive order, recurrent severe without psychotic features.

The "Cottonwood Creek Complaint/Grievance Log 3/24/2019 thru 9/24/2019" was provided. Entry 1922 was documented as a "complaint" received by letter/email with an issue date of 9/01/19. Emails from Patient #11's mother, dated 9/01/19, 9/06/19, and 9/18/19 from the hospital's Patient Advocate were reviewed. Resolution of Patient #11's concern was documented that Patient #11 was reimbursed on 9/17/19 for missing personal items.

The Patient Advocate was interviewed on 9/26/19 beginning at 8:30 AM, and Patient #11's documentation was reviewed in her presence. The Patient Advocate stated she was not aware patient concerns provided via email were considered a written grievance and needed to be addressed and completed.

Patient #11's concern, submitted by his mother via email, was not identified as a grievance and did not include a written grievance resolution.

Based on medical record review, hospital policy review, staff interview, and patient interview, it was determined the hospital failed to ensure patients were allowed to make informed decisions regarding their treatment for 1 of 2 current inpatients (Patient #3) who were interviewed and whose records were reviewed. This resulted in patients not being involved in their treatment decisions. Findings include:

A hospital policy "Patient Rights," revised August 2018, stated "every patient, or his designate [sic] representative, where appropriate shall have the opportunity to participate to the fullest extent possible in planning for his [sic] care and treatment." This policy was not followed.

Patient #3 was a 22 year old female who was admitted to the hospital on 9/10/19, with an admitting diagnosis of depressive disorder. Other diagnoses included history of eating disorder and fibromyalgia. She was a current inpatient at the time of survey.

Patient #3's medical record included an admission "NURSING ASSESSMENT," dated 9/10/19, signed by an RN. The assessment included a section titled "Admitted by:" which stated, "W/Chair [wheelchair.]"

Patient #3's medical record included a physician order, dated 9/11/19, signed by a physician, which stated "Please provide [illegible] w/c [wheelchair] with feet holders."

Patient #3's medical record included a "NURSING REASSESSMENT - DAY," dated 9/11/19, signed by an RN, which stated, "Pt is still reporting some dizziness and is in a wheelchair."

Patient #3's medical record included a "NURSING REASSESSMENT - EVE/NIGHT," dated 9/11/19, signed by an RN, which stated, "Patient remains in wheelchair due to dizziness and unsteady gait."

Patient #3's medical record included a "NURSING ASSESSMENT - DAY," dated 9/12/19, which stated, "Pt was seen by [medical group] for the urinary s/s, antibiotic given, and always 2 staff are going to the room together. Pt transferred to the ICU for closer monitoring." The assessment included a section titled "Ambulation" which stated "Wheelchair." There was no further documentation regarding Patient #3's wheelchair in subsequent assessments. It was unclear if she still had her wheelchair or if it was taken from her.

Patient #3 was a current inpatient at the time of survey and was interviewed on 9/25/19, beginning at 12:02 PM. When asked if she had a wheelchair, Patient #3 stated she had one when she first arrived at the hospital because of her pain, but it was taken from her after she was transferred to the hospital's higher acuity wing (ICU). When asked why the wheelchair was taken from her, Patient #3 stated she was unsure and wasn't told.

The DON was interviewed on 9/26/19, beginning at 8:47 AM, and Patient #3's medical record was reviewed in her presence. When asked if Patient #3's wheelchair was taken from her, she stated, "yes." The DON stated Patient #3's wheelchair was taken from her because ICU staff felt Patient #3 no longer needed it, as she was ambulating without issue. The DON confirmed this was not documented in Patient #3's medical record. Additionally, the DON was unable to provide a physician order to discontinue Patient #3's wheelchair.

Patient #3 was not allowed to make informed decisions regarding her mobility care treatment.

Based on medical record review, policy review, and staff interview it was determined the hospital failed to ensure a process was in place to ask patients if they wanted a family member or representative of his or her choice, and his or her own personal physician notified promptly of their admission to the hospital. This had the potential to interfere with the ability of patients to coordinate their personal and healthcare needs. Findings include:

Ten patient medical records were reviewed. Ten of 10 medical records did not include documentation that patients were asked if they wanted a family member or representative and their physician notified promptly of their admission.

A policy was requested related to the process of ensuring patients were asked at admission if they wanted a family member or representative and their personal physician notified promptly of their admission to the hospital. However, a policy was not provided.

The Director of Nursing, the Director of Risk Management, and the Director of Admissions confirmed during staff interview on 9/25/19 beginning at 3:01 PM the hospital did not ask patients if they wanted a family member or representative of his or her choice, and his or her own personal physician notified promptly of their admission to the hospital. Staff acknowledged the facility did not have a policy, process, or procedure to ensure this was done.

The hospital did not have a process in place to ensure patients were asked if they wanted a family member or representative and a personal physician notified promptly of their admission to the hospital.

Based on medical record review and staff interview, it was determined the hospital failed to ensure patients received accurate and complete suicide risk assessments for 3 of 10 patients (#3, #8, and #9) whose records were reviewed. This had the potential to negatively impact patient care in a safe setting. Findings include:

1. Patient #3 was a 22 year old female who was admitted to the hospital on 9/10/19, with an admitting diagnosis of depressive disorder. Other diagnoses included history of eating disorder and fibromyalgia. She was a current inpatient at the time of survey.

Patient #3's medical record included an admission "NURSING ASSESSMENT," dated 9/10/19, signed by an RN. The assessment included a section titled "SUICIDE RISK ASSESSMENT" in which the RN scored Patient #3 as a "22" on a scale of 0 - 21, with 21 being the highest risk. Underneath the score of 22, the form included the following 3 risk categories and associated interventions:

- "0 - 7 LOW (Patient Denies or has no evidence of suicidal ideation upon assessment" and 1 checkbox option of "Place patient on Routine Q15 minute observations and monitoring for any change in status."

- "8 - 14 MODERATE (Patient has identified some thoughts regarding wishing to die that places patient at risk" and 2 checkbox options of "Place patient on Suicide Precautions" and/or "Place patient on Q5 minute observations until Provider has been notified."

- "15 - 21 HIGH (Patient has active thoughts of suicide with desire)" and 2 checkbox options of "Place patient on Suicide Precautions" and/or "Place patient on 1:1 observation until Provider has been notified."

The "0 - 7 LOW" section, and associated interventions, was checked by Patient #3's RN despite the fact she was assessed as a high suicide risk with a score of 22. It was unclear why the "0 - 7 LOW" section was checked by Patient #3's RN.

Additionally, the form included the following 6 questions which were completed by Patient #3's RN:

- "If Yes, did the patient have such thoughts and/or plans anytime in the past week?...Yes"

- "If Yes, did the patient have such thoughts and/or plans anytime in the past month?...Yes"

- "If Yes, did the patient have such thoughts and/or plans anytime in the past 6 months?...Yes"

- "Has the patient made an attempt anytime in the past week?...Yes"

- "Has the patient made an attempt in the past month?...Yes"

- "Has the patient made an attempt in the past 6 months?...Yes"

The bottom of the suicide risk assessment included a section for physician notification. Patient #3's RN documented a physician's name, but did not indicate the date or time of the notification. It could not be determined when Patient #3's physician was notified of her high suicide risk. It was unclear how Patient #3 was kept safe.

The DON was interviewed on 9/26/19, beginning at 8:47 AM, and Patient #3's medical record was reviewed in her presence. She confirmed it was not clear why Patient #3's RN marked low suicide risk when she was assessed as a high suicide risk. The DON stated the physician may have overridden Patient #3's suicide risk and associated interventions, but confirmed it was not documented. She confirmed Patient #3's suicide risk assessment interventions were not accurate.

Interventions based on Patient #3's suicide risk assessment were not accurate.

2. Patient #8 was a 19 year old female who was admitted on 8/13/19, with an admitting diagnosis of major depressive disorder. Additional diagnoses included multiple suicide attempts and PTSD. She was committed to a State psychiatric facility on 8/23/19.

Patient #8's medical record included a "NURSING ASSESSMENT - DAY," dated 8/14/19, signed by an RN. The assessment included a section titled "Suicide/Homicide Risk (Describe in [narrative])." Under this section were 2 options: "Ideations" and "Plan." The RN documented Patient #8 had suicidal ideations, however, did not document a description of the ideations in the narrative. It was unclear what suicidal ideations Patient #8 had.

Patient #8's medical record included a "NURSING ASSESSMENT - DAY," dated 8/15/19 at 10:00 AM, signed by an RN. The assessment included a section titled "Suicide/Homicide Risk (Describe in [narrative])." Under this section were 2 options: "Ideations" and "Plan." This section was left blank. It could not be determined if Patient #8 was assessed for suicidal ideations/plan by her RN. Later that shift, at 2:00 PM, the same RN documented "Before lunch [Patient #8] took a piece of clothing around neck while she took a shower. Told pt to come talk with me if feeling like doing something like that again. Pt agreed."

Patient #8's medical record included a "Medical Progress Note," dated 8/16/19, signed by a PA, which stated, "[Patient #8] also attempted self-strangulation...She attempted to strangle herself in the shower last night and has marks on her neck...She used a piece of clothing to do so."

Patient #8's medical record included a "NURSING ASSESSMENT - DAY," dated 8/16/19, signed by an RN. The assessment included a section titled "Suicide/Homicide Risk (Describe in [narrative])." Under this section were 2 options: "Ideations" and "Plan." The RN documented Patient #8 had suicidal ideations and a plan, however did not document a description of the ideations and plan in the narrative. It was unclear what suicidal ideations and plan Patient #8 had.

Patient #8's medical record included a "NURSING ASSESSMENT - DAY," dated 8/17/19, signed by an RN. The assessment included a section titled "Suicide/Homicide Risk (Describe in [narrative])." Under this section were 2 options: "Ideations" and "Plan." The RN documented Patient #8 had suicidal ideations and a plan, however did not document a description of the ideations and plan in the narrative. It was unclear what suicidal ideations and plan Patient #8 had.

Patient #8's medical record included a "NURSING ASSESSMENT - DAY," dated 8/18/19, signed by an RN. The assessment included a section titled "Suicide/Homicide Risk (Describe in [narrative])." Under this section were 2 options: "Ideations" and "Plan." The RN documented Patient #8 had suicidal ideations and a plan, however did not document a description of the ideations and plan in the narrative. It was unclear what suicidal ideations and plan Patient #8 had.

Patient #8's medical record included a "NURSING ASSESSMENT - DAY," dated 8/19/19, signed by an RN. The assessment included a section titled "Suicide/Homicide Risk (Describe in [narrative])." Under this section were 2 options: "Ideations" and "Plan." The RN documented Patient #8 had suicidal ideations and a plan, however did not document a description of the ideations and plan in the narrative. It was unclear what suicidal ideations and plan Patient #8 had.

The DON was interviewed on 9/26/19, beginning at 9:10 AM, and Patient #8's medical record was reviewed in her presence. She confirmed Patient #8's suicide risk assessments were not complete.

Patient #8's suicide risk assessments were not complete.



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3. Patient #9 was a 30 year old male who was admitted to the hospital on 8/26/19, with an admitting diagnosis of major depressive disorder, single episode, severe without psychotic features. He was a current inpatient at the time of survey.

Patient #9's medical record included a local acute care hospital ED provider and LMSW documentation, dated 8/25/19. The ED provider notes, dated 8/25/19, signed by the ED physician stated Patient #9's chief complaint was "Suicide Ideation" and "Patient told police that he was trying to kill himself." The LMSW documentation, dated 8/25/19, stated "Pt endorses at least one suicide attempt while in jail...in which he tried to strangle/hang himself with a bedsheet and a spoon. It is somewhat unclear what pt.'s intent was today when he was running through traffic; at times he says he was running away from people who were following him and at other times he says he was trying to die."

Patient #9's medical record included an admission "NURSING ASSESSMENT," dated 8/26/19, signed by an RN. The assessment included a section titled "SUICIDE RISK ASSESSMENT" in which the RN scored Patient #9 as a "8" on a scale of 0 - 21, with a score of 8 placing the patient in the low end of the moderate scale of 8 - 14.

Underneath Patient #9's risk assessment score of 8, the form included the following 3 categories and associated interventions:

- "0 - 7 LOW (Patient Denies [sic] or has no evidence of suicidal ideation upon assessment" and 1 checkbox option of "Place patient on Routine Q15 minute observations and monitoring for any change in status."

- "8 - 14 MODERATE (Patient has identified some thoughts regarding wishing to die that places patient at risk" and 2 checkbox options of "Place patient on Suicide Precautions" and/or "Place patient on Q5 minute observations until Provider has been notified."

- "15 - 21 HIGH (Patient has active thoughts of suicide with desire)" and 2 checkbox options of "Place patient on Suicide Precautions" and/or "Place patient on 1:1 observation until Provider has been notified."

The "8 - 14 MODERATE" section was checked by Patient #9's RN. The box "Place patient on Suicide Precautions" was checked, but the box "Place patient on Q5 minute observations until Provider has been notified" was not checked.

Additionally, the form included the following 6 questions which were not completed by Patient #9's RN:

- "If Yes, did the patient have such thoughts and/or plans anytime in the past week?...No"

- "If Yes, did the patient have such thoughts and/or plans anytime in the past month?...Yes"

- "If Yes, did the patient have such thoughts and/or plans anytime in the past 6 months?" Neither box was checked.

- "Has the patient made an attempt anytime in the past week?" Neither box was checked.

- "Has the patient made an attempt in the past month?" Neither box was checked.

- "Has the patient made an attempt in the past 6 months?" Neither box was checked.

The bottom of the suicide risk assessment included a section for physician notification as well as instructions "If Score is Moderate or High, Provider must be notified." This section was blank. It could not be determined if Patient #9's physician was notified of his suicide risk and if the physician determined Patient #9's observation status and subsequent interventions were appropriate. It was unclear how Patient #9 was kept safe.

A "Psychiatric Progress Note," dated 8/27/19, signed by a psychiatrist, stated, "Nursing staff had reported that patient was found attempting to choke himself with a shower curtain and patient has since been placed on acute 5 minute observations and limited access to clothing, shower curtain and bedding."

The DON was interviewed on 9/26/19, beginning at 8:47 AM, and Patient #9's medical record was reviewed in her presence. She confirmed the process to complete the suicide risk assessment was not consistent between all nursing staff regarding Q15 minute observations versus Q5 minute observations. The DON stated her expectation was for the RN to document suicide precautions and communicate with the physician on the decision to leave the patient on the minimum Q15 minute observations or increase to Q5 minute observations. Additionally, she confirmed admission documentation provided to the hospital during patient admission should be included as part of the suicide risk assessment. The DON confirmed there was no defined process to include admission data in determining a patient's suicide risk assessment score. Finally, the DON stated the 6 questions regarding a patient's suicidal thoughts and attempts should be factored in to the overall risk assessment score; however, she confirmed a uniform process and scoring matrix for the 6 questions were not defined or explained to staff.

The DON stated the physician may have determined the minimum Q15 minute observation checks instead of the Q5 minute observation checks, but confirmed this was not documented.

Patient #9's suicide risk interventions were based upon an inaccurate suicide risk assessment.