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Based on record reviews and interviews, the hospital failed to ensure grievances were resolved in a timely fashion and following established timelines. This deficient practice was evidenced by failure of the hospital representative to provide written communication to the complainant within 7 days as per hospital policy for 2 of 2 (#2, #3) patient grievances reviewed from a total sample of 3.

Findings:

Review of the hospital's policy titled "PC-803: Patient Rights and Responsibilities", revised 03/2025, revealed in part, "The Lead Investigator will provide the following written communication to the complainant within 7 days. -Description of complaint; -Steps taken to resolve complaint; -Date of completion/resolution"

Patient #2
Review of the Grievance Form revealed Patient #2 filed a grievance with the hospital regarding sexually inappropriate behavior from another patient on 04/29/2025. Further review of the document revealed the level at which the resolution occurred was administrator resolved on 04/30/2025.

Review of the written letter to Patient #2's guardian revealed the letter was dated 05/12/2025.

Patient #3
Review of the Grievance Form revealed Patient #3 filed a grievance with the hospital regarding sexually inappropriate behavior involving another patient on 04/29/2025. Further review of the document revealed the level at which the resolution occurred was administrator resolved on 04/30/2025.

Review of the written letter to Patient #3's guardian revealed the letter was dated 05/12/2025.

In an interview on 05/29/2025 at 10:11 AM S3CCC verified the letters to Patient #2 and Patient #3's guardians were not sent within 7 days as per hospital policy.

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed, and kept current, an individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice was evidenced by failing to update the care plan of 1 of 1 (#3) patient records reviewed for treatment plans from a total sample of 3.

Findings:

Review of the hospital's policy titled "PC-501: Treatment Plans", effective date 07/10/2012, revealed in part, "Policy: Each patient will have an individualized inter-disciplinary treatment plan developed under the direction of the psychiatrist. This comprehensive plan is initiated upon admission following assessments by the various disciplines and will reflect the individual's clinical needs, condition, functional strengths, and limitations. The treatment plan will coordinate treatment interventions and outline individualized specific short-term and long-term goals to evaluate therapeutic progress. The plan will be revised throughout the patient's hospitalization to reflect progress towards the treatment goals. The treatment team is led by the attending psychiatrist and is a collaborative effort to ensure effective treatment planning."

Review of Patient #3's medical record revealed an admission date of 04/09/2025 with a diagnosis of unspecified mood disorder. Further review of the record revealed Patient #3 was in restraints on 04/29/2025 and 05/12/2025. Review of the Behavioral Restraint/Seclusion Flowsheet dated 04/29/2025 revealed restraints were initiated at 5:45 PM and discontinued at 5:55 PM. Review of the Behavioral Restraint/Seclusion Flowsheet dated 05/12/2025 revealed restraints were initiated at 10:16 AM and discontinued at 10:50 AM. Review of the treatment plan failed to reveal the plan was updated after Patient #3 was placed in restraints.

In an interview on 05/29/2025 at 11:47 AM S3CCC verified Patient #3's treatment plan was not updated to include the intervention of restraints.

Based on observation, record review, and interview the hospital failed to ensure supplies were maintained to ensure an acceptable level of safety and quality. This deficient practice was evidenced by failure to ensure expired supplies were not available for patient use.

Findings:

Review of the hospital's policy titled "EC-201: Unsafe Equipment / Repair / Product Recall / Warnings / Alerts", effective date 07/02/2012, revealed in part, "Outdated Supplies: 2. When supplies are found to be expired or compromised, they shall be immediately removed from use and immediately replaced with new/sterile items. 3. No item will be processed for reuse once expiration date or compromising even occurs."

Observation of the hospital on 05/28/2025 at 10:09 AM - 10:38 AM accompanied by S1CEO and S2PD revealed the following supplies were expired and were located in the central supply room:
30 of 30 InteliSwab COVID-19 Rapid Test with an expiration date of 03/31/2024

In an interview during the observation S1CEO verified the above stated supplies were expired.

Based on observations and interviews the hospital failed to maintain a clean and sanitary environment to avoid transmission of infection in all areas of the hospital. This deficient practice was evidenced by 1) clean linen stored on top of the linen cart uncovered; 2) the upholstery of chairs were worn down exposing tiny holes to the seat and/or chair back; and 3) the top load washing machine had multiple rust areas noted to the door, around the top of the drum, and inside the drum and there was white powder caked between the door and drum.

Findings:

A tour of the hospital was conducted on 05/28/2025 at 10:09 AM - 10:38 AM accompanied by S1CEO and S2PD. Observation revealed clean linen stored on top of the clean linen cart uncovered located in the clean workroom. Observation revealed the upholstery of 9 chairs were worn down exposing tiny holes to the seat and/or chair back located in the group therapy room. Observation revealed the top load washing machine had multiple rust areas noted to the door, around the top of the drum, and inside the drum and there was white powder caked between the door and drum located in the laundry room.

In an interview during the observation S1CEO and S2PD verified the above stated findings.