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Based on record review and interview, the hospital failed to ensure the effectiveness of the grievance process to review and resolve patient's grievances. This deficient practice was identified for 1 (#1, #2, #3) of 4 (#1, #2, #3, #4) patient's grievances reviewed. This deficient practice had the potential to affect any patients or representatives filing grievances.
Findings:

Review of the policy and procedure titled, "Patient Grievance Process" effective 01/11/2016 and last revised on 02/01/2023 revealed, in part, the purpose of the policy is to provide an internal process that establishes guidelines for: Submission of a patient and/or family's grievance allegation to the facility; Timely review and investigation of the allegation; Provision of a response; and, Timely referral to the appropriate external agency as deemed necessary. The policy further stated that each facility has identified an individual to serve as the facility's Patient Advocate who is responsible for the follow-up and response to grievances submitted by a patient or caregiver. This facility has adopted an internal grievance process in accordance with Title 42 CFR 482.12 which provides for prompt resolution of patient and/or patient representative concern regarding violation of a patient's rights, quality of care, and other complaints involving the patient's treatment stay. Also, this procedure includes the resolution of grievances alleging any action prohibited by the U.S. Department of Health and Human Services Regulations (45 C.F.R. Part 84) implementing Section 504 of the Rehabilitation Act of 1973 as amended (29 UU.S.C. 794).
Definitions: The policy defined a grievance as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, and/or patient's rights.
Procedure: The grievance procedure indicated, in part, 1. The Patient Advocate logs the grievance allegation onto the "Complaint/Grievance Log" and contacts the patient or representative and opens an investigation to determine the validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation; 2. The patient advocate completes the investigation using the "Grievance Report" within 7 calendar days of the date of the notification or receipt of the grievance allegation; 3. An extension letter should be sent to the grievant if the investigation is ongoing on the 7th day; 4. The patient advocate issues a final written response to the grievant by the 7th day, or no later than the date referenced on the extension letter, from the date of the grievance allegation and will include the name of the facility contact person, the steps taken on behalf of the person reporting to investigate the grievance, the results of the grievance process and the facility's decision, the date of completion and the contact information to appeal the offered resolution. The role of the Patient Advocate was to 2. Complete a thorough investigation of all grievances repressing the expressed desires of the individuals served and advocating for the resolution of their grievances, and 3. Responsible for reporting all grievance investigation findings and resolutions to QAPI committee hierarchy.

Review of the Patient Advocate /Section 504 Civil Rights Coordinator Job Descriiption Addendum revealed, in part, the company reserves the right to change or reassign job duties or to combine positions at any time.

Review of the hospital's most recent organizational chart revealed no position identified as the Patient Advocate.

Review of the Quality Assurance/Performance Improvement Minutes were reconciled with Grievance Log and revealed inaccurate reporting as follows: Review of the QAPI meeting minutes for 05/03/2023 revealed an agenda item titled, "Compliance/Legal". Further review revealed under the heading of Grievances - January 0, February 3 and March 11. Grievance appropriateness was rated as January 0%, February 66.67% and March 100%. Under the columns "Action" and "Responsible Party" sections were left blank.

Review of the Complaint and Grievance Log for January 2023 revealed discrepancies in reporting with 3 grievances documented.

Review of the Complaint and Grievance Log for February 2023 revealed discrepancies in reporting with 2 grievances documented.

Review of the QAPI meeting minutes for 07/21/2023 revealed an agenda item titled, "Compliance/Legal". Further review revealed under the heading of Grievances - April - 1, May 0 and June 3. Grievance appropriateness was rated April 100%, May n/a and June 100%. Under the column "Action" it was noted as "discussion", and under the column "Responsible Party" it was noted as "Administrator".

Review of the Complaint and Grievance Log for May 2023 revealed discrepancy in reporting with 1 grievance documented.

Based on review of grievances filed for 3 (Pt. #1, Pt. #2 and Pt. #3) of 4 (Pt. #1, Pt. #2, Pt. #3 and Pt. #4) patients sampled, the following deficient practices were noted:

Patient #1
Review of a grievance filed by or on behalf of Patient #1 revealed on 02/16/2023 Patient #1 filed a grievance related to patient care, personnel and patient rights.

On 02/17/2023 Patient #1 was sent an acknowledgement letter related to the grievance and notification of an extension necessary to conduct the investigation.

On 03/13/2023 Patient #1 was sent a follow-up letter regarding the grievance, however, there was no evidence to demonstrate what steps the hospital took to ensure the grievance was sufficiently investigated and the hospital's findings.


Patient #2
Review of a grievance filed by or on behalf of Patient #2 revealed on 12/29/2022 Patient #2 filed a grievance related to patient care and personnel.

On 01/05/2023 Patient #2 was sent an acknowledgement letter signed and dated by S1DCS and notification of an extension for a final resolution date of 01/30/2023

Review of the Patient Advocate binder revealed no evidence that an investigation took place or that a final resolution was sent to Patient #2 by 01/30/2023.

Patient #3
On 03/19/2023 Patient #3 filed a grievance related to patient care, patient rights and personnel including a potential breech in confidentiality/HIPAA.

Review of the Patient Advocate binder revealed Patient #3 was sent a letter of acknowledgement by the previous administrator of the hospital on 03/23/2023.

Further review of the Patient Advocate binder revealed no evidence of how the investigation was conducted, the results of that investigation and notification to Patient #3 the results of the hospital's investigation, action taken or findings.

In an interview on 08/21/2023 at 2:15 p.m., S2QM indicated there were no additional documents available related to the hospital's attempts to investigate the grievances filed by Patient #1, Patient #2 or Patient #3.

In an interview on 08/21/2023 at 2:27 p.m., S2QM indicated the current patient advocate is S1DCS and the patient advocate prior to that was the previous administrator.

In an interview on 08/21/2023 at 2:35 p.m. S1DCS indicated she was just assigned to the role of Patient Advocate last week and that she was previously the Patient Advocate until December of 2022. S1DCS verified that she is currently the Patient Advocate at this location and the activity therapist is the Patient Advocate at the other location.S1DCS verified the previous administrator was the Patient Advocate beginning January 2023 through last week and that all investigative material including evidence of the investigations were in the Patient Advocate binder.

Review of the Patient Advocate binder revealed no evidence of investigative materials, steps taken or actions documented related to the aforementioned grievances filed.

In an interview on 08/22/2023 at 1:43 p.m., S2QM indicated the documents provided on the first day of the survey was all that was available related to the aforementioned grievances.

In an interview on 08/22/2023 at 3:45 p.m. S__CC indicated the Patient Advocate position is not a position with a single role. Further interview indcated a clarification that the Patient Advocate is appointed to personnel who already have other job titles, such as the Director of Clinical Services or the Administrator.

Based on record review and interview, the hospital failed to provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion for 3 (#1, #2, #3) of the 4 (#1, #2, #3 and #4) grievances filed. This deficient practice has the potential to affect any patient or patient's representative filing a grievance.
Findings:

Patient #1
Review of a grievance filed by Patient #1 revealed on 02/16/2023 Patient #1 filed a grievance related to patient care, personnel and patient rights.

On 03/13/2023 Patient #1 was sent a follow-up letter regarding the action taken as a result of the grievance, however, the letter did not include the date of completion of the investigation or the steps taken to investigate the grievance.

Patient #2
Review of a grievance filed by Patient #2 revealed on 12/29/2022 Patient #2 filed a grievance related to patient care and personnel.

Review of the Patient Advocate binder revealed no evidence that an investigation took place or that a final resolution was sent to Patient #2 by 01/30/2023.

Patient #3
On 03/19/2023 Patient #3 filed a grievance related to patient care, patient rights and personnel.

Review of the Patient Advocate binder revealed no evidence of how the investigation was conducted, the results of that investigation and notification to Patient #3 by the extension date of 01/30/2023 the results of the hospital's investigation and findings.

In an interview on 08/22/2023 at 1:43 p.m., S2QM verified there was no additional evidence related to the grievances filed by the aforementioned patients.

Based on record review and interview, the hospital failed to ensure the patient's right to participate in the development of their plan of care. This deficient practice was evidenced in 2 (#2, #3) of the 5 (#1, #2, #3, #4 and #5) medical records review for treatment planning. This deficient practice has the potential to affect any patient receiving services at this hospital.
Findings

Review of the policy and procedure titled, "Treatment Planning: Integrated Multidisciplinary" effective 01/11/2016 and last revised on 04/01/2021 revealed, in part, the treatment plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment tea, with the patient's involvement, throughout the course of treatment. The treatment plan shall be signed by all members of the interdisciplinary team. If the patient is unable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient's medical record.

Patient #2
Review of the medical record for Patient #2 revealed an admit date of 12/25/2022 with diagnoses of Schizoaffective Disorder, Bipolar and Anxiety Disorder. Further review revealed a treatment plan start date of 12/27/2022 with no signatures by the RN or patient, and there was no documentation regarding the reason Patient #2 did not participate in the development of the plan of care.

Patient #3
Review of the medical record for Patient #2 revealed an admit date of 3/10/2023 with diagnoses of Acute Psychosis related to Alcohol Abuse and Bipolar Mood Disorder. Further review revealed a treatment plan start date of 03/15/2023 with no signatures by the RN or patient, and there was no documentation regarding the reason Patient #3 did not participate in the plan of care.

In an interview on 08/22/2023 at 1:43 p.m., S2QM verified the absence of signature by all members of the multi-disciplinary treatment team and the patients identified above.

Based on record review and interview, the hospital failed to ensure the verbal orders were used to meet the care needs of the patient as evidenced by incomplete documentation of a discharge order for 1 (#1) of 5 (#1-#5) patient's medical records reviewed for discharge orders. This deficient practice had the potential to affect any patients being discharged from the hospital.
Findings:

Review of the policy and procedure related to physician's orders revealed this procedure was included in the medical staff rules and regulations, part 14, reading in part, all orders for treatment must be in writing. An order will be considered to be in writing if dictated to authorized personnel including any RN, LPN or other allied health Professional within the scope of their professional practice. Orders dictated shall be authenticated by the prescriber within the timeframes specific to the state in which the order is executed.

Review of the policy and procedure titled, "Verbal Orders" effective date 01/11/2016 and last revised on 12/01/2022 revealed, in part, verbal communication of orders is limited to urgent situations in which immediate written or electronic communication is not feasible. 6. Documentation of verbal orders must include all components of a valid written order.

Review of the verbal discharge order for Patient #1 revealed a failure to document the justification for the prescribing of multiple antipsychotic medications upon discharge, and the patient's activity, diet, condition, prognosis and follow-up appointments upon discharge.

In an interview on 08/22/2023 at 1:43 p.m., S2QM verified the insufficient documentation related to the discharge order.

Based on record reviews and interviews, the hospital failed to ensure discharge orders for medications included the indication for use on 1 (#1) of 5 (#1-#5) records reviewed for medication orders. This deficient practice had the potential to impact any patient receiving medications while in the hospital and upon discharge from the hospital.
Findings:

Review of the Medical Staff's Rules and Regulations included, in part, 3. For medication orders, prescribers will include the indication for use of the drug to ensure that the order makes sense in the context of the patient's condition.

Patient #1
Review of Patient #1's medical record revealed an admit date of 02/21/2023 for depression with suicidal ideation. Subsequently, on 02/20/2023 Pt. #1 was discharged to home with self-care.

Review of the discharge medication reconciliation order/transition record revealed the following medications were prescribed upon discharge, did not contain possible side effects and did not document the indications which could impact patient compliance with medications prescribed as follows:
Remeron 15mg by mouth once daily at 9:00 p.m.;
Norvasc 10mg by mouth once daily at 9:00 a.m.;
Multi-vitamin by mouth once daily at 9:00 a.m.;
Prenatal vitamin by mouth once daily at 9:00 a.m.;
Vistaril 50mg by mouth three times per day beginning at 2:00 p.m.; and,
Prozac 60mg by mouth once daily at 9:00 a.m.

In an interview on 08/22/2023 at 1:43 p.m., S2QM verified there were no indications documented on the discharge reconciliation form as per the medical staff rules and regulations.

Based on record review and interview, the hospital failed to ensure a patient was assessed by the physician on the day of discharge to ensure the safety of the patient. This deficient practice was evidenced by review of 1 (#2) of 5 (#1, #2, #3, #4 and #5) discharge records reviewed for compliance with discharge procedures.
Findings:

Review of the "Medical Staff Rules and Regulations" revealed, in part, the attending medical staff will be responsible for the preparation of a complete and legible medical record for each patient. Its content shall be pertinent and current for the patient and shall include, in part, condition on discharge, and instructions given for further care, such as medications, diet or limitations of activity.

Review of the medical record of Patient #2 revealed, in part:
A discharge order written by a Nurse Practitioner on 12/30/2022 at 9:40 p.m.;
MD authentication of the order on 12/31/2022;
Patient #2 left the hospital on 01/01/23 at 7:35 p.m. or 45 hours and 55 minutes following the initial verbal discharge order. There was no evidence that the attending MD assessed the patient on the date of discharge.

In an interview on 08/22/2023 at 1:35 p.m., S2QM verified the order was written approximately 2 days prior to discharge, and the physician authenticated the order the day prior to discharge.