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Based on interview and record review the hospital failed to ensure the right of the patient to receive, at the time of admission, information about the hospital's patient rights policy(ies) including the mechanism for the initiation, review, and when possible, resolution of patient complaints concerning the quality of care; in that,

9 of 9 patient (Patient #1, #2, #3, #4, #5, #6, #7, #8, and #9) records did not document patient receipt of patient rights including the mechanism for the initiation, review, and when possible, resolution of patient complaints concerning the quality of care.

Findings included

Patient #1's, #2's, #3's, #4's, #5's, #6's, #7's, #8's, and #9's records did not document patient receipt of patient rights including the mechanism for the initiation, review, and when possible, resolution of patient complaints concerning the quality of care.


During an interview on 2/01/17 at 3:00 PM, Personnel #2 was informed of the above findings. Personnel #2 confirmed the findings. Personnel #2 stated, "They used to have it on the consent for treatment form. It is not there."

The facility's 11/20/15 "Complaint/Grievance Process" required, "The patient/patient representative shall be informed of whom to contact to file a complaint/grievance in the facility...additionally, information - telephone number and address - shall be provided in regards to lodging a complaint with the State hospital licensure agency..."

Based on record review and interview, the hospital failed to ensure the patient right to recieve a written notice of the 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 in the resolution of submitted grievances was provided, at a minimum, in that,

5 of 9 reviewed (Patient #2, #3, #4, #5, and #7) grievances did not document initial hospital letters (within 7 days) or resolution hospital letters (14 - 30 days) that contained 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 in the resolution of submitted grievances to the complainant.

Findings included

Patient #2's, #3's, #4's, #5's, and #7's grievance did not document timely initial hospital letters or resolution hospital letters to the complainant.

Patient #2's/daughter's grievance on 2/24/16 documented an initial hospital letter after the 7 day timeframe on 3/09/16 and no resolution letter.

Patient #3's 4/13/16 complaint submitted after his 3/03/16 discharge and did not document a timely initial or resolution letter.

Patient #4's 8/16/16 grievance was received after his 8/10/16 discharge and did not document a timely initial or resolution letter.

Patient #5's 9/13/16 grievance did not document a timely initial or resolution letter and remained unresolved at the time of survey.

Patient #7's/friend's grievance was received after his discharge and did not document a timely initial or resolution letter. There was an address on file for both the patient and the friend.

During an interview on 2/02/17 at 9:25 AM, Personnel #5 was informed of the above findings. Personnel #5 confirmed the findings and stated, "Not many letters to patients. Most of our contact is verbal." Personnel #5 was asked to review the policy stated below. Personnel #4 read the policy and agreed it was correct.

The facility's 11/20/15 "Complaint/Grievance Process" required, "A patient grievance is defines as a written or verbal complaint when the verbal complaint is not resolved at the time of the complaint by staff present...regarding the patient's care, abuse, neglect, issues related to the hospital's compliance with the CMS Hospital (Conditions for Coverage) CoP's...postponed for later resolution...referred to other staff for later resolution...requires investigation and/or further actions for resolution...The Hospital Quality Improvement Committee ensures the patient is provided written notice of its decision regarding a complaint/grievance within seven (7) days of the Hospital's receipt...notice shall contain the following: Hospital contact person...steps...to investigate the grievance...results...Date of completion...investigation will be initiated within 72 hour...The CEO or Senior Leader Designee, is responsible for finalizing and sending a resolution letter...initial letter shall be sent no later than 7 days from notification...The resolution response letter shall be mailed...goal of 14 business days and no longer that 1 month..."

Based on record review and interview, the facility failed to ensure an RN (registered nurse) supervised and evaluated the nursing care for each patient according to the patient's needs, in that;

Patient #3 had an unknown, unsupervised, elopement outside the hospital on 3/03/16 and there was no RN patient assessment documented upon his return.

Findings included

There was no documented RN reassessment after the return of Patient #3 on 3/03/16 after his unknown, unsupervised, elopement outside the hospital.

During an interview on 2/02/17 at 12:27 PM, Personnel #3 was asked for the patient's reassessment by the RN after his return from the elopement on 3/03/16. Personnel #3 stated she did not find one. Personnel #3 was asked if there should have been a reassessment. Personnel #3 stated, "Absolutely."