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Based on policy and procedure review, grievance review and staff interviews, the facility staff failed to follow the grievance process in 3 of 3 sampled grievances (Patient #6, Patient #5 and Patient #7).

The findings included:

Review of the policy and procedure titled "Patient Grievance/Complaint" reviewed 05/25/2021 revealed "POLICY: ...C. All complaint and/or grievances are addressed in a timely manner and an appropriate intervention or response is provided to the patient and/or family member ...E. Patient grievances whether written or verbal shall be documented on a Compliment, Complaint, Suggestion Form. F. Patient Advocate is the designated individual responsible for the facilitation of patient/family grievances. G. If the grievance is not resolved with the Unit Staff, Nurse, Nursing Supervisor/Director, Program Manager, or Milieu Manager, the patient may contact the hospital Patient Advocate the next working day...Patient Advocate will investigate the grievance...Definitions: A patient grievance is defined as a formal, written or verbal grievance which is filed by a patient, when a patient issue cannot be resolved promptly by staff present...PROCEDURE:...D. Patients and/or families...may contact the facility...E. Patient Advocate who will make contact with the patient making the request within two working days of receipt of the grievance. 1. Jointly, the patient and the Patient Advocate will discuss the patient's verbal or written request in order to clarify the patient's concerns and formulate a statement of grievance. 2. Should the Patient Advocate and the patient come to a resolution of the problem expressed, no further action will be necessary. 3. A written response will be provided to the patient within (7) seven working days of the initial meeting of the Advocate and the patient..."

1. Review of a Discharge summary dated 12/07/2020 revealed a 59-year-old male was admitted on 10/10/2020 for aggression with diagnosis of Lewy Body and Alzheimer's dementia (Neurological diseases that affects thinking, memory loss, movement, behavior, and mood). Patient #6 was discharged to a long-term care facility on 12/07/2020. Review of the wife's emails sent to MSW #4 dated 12/07/2020 at 1609 revealed "...I could not believe his nails and his matted hair. It hurt me so to see him that way for I kept him so clean and manicured...."

Interview on 07/14/2021 at 1030 with Therapist #4 revealed the wife sent the emails after patient #6 was discharged. Interview revealed the wife's statements about his matted hair and nails were not sent to management. Interview revealed the concerns should have been sent to risk management for investigation.

Interview on 07/14/2021 at 1430 with DON #2 revealed the wife's concerns were never escalated to the Risk management staff for investigation. Interview revealed the policy was not followed.



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2. Review of the "Grievance & Positive Recognition Form" dated 03/16/2021 time unknown by Patient #5 revealed "Identify person (s) this is regarding: (Named) staff Describe Complaint or Positive Recognition: she cant do her job. How can this be resolved/recognized? Fire her! Steps taken on behalf of the patient to investigate: Shared concerns with Director. Will continue to work with patient ..." Review reveled Patient Advocate #1 "resolved" and signed the grievance on 03/18/2021. Review of the Patient signature box revealed Patient #5 "refused" to sign.

Interview on 07/14/2021 at 1047 with Patient Advocate #2 revealed her process was to check the grievance box daily (box located on the patient's hall where they can complete the grievance form) and discuss with the patient their concerns. Patient Advocate #2 stated following patient discussion, if further action was required, she forwarded the action items to the director of the unit. Interview revealed the director of the unit then talked to staff involved in a named grievance and/or reviewed video if that was required. Patient Advocate #1 stated after the director of the unit was done investigating the concerns of the patient grievance, they followed up with her. Patient Advocate #2 stated she "resolved" a grievance after reviewing the grievance form with the patient and the patient was "accepting" of the actions staff were going to complete. Interview revealed Patient Advocate #2's process was to close the grievance before the actions of the staff or investigation was completed. Interview revealed Patient Advocate #2 did not send resolution letters to the patient's following a resolution.

Interview on 07/14/2021 at 1154 with the Director of Quality and Risk Management revealed Patient Advocate #2 resolved a patient grievance after she communicated with the patient. Interview revealed resolution letters were not mailed to the patients following a grievance.

3. Review of the "Grievance & Positive Recognition Form" dated 06/28/2021 at "second shift" by Patient #7 revealed "Identify person (s) this is regarding: (Named) MHT (mental health technician) Describe Complaint or Positive Recognition: he pulled the girl by head and that made me angry. How can this be resolved/recognized? I don't know Steps taken on behalf of the patient to investigate: Will request video review of 600 hall." Review revealed Patient Advocate #1 "resolved" and signed the grievance on 06/29/2021. Review revealed Patient #7 signed the signature box.

Interview on 07/14/2021 at 1047 with Patient Advocate #2 revealed her process was to check the grievance box daily (box located on the patient's hall where they can complete the grievance form) and discuss with the patient their concerns. Patient Advocate #2 stated following patient discussion, if further action was required, she forwarded the action items to the director of the unit. Interview revealed the director of the unit then talked to staff involved in a named grievance and/or reviewed video if that was required. Patient Advocate #1 stated after the director of the unit was done investigating the concerns of the patient grievance, they followed up with her. Patient Advocate #2 stated she "resolved" a grievance after reviewing the grievance form with the patient and the patient was "accepting" of the actions staff were going to complete. Interview revealed Patient Advocate #2's process was to close the grievance before the actions of the staff or investigation was completed. Interview revealed Patient Advocate #2 was unsure if the video review was ever completed for Patient #7's grievance. Interview revealed Patient Advocate #2 did not send resolution letters to the patient's following a resolution.

Interview on 07/14/2021 at 1154 with the Director of Quality and Risk Management revealed Patient Advocate #2 forwarded him Patient #7's grievance with a named MHT. Interview revealed the grievance was discussed with the safety committee during their daily safety meeting. Interview revealed the video review as suggested by Patient Advocate #2 on Patient #7's grievance form was not done. Interview revealed Patient Advocate #2 resolved a patient grievance after she communicated with the patient. Interview revealed resolution letters were not mailed to the patients following a grievance.

Based on review of medical staff Bylaws, credentialing file reviews, Collaborative Agreements, and staff interview, the facility medical staff failed to evaluate the delineation of clinical privileges and Collaborative Agreements of Allied Health Providers (AHPs) for reappointment according to medical staff bylaws for 2 of 2 sampled AHP files reviewed (Physician Assistant) (PA #4 and PA #6 ).

The findings include:

Review of the hospital's "Bylaws of the (Name of Hospital) Hospital 2021" adopted 2021 revealed "... Section 1. ACTIVE MEDICAL STAFF... Allied Health Professionals ("AHP") may exercise only the privileges granted to them. In determining all need for and type of privileges for AHPs, consideration must be given to federal and state laws and regulations governing scope of practice and supervision. Licensure shall not be the sole criterion for determining the need and scope of services. [FOR STATES REQUIRING COLLABORATIVE AGREEMENTS: AHPs may, under a collaborative practice agreement with a physician and, as privileged, serve under the supervision of a physician member of the Medical Staff, but they are not allowed to admit or discharge patients.]..."

1. Review on 7/14/2021 of PA #4s credential file revealed "SPECIALTY OF CERTIFIED PHYSICIAN ASSISTANT DELINEATION OF CLNICAL PRIVILEGES... Scope of service and Responsibility... The PA-C will collaborate with the supervising physician in managing care, and discharging patients from the hospital/ facility... Core Physician Assistant Core Privilege: Tele-Medicine: ..Administer admit orders and initial orders.." Review revealed PA #4 appointment period for clinical privileges is for 05/01/2021-04/30/2023 and approved on 04/28/2021. Review of the Collaborative Agreement signed on 05/06/2021 revealed "... Admissions: The physician assistant is permitted to admit and discharge patients to and from "named facility".

Interview on 07/15/2021 at 1200 with the Assistant in charge with Credentialing revealed the Medical Staff Bylaws are correct and the medical staff are supposed to be following those guidelines. Interview revealed the Bylaws are set by corporate and not individual facilities.

Interview on 07/15/2021 at 1345 with PA#4 revealed he does adnit and discharge patients to the facility. Interview revealed he "skimmed" the Bylaws and did not read them.

Interview on 07/15/2021 at 1415 wit the CEO revealed the the medical staff Bylaws guidelines should be followed. Interview revealed they will work on getting the process fixed. Interview confirmed Physcian Assistants should not be admitting and discharging patients.

2. . Review on 7/14/2021 of PA #6s credential file revealed "SPECIALTY OF CERTIFIED PHYSICIAN ASSISTANT DELINEATION OF CLNICAL PRIVILEGES... Scope of service and Responsibility... The PA-C will collaborate with the supervising physician in managing care, and discharging patients from the hospital/ facility... Core Physician Assistant Core Privilege: Tele-Medicine: ..Administer admit orders and initial orders.." Review revealed PA #6 appointment period for clinical privileges is for 07/01/2021-06/30/2023 and approved on 06/30/2021. Review of the Collaborative Agreement signed on 06/28/2021 revealed "... Admissions: The physician assistant is permitted to admit and discharge patients to and from "named facility".

Interview on 07/15/2021 at 1200 with the Assistant in charge with Credentialing revealed the Medical Staff Bylaws are correct and the medical staff are supposed to be following those guidelines. Interview revealed the Bylaws are set by corporate and not individual facilities.

Interview on 07/15/2021 at 1415 wit the CEO revealed the the medical staff Bylaws guidelines should be followed. Interview revealed they will work on getting the process fixed. Interview confirmed Physcian Assistants should not be admitting and discharging patients.

Based on review of policies, medical records, and interviews with staff, the nursing staff failed to supervise patient care by failing to ensure a patient was bathed every other day for 1 of 10 sampled patients reviewed (#6); performing weekly weights for 1 of 10 sampled patients reviewed (#6); and by failing to administer a medication per physician's order for 1 of 6 geriatric patients reviewed (#2).

The findings include:

A. Review of policy titled "Weights, Obtaining Balances Scales" with revision date of 12/05/2020 revealed "POLICY: Accurate weights will be obtained on all patients at the time of admission, weekly on all residential patients and as ordered by the physician for all units throughout the patient's hospital stay. NOTE: If patient becomes weak at any time or unable to stand, stop immediately and assist patient to chair or bed. Obtain weight per chair scale. CHAIR SCALES are used when a patient is unable to ambulate or stand- alone without support."

1. Review of Patient #6's Psychiatric Initial Evaluation dated 10/11/2020 revealed a 59- year-old male admitted on 10/10/2020 with an IVC (involuntary commitment) due to aggression with diagnosis of Lewy Body and Alzheimer's Dementia. (Neurological diseases with symptoms of changes in thinking, movement and behavior and mood). Review of "Weekly Weights" for Patient #6 revealed a weight was documented as 226 lbs (pounds) for 10/11/2020 (day after admission), 211.2 lbs on 10/26/2020 (15 days later), 206.8 lbs on 11/11/2020 (16 days later), and 199 lbs on 11/26/2020 (15 days later). Review of documented weights revealed a weight loss of 27 lbs in 46 days. Review revealed weights were not documented weekly as ordered. Patient #6 was discharged to a long-term care facility on 12/07/2020.

Interview on 07/13/2021 at 1555 with PA-C (Physician Assistant Certified) #4 revealed weights were not documented as ordered. Interview revealed Patient #6 should have been weighed more frequently due to weight loss during hospital stay. Interview revealed Patient #6 was overweight on admission. Review of documentation revealed Patient #6 lost 27 lbs during hospitalization.

Interview on 07/15/2021 at 0925 with Registered Dietitian #7 revealed Patient #6 was not weighed as ordered, while reviewing the chart. Interview revealed obtained weights are important in dementia patients to prevent further decline. Interview revealed Patient #6 should have been weighed as ordered.

B. Review of policy titled "Bathing of Patients" with revision date of 02/2017 revealed "POLICY: It is the policy of (Named facility) to assist those patients unable to be independent with their bathing needs and to assist and encourage independent patient to maintain appropriate personal hygiene practices. PROCEDURE: ... 2. Patients who need assistance will have a shower and shampoo by staff every other day or PRN (as needed) if indicated. Document completion of task and any adverse findings."

2. A closed record review of Patient #6 revealed a 59-year-old male admitted on 10/10/2020 with an IVC (involuntary commitment) due to aggression with a diagnosis of Lewy Body and Alzheimer's Dementia. (Neurological diseases with symptoms of changes in thinking, movement and behavior and mood). Review of a sampled nursing documentation of baths dated 11/28/2020 through 12/07/2020 revealed two baths were documented. Review revealed the patient was not bathed every other day. Patient #6 was discharged on 12/07/2020 to a long-term care facility.

Interview on 07/14/2020 at 1150 with CNA (Certified Nurses Assistant) #5 revealed documentation of baths are written as a narrative. Interview revealed there was no documentation of baths every other day on Patient #6.

Interview on 07/14/2021 at 1450 with DON (Director of Nursing) #2 revealed Patient #6's documentation did not show baths were performed every other day during the week before discharge. Interview revealed the baths have to be documented in the narrative. Interview revealed Patient #6 was not bathed according to policy.



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C. 3. Review of a closed medical record revealed Patient #2 was a 67-year-old female involuntarily committed to the hospital on 01/26/2021 for suicide ideation. Review of the "Physician Order Sheet" revealed on 02/10/2021 at 1205, Physician Assistant (PA) #6 wrote an order for "Haldol 5 mg (milligrams)...1x (time) now..." Review of a "Medication Variance Report" dated 02/11/2021 revealed "Physician order for Haldol injection 5mg, patient given Haldol decanoate (long acting) 50mg injection..."

Interview on 07/14/2021 at 1215 with Registered Nurse (RN) #8 revealed she inadvertently removed a haldol decanoate 50mg vial instead of a haldol 5mg vial from the medication dispensing system. Interview revealed RN #9 witnessed the haldol vial that was removed from dispensing system.

An interview was requested with RN #9 who was not available for interview.

Interview with the Director of Pharmacy revealed the medication dispensing system requires a witness to enter their user identification before the long-acting haldol decanoate can be removed. Interview revealed this safety stop is in place to help ensure the correct medication is removed. Interview revealed the short acting haldol does not require a witness in order to remove it from the dispensing system. Interview revealed RN #8 and RN #9 should have realized the reason the dispensing system required a witness and should have verified the physician order.

Interview on 07/14/2021 at 1237 with the Director of Nursing (DON #2) revealed RN #9 should have verified the physician order prior to signing as a witness for the haldol decanoate. Interview revealed RN #9 did not receive re-education on the role of the nurse as a witness when removing medications from the dispensing system. Interview revealed there was not hospital wide re-education for nurses as a witness for medications.

Based on policy and procedure review, medical record reviews, and staff and physician interviews, the facility staff failed to ensure physician telephone orders were authenticated for 2 of 5 restraint medical records reviewed. (Patient #5; #2)

Findings included:

Review on 07/14/2021 of the facility policy titled, "Seclusion and Physical or Chemical Restraint," revised 04/28/2020, revealed "...2. Restraint or seclusion and Orders ...f. The psychiatrist`s or LIP`s [Licensed Independent Practitioner] telephone order for physical or chemical restraint or seclusion must be followed with the psychiatrist`s signature verifying the telephone order within 24 hours of receipt of the order ..."

1. Open medical record review on 07/14/2021 of Patient #5, revealed a 14-year old female patient admitted on 02/08/2021 for suicidal ideation with severe depression. Review of a "...MD Order Form, Seclusion/Restraint/Manual Hold" dated 02/26/2021 revealed a telephone order was obtained on 02/26/2021 at 1824 by a Registered Nurse. Review revealed the telephone order was obtained from a Nurse Practitioner (LIP) and no available documentation was available that a physician authenticated the order. Review of a "...MD Order Form, Seclusion/Restraint /Manual Hold" dated 03/22/2021 revealed a telephone order was obtained on 03/22/2021 at 1950 by a Registered Nurse. Review revealed the telephone order was obtained from a Nurse Practitioner and no available documentation was available that a physician authenticated the order. Review of a "...MD Order Form, Seclusion/Restraint /Manual Hold" dated 03/27/2021 revealed a telephone order was obtained on 03/27/2021 at 2130 by a Registered Nurse. Review revealed the telephone order was obtained from a Nurse Practitioner and no available documentation was available that a physician authenticated the order. Review of a "...MD Order Form, Seclusion/Restraint/Manual Hold" dated 04/03/2021 revealed a telephone order was obtained on 04/03/2021 at 1940 by a Registered Nurse. Review revealed the telephone order was obtained from a Nurse Practitioner and no available documentation was available that a physician authenticated the order. Review of a "...MD Order Form, Seclusion/Restraint/Manual Hold" dated 04/19/2021 revealed a telephone order was obtained on 04/19/2021 at 2035 by a Registered Nurse. Review revealed the telephone order was obtained from a physician and no available documentation was available that a physician authenticated the order. Review revealed the five telephone orders were not authenticated per the facility policy.

Interview on 07/14/2021 at 0940 with RN #1, revealed physicians were expected to authenticate telephone orders within 24 hours.

Interview on 07/14/2021 at 1610 with the Chief Nursing Officer revealed restraint orders not being authenticated were identified last week during an internal audit. Request for documentation to support the identified concern with restraint orders not being authenticated by a physician discovered last week, yielded no supportive documentation. Additional request on 07/16/2021 at 1130 for the facility`s identification of restraint orders not being authenticated by a physicain from last week's internal audit yielded no supportive documentation provided.

Interview on 07/15/2021 at 1415 with the Chief Executive Officer, revealed "I agree a physician should authenticate restraint orders."

2. Closed medical record review revealed Patient #2 was a 67- year-old female involuntarily committed to the hospital on 01/26/2021 for suicide ideation. Review of the "MD Order for Restraint/Seclusion/Manual Hold" form revealed a telephone order for a manual hold was obtained on 02/02/2021 at 1811 by a Registered Nurse. Review revealed the telephone order was obtained from Physician Assistant #4. Review revealed the Name; Date; and Time lines next to "Attending physician notified if not MD ordering intervention" were blank. Review failed to reveal evidence the attending physician authenticated the order for the manual hold. Review of a "MD Order Form Seclusion/Restraint/Manual Hold" revealed PA #4 ordered a manual hold on 02/04/2021 at 1938. Review revealed the Name; Date; and Time lines next to "Attending physician notified if not MD ordering intervention" were blank. Review failed to reveal evidence the attending physician authenticated the order for the manual hold.

Interview on 07/14/2021 at 0940 with RN #1, revealed physicians were expected to authenticate telephone orders within 24 hours.

Interview on 07/14/2021 at 1610 with the Chief Nursing Officer revealed restraint orders not being authenticated were identified last week during an internal audit. Request for documentation to support the identified concern with restraint orders not being authenticated by a physician discovered last week, yielded no supportive documentation. Additional request on 07/16/2021 at 1130 for the facility`s identification of restraint orders not being authenticated by a physician from last week's internal audit yielded no supportive documentation provided.

Interview on 07/15/2021 at 1415 with the Chief Executive Officer, revealed "I agree a physician should authenticate restraint orders."

NC00172397, NC00174413, NC00176961