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Based on medical record review, review of the grievance and complaint log, staff interview, observation, procedure review and policy review, the facility failed to ensure all grievances were reviewed in the specified time frame and a response issued (A122). The facility failed to ensure patients had the right to participate in the development and implementation of his or her plan of care (A130). The facility failed to ensure patients had the right to care in a safe setting (A144).

Based on medical record review, review of the grievance and complaint log, staff interview and policy review, the facility failed to ensure all grievances were reviewed in the specified time frame and a response issued for four of seventeen complaint/grievances reviewed (Patient #1, #4, #16, #17). The active census was 93 patients.

Findings include:

Review of the policy titled, Patient Rights and Responsibilities, Policy Number CS-400.9 and reviewed/revised 3/21, revealed the Patient Advocate is required to investigate and attempt to resolve grievances within seven (7) business days. The Patient Advocate will initiate the investigation within two (2) working days of the filing of the grievance, and will notify the grievant in writing that the investigation has been initiated. If a quick resolution is not obtained, the Patient Advocate or the impartial Committee will gather all pertinent information and will notify the grievant in writing when the information is completed.

1. Review of the grievance and complaint log revealed Patient #1 and a family member filed a grievance in regard to treatment needs and concerns on 11/16/21. Staff D confirmed on 12/14/21 at 1:15 PM no resolution was provided.

2. Review of the grievance and complaint log revealed Patient #16 filed a complaint on 10/28/21 with regard to customer service stating nurses were mistreating patients. Staff C reported on 12/16/21 at 11:19 AM repeated attempts to interview the patient was noted by the patient advocate. There was no documentation the complaint was investigated and/or resolution was provided.

3. Review of the grievance and complaint log revealed the spouse of Patient #17 filed a complaint on 11/19/21 in regard to customer service. The spouse emailed the facility with concerns of the online facility reviews and was concerned. Staff C confirmed on 12/16/21 at 11:19 AM the complaint was investigated, however left the resolution to the patient to contact the spouse regarding the concerns.


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4. Review of the grievance and complaint log noted the Patient #4's sister called the facility on 10/25/21 regarding treatment needs or concerns. The sister reported the patient told her that while hospitalized at the facility he was hit, pushed and had fallen several times. There was no documentation the complaint was investigated and/or resolution was provided.

Staff C confirmed in an interview on 12/20/21 at 11:30 AM the complaint allegations had not been investigated by the facility and no resolution provided.

Based on medical record review, staff interview, and policy review, the facility failed to ensure patients had the right to participate in the development and implementation of his or her plan of care for one of eleven medical records reviewed (Patient #1). The active census was 93 patients.

Findings include:

Review of the policy titled, Special Services Hearing/Vision/Speech/Manual Impairments and Limited English Proficiency, Policy Number CS-200.56, and reviewed/revised 03/21, revealed when an individual identifies as a person with a disability that affects the ability to communicate, staff will consult with the individual to determine what aids or services are necessary to provide effective communication. The patient shall have the option to choose a preferred method of communication and their choice should be documented in the medical record. Free aids and services are provided to people with disabilities to communicate effectively such as sign language or oral interpreter, written communication with pen and paper, lip reading, supplemental hearing devices, communication board etc. In addition, the policy states the admissions office or unit staff shall notify the Director of Nursing or Designee immediately when a person is deaf or hard of hearing or has other sensory or manual impairments when referred and/ or admitted to the facility.

Review of the medical record for Patient #1 revealed upon admission on 11/12/21 the patient arrived with cochlear implants. Review of the interdisciplinary treatment plan revealed it noted the patient had cochlear implants, however no interventions were listed to ensure the patient could effectively communicate during the hospitalization. The medical record lacked evidence the Director of Nursing/Designee was contacted upon admission and/or the patient's preferred method of communication was documented in the medical record as per policy.

Review of the complaint/grievance log revealed on 11/12/21 a complaint was filed in regard to treatment needs/concerns. Per the log a staff member contacted the patient advocate and reported the patient was hearing impaired and wanted to call his wife and staff was unsure of what to do.

An interview was conducted with Staff D on 12/14/21 at 1:15 PM who reported the complaint was investigated and substantiated because the patient was hearing impaired and required accommodations.

This deficiency substantiates Substantial Allegation OH00127841.

Based on observation, procedure review, and staff interview, the facility failed to ensure patients had the right to care in a safe setting. This could affect all patients receiving services from the facility. The facility census was 93 patients.

Findings include:

1. Review of the undated facility housekeeping procedure revealed showers are to be cleaned daily by removing all pieces of soap and debris, wipe down walls with a germicidal detergent solution and a clean cloth, flood the floor with a germicidal detergent solution and a mop. Scrub floors with a brush when needed and flush afterward with clear water. Wet wipe curtains or change curtains as needed.

A tour was conducted on Intensive Treatment Unit II on 12/13/21 at 1:31 PM in which the shower room was observed. The shower room had two individual showers that were separated by a concrete wall. Both showers appeared to have an unknown black substance in the flooring tile/grout.

A tour was conducted on Intensive Treatment Unit I on 12/13/21 at 1:50 PM in which the unit was observed to have a foul smell. The shower room had two individual showers that were separated by a concrete wall. Both showers appeared to have an unknown black substance in the flooring tile/grout.

An interview was conducted with Staff J on 12/14/21 at 4:50 PM who reported housekeeping conducted daily cleaning on the inpatient psychiatric units. The showers were cleaned daily by housekeeping staff and the behavioral health associates cleaned the showers between patient use.

An interview was conducted with Staff N on 12/15/21 at 10:08 AM who reported assisting with emptying trash on the unit and cleaning of the showers after patient use. The showers were cleaned with a disinfectant, however there was no tracking log of the showers being cleaned after patient use. The housekeeping staff were required to do daily cleaning on the inpatient psychiatric units.

An interview was conducted with Staff G on 12/15/21 at 1:34 PM who reported due to Covid-19 the facility recently had high staff turn over with no housekeeping weekend coverage. The psychiatric units, patient rooms, and showers were required to be cleaned daily by housekeeping per facility protocol. The behavioral health associates were supposed to clean the showers in between patient use. During the interview the surveyor asked Staff G what the black substance in the flooring tile/grout was that was observed in the shower rooms on Intensive Treatment Unit I and Intensive Treatment Unit II. Staff G stated he would observe the shower rooms and report back to the surveyor. Staff G never reported back his observations to the surveyor.

A request was made for the housekeeping cleaning logs for the month of November 2021 for the three observed units. Review of the daily cleaning logs lacked evidence housekeeping services was provided on the Adult Behavioral Unit on 11/06/21, 11/07/21, 11/12/21, 11/13/21, 11/14/21, 11/15/21, 11/16/21, 11/17/21, 11/18/21, 11/19/21, 11/20/21, 11/21/21, 11/22/21, 11/23/21, 11/24/21, 11/25/21, 11/26/21, 11/27/21, 11/28/21, 11/29/21, and 11/30/21.

A request was made for documentation of the shower disinfection after patient use that was required to be completed by the behavioral health associates. An interview was conducted with Staff C on 12/15/21 at 3:21 PM who confirmed the behavioral health associates did not track when the shower was cleaned and/or disinfected.

Staff G stated on 12/16/21 at 7:56 AM the housekeeper responsible for cleaning the Adult Behavioral Unit was no longer employed with the facility. The housekeeping supervisor trained all housekeeping staff on the recording of daily cleaning logs, however there was no documentation for the missing days.

2. Review of the policy titled, Security Management Titled: Identification Badges, Policy Number SEM-005, approved 05/21, revealed it is the policy of the hospital that all staff, visitors, and partial program patients of the hospital wear identification while on hospital property. Identification badges are to be worn above the waist.

During tour of the Intensive Treatment Unit II on 12/13/21 at 1:31 PM two behavioral health associates were identified with no visible identification badges. This finding was confirmed with with Staff C during the tour.

This deficiency substantiates Substantial Allegation OH00127841.

Based on review of incident reports, staff interview, and policy review, the facility failed to track adverse patient events for two of eleven medical records reviewed (Patient #1 and #10). The facility census was 93 patients.

Findings include:

Review of the policy titled, Incident Reporting (Major Unusual Incidents), Policy Number CS-200.5, and reviewed/revised 06/21, revealed an incident is an unanticipated event that is not consistent with the standard of care and/or operation of the facility and may have occurred due to a violation of policy and procedure. It results in, or nearly causes a negative impact on a patient receiving care at the facility. Any harm can be temporary, long term, or permanent and range from no obvious or significant injury up to death. The incident report will help the various facility committees and administration in identifying potential areas of risk and implementing measures to improve the overall quality of care throughout the facility. Under reporting and/or failure to report is not acceptable. Further review of the policy revealed a fall is defined as unintentionally coming to the ground, floor, or other lower level. An incident report should be documented for an unobserved fall if a patient or visitor reports falling but the fall was not witnessed by anyone else. The policy states an incident report should be documented when pharmacy has an unavailable medication. The policy also states an incident report should be documented when a laboratory specimen is not collected and/or test results not found in the medical record.

1. Review of the medical record for Patient #1 revealed the patient's spouse called the facility advising the patient reported having a fall in the shower. There was no evidence an incident report was created regarding the unwitnessed fall. Staff C confirmed this finding on 12/20/21 at 1:13 PM.

Further review of Patient #1's record revealed a seizure medication was ordered on 11/14/21 and was not available by the onsite pharmacy and required ordering from a supplier. The medication was not delivered until two days later resulting in the patient missing two doses. There was no evidence an incident report was created based on the unavailable medication. Staff C confirmed this finding on 12/16/21 at 2:09 PM.

2. Review of the medical record for Patient #10 revealed a STAT hemoglobin and hematocit laboratory specimen was ordered. The medical record revealed the lab specimen was not collected. There was no evidence an incident report was created regarding the missed lab work. Staff C confirmed this finding on 12/16/21 at 10:15 AM.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care (A395).

Based on medical record review, staff interview, and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for three of eleven medical records reviewed (Patient #1, #4, and #10). The facility census was 93.

Findings include:

1. Review of the policy titled, Care of Patient at Risk for Falls, Policy Number: CS-200.7, reviewed/revised 3/21, revealed all patients admitted to the hospital will be assessed using the MORSE Falls Assessment as part of the Nursing Assessment. Based on this assessment, each patient will be placed in a risk category. A Morse Falls Assessment will be completed weekly at treatment team, after every fall, and/or upon any change in medical condition. Interventions to occur after a fall included an incident report will be completed and submitted to the Director of Compliance; the medical practitioner will be contacted by the Nurse to determine course of treatment; the patient will be identified as a fall risk, if not done so upon admission; patient risk for falls will be reassessed and appropriate interventions implemented; treatment plans will be reviewed and revised; nurse will assure post fall evaluation is completed within 24-48 hours; if fall is unwitnessed, initiate neurochecks.

Review of the medical record for Patient #4 revealed the patient was involuntarily admitted to the facility with a diagnosis of major depressive disorder and suicidal ideation on 10/14/21. Review of the initial nursing assessment dated 10/14/21 revealed the registered nurse documented the patient had no history of falls yet had a history of left hip surgery several months prior and no skin integrity issues.

The medical record lacked a fall risk assessment.

Review of the incident log revealed Patient #4 had three incidents on 10/17/21. Review of the incident report for 10/17/21 at approximately 9:30-10:00 AM revealed Staff L documented an unobserved fall for Patient #4 at the Dual Diagnosis Unit nursing station. There were no possible injuries noted. The interventions added at that time were non-skid socks and placing the patient in the observation room. The facility supervisor was notified. Labs and a STAT X-ray were noted as ordered.

Another incident report dated 10/17/21 for 11:20 AM revealed Staff M documented that there was a medical transfer/change in medical condition. In the summary it was written "see attached nurses notes." The Nursing Assessment and injury description said, "see attached." The interventions were to transfer the patient to the hospital via emergency medical services.

Review of the Incident report form dated 10/17/21 at approximately 11:45 AM Staff M documented that the patient had an unobserved fall in the patient's bathroom. Other parties involved were listed as Staff K and Staff I who were both Behavioral Health Associates (BHA). The summary of events stated the nurse was informed that the patient was found on the floor in the bathroom while showering. The patient was sitting against the wall with a towel draped over him. There were no visible injuries noted. Patient transferred to the Generations Unit for safety. An X-ray ordered STAT. The physician was notified.

Review of the medical record revealed there was no nursing note for 10/17/21.

Review of the physician orders revealed on 10/17/21 at 12:38 AM the patient was given Haldol 10 milligrams (mg) and Benadryl 50 mg intramuscularly now for agitation and extrapyramidal symptoms. On 10/17/21 at 9:41 AM the physician put in an order for STAT left shoulder X-ray-status post fall/pain. At 11:30 AM an order was written to transfer the patient to the Generations Unit.

Interview with Staff C at 10:00 AM revealed they could not find the note for 10/17/21. There was no explanation as to why the second and third incident were not chronological.

Staff I was interviewed on 12/20/21 at 10:32 AM who reported arriving on shift on 10/17/21 at 7:00 AM. At approximately 9:00 AM the patient was asking for a shower and reported he could not walk because his hip hurt. The staff member informed the nurse who reported being aware of the patient complaint. The staff member then went to get a Geri chair and took the patient from the observation room to another patient's room to shower. Staff I and another Behavioral Health Associate placed the patient in the shower chair and told the patient to "holler" when he was ready. The staff member said within five minutes of leaving the patient in the shower another patient in the room called out reporting the patient fell in the shower.

Staff K stated in an interview on 12/20/21 at 11:00 AM he/she recalled transferring the patient from the wheelchair to the shower chair so the patient could shower. Staff K stated he/she left the patient in the shower in order to go do fifteen minute checks and heard a noise and found the patient on the floor. He/she then alerted the nurse who assessed the patient. They assisted the patient back into the wheelchair and placed him near the nurses' station.

An interview was conducted with Staff L on 12/20/21 at 11:20 AM who was able to recall the patient falling on 10/17/21. The patient was reported as very confused and urinating in his room throughout the night and the patient was moved to observation. When arriving for shift the morning of 10/17/21 the patient was by the nurses' station confused with unsteady gait and urinating on himself. Staff L stated "That is why I placed him a wheelchair." The patient then got up and started messing with a door knob and could not figure it out and was confused and fell. Staff L asked Behavioral Health Associates (Staff K and I) to take the patient to a patient room to shower (the observation room did not have a shower). Staff L stated the Behavioral Health Associates were informed the patient was confused and soiled so she asked them to get a shower chair. Staff L then added a fall intervention by putting non-skid socks on the patient. Staff L stated while cleaning up urine in the observation room he/she was informed that the patient fell in the shower. Staff L then contacted the doctor to get the patient moved to the Geropsychiatric unit (Generations Unit). Staff L stated the patient was assessed and there were no injuries noted and this was documented.

The medical record lacked evidence of a falls risk assessment and/or post falls assessment on 10/17/21. There was no evidence neuro checks were initiated for the unwitnessed fall.

Interview on 12/20/21 at 12:30 PM, Staff C verified the above findings.

The patient was transferred to the emergency room on 10/17/21 for further evaluation.

A request was made for the hospital medical record on 12/21/21 with review of the emergency room evaluation which confirmed the patient arrived to the emergency room on 10/17/21 at 1:21 PM as a level two trauma. The medical record confirmed a dislocation of the left hip prosthesis, acute left proximal femur fracture, left gluteal and anterior thigh hematomas due to multiple ground level falls.

2. Review of the medical record for Patient #1 revealed and admission date of 11/12/21 with a diagnosis of diabetes and neuropathy. Review of the medical nurse practitioner note dated 11/12/21 revealed a blood sugar of 236 with additional labs ordered to include a hemoglobin A1C. Per the documentation due to the history of diabetes, accu-checks (blood sugar checks) were to be obtained twice daily and staff were to report a blood glucose level greater than 200. Review of the medical record lacked evidence blood sugar levels were monitored while the patient was admitted from 11/12/21 through 11/16/21.

Staff C stated on 12/16/21 at 11:33 AM the order for accu-checks twice daily was not written.


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3. Review of the medical record for Patient #10 revealed an admission date of 11/07/21 with a diagnosis of major depressive disorder. Review of physician orders dated 11/08/21 revealed the physician ordered a STAT hemoglobin and hematocrit lab draw to be completed for reports of rectal bleeding. Further review of the medical record revealed there was no evidence the lab was ever drawn. The patient was discharged to home on 11/12/21.

Staff C confirmed on 12/16/21 at 10:15 AM the blood work had not been drawn as ordered.