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Based on record review and interview the facility failed to establish a process for informing each patient and providing the patient or the patient's representative a phone number and address for lodging (submitting) a grievance with the State Agency for all patients treated at this facility. This failed practice can lead to patients being unable to lodge complaints that can lead to ongoing patient harm.

The findings are:

A. Record review of facility's "Patient Admission Packet," not dated, does not include the State of New Mexico Department of Health Complaints contact information.

B. On 05/17/22 at 2:00 pm during interview with S(staff)1 (Administrator) who confirmed, "We don't have the Department of Health contact information provided to patients right now but it will be added immediately."

Based on record review and interview the facility 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 all patients/family members submitting grievances at this facility. This failed practice can lead to unresolved grievances and repeat instances of grievance causing situations that can lead to patient harm.

The findings are:

A. Record review of "Grievance Resolution Log" dated 02/2022 contains 10 entries that shows all grievances were resolved within 72 hours and the Action/Outcome was: 1 grievance had a resolution that the Director was notified of request for a grievance, 8 grievances had a resolution that the staff was counseled by a supervisor and 1 grievance the Director was notified as the grievance was resolved.

B. Record review of facility policy titled, "Grievance Policy" dated 12/21, confirms under area titled "Procedure" section 4.4 "[the filled grievance] form is then given to the appropriate supervisor (program director or charge nurse for investigation and response). Section 5 paragraph 2 "If the complaint is one of a less serious nature and cannot be resolved by the supervisor or the staff, the complaint will be addressed by appropriate members of the client's treatment team (comprised of the physician, therapist, nurse program director and utilization review staff). This will be done within 72 hours of the placement of the complaint. Section 5 paragraph 3 "In all cases of complaints, the person making the grievance will be given the name and phone number of a person involved with the grievance to contact." Section 6 "Once the complaint has been addressed, the person(s) responsible for dealing with the grievance will document on the grievance form how the process was done. If the complaint deals with members of the staff, then an interview with the staff member must be part of the process documentation." Section 7 "Once the complaint has been initially resolved, the person responsible for resolving the complaint (or a member of the client's treatment team) and the person who filed the complaint will discuss the proposed resolution. The documentation of the steps taken to resolve the issue is shared with the complainant. If the complainant is satisfied with the results, then he/she will document that the resolution was satisfactory and will date and sign the complaint form accordingly."

C. On 05/18/22 at 2:00 pm during interview with S (staff)4 (Risk Manager) who confirmed, "The process for resolution of grievances is to report to the director to take care of and it is noted as "director notified" or "Staff counseled by supervisor" but there is nothing else documented.

Based on record review and interview the facility failed to ensure the safety of 1 (P #1) of 6 patients (P #1-P #6) reviewed. This failed practice could likely result in injuries significant enough to require a visit to an emergency department.

A. Record review of facility Compliance Investigation Report regarding an incident that occurred on 02/06/22 that began at 11:26 am, stated the following: S (staff) #11, Mental health Technician (MHT), recalled that P #1 was in the hallway "punching," "hitting," and "kicking" walls. In an attempt to deescalate P #1, S #10 (MHT) and S #11 were attempting to verbally process (deescalate) with him. However, he continued to be agitated. He [S#11] alleged that S #10 escorted P #1 to his room. P #1 became confrontational at the time and "goes at" S #10. P #1 began to swing at S #10 and proceeded to grab S #10 by the waist. S #10 fell to the ground along with P #1 at that time. S #10 and P #1 were able to stand back up and P #1 "attacked" S #10 once more. S #11 stated that he observed S #10 attempt to initiate a CPI [Crisis Prevention Institute] hold. S #11 stated that he witnessed the interaction between P #1 and S #10 and did not feel it necessary to initiate a "code purple" [behavioral emergency] nor to offer assistance to S #10. S #11 stated that at the end of the incident P #1 was observed to be "flushed" and "seemed red". Further record review of Conclusion of the Compliance Investigation Report stated "It appears any injuries that P #1 may have obtained may have occurred because of him "rushing" at staff which resulted in them both falling to the ground."

B. Record review of Nursing Progress Note dated 02/08/22 at 04:47 (4:47 am) stated: " ...Area of bluish discoloration noted right lower orbit [bruise on right eye]. Patient states that his entire lips and face are swollen. On bowel movement bright red blood noted in toilet. Patient reports facial pain 9/10 on scale [pain scale of 0-10]. Patient transferred to acute hospital for further evaluation."

C. Record review of S #10 training shows that staff was trained in CPI as an Associate Level Instructor on 3/12/2021. S #11 training shows that S#11 was trained in CPI on 9/30/2021.

D. Record Review of Crisis Prevention Institute Nonviolent Crisis Intervention 2nd Edition With Advanced Physical Skills Workbook Page 53 shows the "Decision-Making Matrix" of likelihood (chance that an event or behavior may occur) and severity (level of harm that may occur) which guides staff in "assessing the risk (the chance of a bad consequence) and choosing appropriate response" to a patient in crisis. The matrix shows that in this case with high Severity (injury significant enough for an Emergency Room visit) and high likelihood (the event did occur) then the following responses would fall into the Higher-Level Risk category. In the "Holding Skills" section of the Workbook on page 59-64 show all Higher-Level Risk holding positions of an adult with 2-3 staff holding a patient. There is no evidence that a Higher-Level Risk patient should be held by one staff.

E. Record review of policy labeled 1000.34 Subject: Seclusion/Restraint/Physical Hold - CPI, Effective Date: 06/1996 Revised Date: 12/2021 Philosophy States: "Seclusion and restraint interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patients or others. Under Procedure section Item 8 States: "If physical restraint is indicated, 2 staff must participate in the physical hold application."

F. On 05/19/22 at 2:30 pm, during an interview with S #1, Chief Executive Officer, confirmed that according to CPI guidance the patient should have been restrained. S#1 went on to state "I don't know why he wasn't restrained; they probably should have."

Based on observation, interview, and record review, the facility failed to maintain a process to protect patient's medical information. This failed practice is likely to allow for patient's medical information to be viewed and shared by others without authorized permission.

The findings are:

A. On 05/17/22 at 3:00 pm, during a tour of Adult Unit III, at the nurse's station, observed several patient's medical document information on the countertop not covered and accessible to be viewed.

B. On 05/17/22 at 3:05 pm, during an interview, S (staff) #3 CNO (Chief Nursing Officer) and S #2 ICP (Infection Control Preventionist) confirmed patient medical information should not be on countertop uncovered. Surveyor requested a copy of the HIPPA (Health Insurance Portability and Accountability Act) policy for the facility.

C. Record Review of [name of facility] Medical Record Policies, Policy and Procedure: Medical Record Confidentiality, Department: Compliance- HIPPA/HITECH, (Health Information Technology for Economic and Clinical Health) dated 12/01/2021, revealed, Under Policy section, "It is the facility policy that CONFIDENTIALITY will be maintained and practiced for all facility patients in accordance with State and Federal Confidentiality Rules and Regulations." And under Statement section, "The patient has the right to expect that records pertaining to his care will be treated as confidential, and the facility has the obligation to safeguard his records against unauthorized disclosure."

Based on record review and interview the facility failed to include Quality Assessment & Performance Improvement (QAPI) programs that mentions its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas in the Governing body meeting minutes. To include information of incidents (physical abuse) or adverse events (unexpected medical problem that happens during treatment with a drug or other therapy) and actions aimed at performance improvement and, and measure its success, and track performance to ensure that improvements are sustained. This failed practice has the potential to affect health outcomes, patient safety, and quality of care by not identifying opportunities and changes to implement that will lead to improvement.
The findings are:

A. Record review of [name of facility] Governing Board minute meetings, dated April 29, 2021, revealed, under Risk Management and Compliance Report (QAPI) section, "Grievances for hospitalized and discharged patients were followed up on and were addressed with the applicable directors for a team collaboration in resolving those in a timely manner." No information of incidents or adverse events or resolutions of track and trending and to put in place processes to minimize any issues or concerns identified in high-risk, high-volume, or problem-prone areas.

B. Record review of [name of facility] Governing Board minute meetings, dated February 25, 2022, revealed, under Quality/Performance Improvement Reports (QAPI) section, no information of incidents (physical abuse or adverse events) or resolutions to track and trend and to put in place processes to minimize any issues or concerns identified in high-risk, high-volume, or problem-prone areas.

C. Record review of [name of facility] Quality, Compliance, Risk Management Governing Board Report, Dated: 07/01/2021, Reporting Period April, May, June (Quarter 2), revealed, under Quality Results section, "Grievances for hospitalized and discharged patients were followed up on and were addressed with the applicable directors for a team collaboration in resolving those in a timely manner." No information of the resolutions to track and trend and to put in place processes to minimize any issues or concerns identified in high-risk, high-volume, or problem-prone areas.

D. Record review of [name of facility] Quality, Compliance, Risk Management Governing Board Report, Dated: 01/04/2022, Reporting Period October, November, December (Quarter 4), revealed, under Quality Results section, "Grievances for hospitalized and discharged patients were followed up on and were addressed with the applicable directors for a team collaboration in resolving those in a timely manner." No information of the resolutions to track and trend and to put in place processes to minimize any issues or concerns identified in high-risk, high-volume, or problem-prone areas.

E. On 05/19/2022 at 1:30 pm, during an interview, Staff (S) #1 (Administrator), confirmed the Governing Board meets quarterly (every three months.) S #1 reviewed the Governing Board meeting minutes dated 02/25/2022 and confirmed under the Quality results section there isn't any information specific to incidents or adverse events to include what the facility did to resolve the issue or processes that need to be implemented to minimize incidents or adverse events. S#1 confirmed the facility has daily safety meetings, review recent grievances, incidents, and compliments. Review videos of incidents if necessary.

Based on record review and interview the facility failed to ensure that an RN (Registered Nurse) was evaluating the care for each patient upon admission for 1 (P #2) of 6 patients (P #1 through P #6) reviewed. This failed practice could likely lead patients to not receiving a registered nurse skilled assessment.

A. Record review of P #2 face sheet shows admission on 05/12/22 at 16:41 [4:41pm].

B. Record review of Nursing Progress Note and Admission Assessment for P #2 dated 05/12/22 18:07 [6:07 pm] is e-signed by a LPN (Licensed Practical Nurse).

C. Record review of Policy labeled 1000.68 Subject: Nursing Admission Assessment Effective Date: 11/2002 Revised Date: 12/2021 States Item 1: "A Registered Nurse is responsible for the entire assessment of all clients assigned to his/her care."

D. On 05/19/22 at 2:30 pm, during an interview with S #3, Chief Nursing Officer, confirmed that The RN on the unit is to conduct the admission nurse assessment, not the LPN's.

Based on record review and interview, the facility failed to ensure that nursing staff were adhering to the policies and procedures of the facility regarding medication administration for 5 (P#1, P#3, P#4, P#5 P#6) of 6 patients (P#1, P#2, P#3, P#4, P#5 P#6) that were reviewed. This deficient practice could lead to patient harm and ineffective treatment by not monitoring for the desired reaction to the administered medication.

The findings are:

A. Record review of [name of facility] policy and procedure: 1000.51 Subject: Medication Administration, Effective Date: 10/1999, Revised: 12/2021 revealed under Item 34.1 "The nurse will administer and chart the STAT [immediate] medication and client's response to the medication."

B. Record review of the Medication Administration Record (MAR) and Nursing Progress Notes for P#1, P#3, P#4, P#5, and P#6 revealed several mood-altering medications administered under a STAT order were not monitored for response to medication nor a reason(s) for administration.

C. On 05/19/22 at 2:30 pm, during an interview with S (Staff) #3, Chief Nursing Officer, confirmed "The nurses should document [follow up] on the MAR. PRN [as needed medication] has a notification that pops up on the EMR [Electronic Medical Record]. STAT orders, they should still document, but the system does not prompt them."

Based on record review and interview, the facility failed to maintain documentation of drug STAT (immediate) and NOW (immediate) orders from the prescribing practitioner for 1(P#6) of 6 patients (P #1- P#6) reviewed. This failed practice could likely lead to patient harm by not having all medication orders documented.

A. Record review of P#6 Medication Administration Record (MAR) revealed patient was administered the following medications:
1. "Lorazepam [anti anxiety medication] injectable [administered via syringe] 2 mg/ml [milligrams per milliliter] SOLN [solution] STAT for Acute Psychosis [a mental state of impaired reality] on March 11, 2022 at 13:29 [1:29 pm]
2. Haloperidol [treats psychosis] injectable 5 mg/ml SOLN STAT for Psychosis on March 12, 2022 at 01:12 [1:12 am]
3. Lorazepam injectable 2 mg/ml SOLN STAT for Anxiety on March 12, 2022 at 01:13 [1:13 am]
4. Haloperidol injectable 5 mg/ml SOLN STAT for Acute Psychosis on March 12 , 2022 at 23:30 [11:30 pm]
5. Lorazepam injectable 2 mg/ml SOLN STAT for Acute Psychosis on March 12, 2022 at 23:30 [11:30 pm]
6. Haloperidol injectable 5 mg/ml SOLN NOW for Acute Psychosis on March 17, 2022 at 13:06 [1:06 pm]
7. Lorazepam injectable 2 mg/ml SOLN STAT for Acute Psychosis on March 19, 2022 at 11:22 [11:22 am]"

B. Record review of Physician's Orders form for P#6 for dates March 10, 2022 to March 18, 2022 do not show any handwritten orders for the medications mentioned in finding A for P#6.

C. On 05/19/22 at 2:30 pm, during an interview with S (Staff) #3, Chief Nursing Officer, When surveyor asked "Tell me about how a nurse obtains a STAT order?". S#3 stated "If it is a doctor that will not login into the EMR [Electronic Medical Record] then the nurse will write the order on the order form and the doctor will sign it next time he is on site." S#3 confirmed there was not a handwritten order on the Physicians Order form for P#6.

Based on observation and interview, the facility failed to maintain a safe physical environment by not identifying and managing the condition of the patient daily activity room and patient rooms to minimize causing potential bodily harm. This failed practice is likely to expose patients to harm while receiving medical treatment due to the condition of the facility.

The findings are:

A. On 05/18/22 at 3:20 pm, during a tour of the Adult I Unit, the following was observed:
1. In the dayroom where patients go to watch television, two out of three wooden chairs were missing the sitting and back support cushions and one chair was missing the back support cushion. The wooden chairs are made to sit near the ground, creates a potential to accidentally slip in and get hurt.

2. Observed in Room 202 the toilet tank lid was held in place with two pieces of wood that were screwed into the wall. Surveyor checked how stable the lid was in place and it was very loose and could be taken off by anyone.

3. Observed in Room 204 the toilet tank lid was loose and not secure. It can be easily lifted and removed from the toilet tank.

B. On 05/17/22 at 3:25 pm, during an interview, Staff (S)#2 ICP (Infection Control Preventionist) confirmed the cushions for the three wooden chairs are being reupholstered and should have them within a few weeks.

C. On 05/17/22 at 3:30 pm, during an interview, S#6 EVS (Environmental Services Supervisor) confirmed the repair to the toilet was not a temporary fix and the method used to secure the toilet tank lid was not appropriate or safe.

D. On 05/17/22 at 3:55 pm, during an interview, S#7 Maintenance Supervisor, confirmed work orders are submitted online, and the main means of communication is by phone. During staff morning meeting they are informed of issues with the physical environment and arranges for repair. S #7 usually does morning walk-through, if there is a major repair needed will get bids from contractors. The turnaround time for maintenance repairs is within a day, or sooner depending on the issue. Total staff maintenance crew is three.

E. On 05/17/22 at 4:00 pm, during an interview, S#2 ICP confirmed does a walk-through once a week to identify any infection control issues and reports any repairs needed to S#6 EVS supervisor.

Based on record review and interview the facility failed to implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 (a respiratory illness), which includes tracking and securely documenting the staff vaccination status and ensuring the implementation of additional precautions, intended to mitigate the transmission and spread for 5 (Staff (S)#20, 28, 30, 32, 33) of 21 (S#13- 33)) facility staff. This failed practice can likely affect all residents in the facility if staff are not fully vaccinated or following safety guidelines to minimize exposure to residents causing illness or death.

The findings are:

A. Record review of facility staff COVID-19 vaccination tracking log of clinical staff, undated, revealed, S#20, S#28, S#30, S#32, S#33) have no dates noted for 1st dose, 2nd dose, or exemption.

B. Record review of [name of facility] policy titled, "Department: Infection Prevention and Control", "Subject: Management of Coronavirus (2019-CoV)," page 4 of 5, dated 03/2022, revealed, under Item I. Vaccination, (2019-CoV), No specific information of what procedures or standards the facility follows for infection prevention and control practice, especially by those staff unvaccinated or not yet fully vaccinated. To include requiring at least weekly testing of unvaccinated staff, and reassigning unvaccinated staff to non-patient care areas, duties being performed remotely, or to duties which limit exposure to the most at risk and requiring unvaccinated staff to use a NIOSH-approved N95 (respiratory protective device) or equivalent for source control, regardless of whether they are providing direct care to or otherwise interacting with patients.

C. Record review of [name of facility] COVID-19 Plan, undated, revealed, under Item 10. Vaccination, No specific information of what procedures or standards the facility follows for infection prevention and control practice, especially by those staff unvaccinated or not yet fully vaccinated. To include requiring at least weekly testing of unvaccinated staff, and reassigning unvaccinated staff to non-patient care areas, duties being performed remotely, or to duties which limit exposure to the most at risk and requiring unvaccinated staff to use a NIOSH-approved N95 or equivalent for source control, regardless of whether they are providing direct care to or otherwise interacting with patients.

D. On 05/18/22 at 3:30 pm, during an interview, Staff (S)#2 (Infection Control Preventionist) confirmed, the staff that had no dates noted for 1st dose, 2nd dose, booster or exemption. And the policy not including information for unvaccinated staff to COVID-19 test weekly, being reassigned to non-patient care areas, and suggested masks to use when providing direct patient care.

Based on record review and interview the facility failed to maintain informed consent records for psychotropic medications (medications that affect the mind, emotions, and behavior) that will be used in the patient's treatment plan for 6 (P#1, P#2, P#3, P#4, P #5 and P#6) of 6 patients (P#1-P#6). This failed practice could lead to a violation of patient's rights by not being counseled about medication, its intended effects, and the potential side effects.
The findings are:

A. Record review of P#1, P#2, P#3, P#4, P#5 and P#6 medical chart revealed that there is no evidence that staff obtained consent from the patient before administering psychotropic medications.

B. On 05/19/22 at approximately 3:00 pm, during an interview with S (staff) #8, Educator and Milieu (patient's social environment) Manager, confirmed that although there is a date and name of medication on the EMR (Electronic Medical Record) system that is visible, the actual medication consent cannot be retrieved.

C. On 05/19/22 at 5:36 pm, during an interview with S#3, Chief Nursing Officer, via telephone call, confirmed that they [facility] will not be able to retrieve the medication consent.

Based on record review and interview the facility failed to ensure that an appointment date and time for follow up appointments were scheduled within business hours for 1 (P#1) of 6 patients (P#1- P#6) reviewed. This failed practice could lead to lack of continuity of care and regression of the patient.

A. Record review of P#1 Discharge Continuing Care Plan Assessment revealed under the header Follow-Up Appointments an appointment with the date and time of 02/22/22 at 00:31 am [12:31 am].

B. On 05/19/22 at 2:30 pm, during an interview with S (Staff) #1, Chief Executive Officer, confirmed that the Discharge Continuing Care Plan Assessment is the form that is sent home with the patient and tells the patient the date and time of the follow up appointment. S#1 reviewed the Discharge Continuing Care Plan for P#1 and saw the appointment time and stated, "That's not supposed to be like that [appointment time]".

Based on record review and interview, the facility failed to provide Therapists to engage in discharge planning for 3 (P#1, P#5, P#6) of 6 patients (P#1- P#6) reviewed for discharge planning. This failed practice could lead to patients not receiving a completed evaluation of risk.

A. Record review of policy labeled 1200.03 A Subject: Aftercare/Discharge Plan Acute Hospital, Revised Date: 12/2021 States Item 7 "Therapist will complete evaluation of risk with the patient at discharge. Any risks identified will be reviewed with physician for re-assessment prior to discharge."

B. Record review of P#1 Discharge Continuing Care Plan Assessment revealed the RN (Registered Nurse) signature on 02/14/22 at 12:00 pm the Patient signature on 02/14/22 at 12:00 pm and Therapist Signature as "Pending Signature" and does not show an evaluation of risk was completed.

C. Record Review of P#5 Discharge Continuing Care Plan Assessment shows the RN signature on 02/20/22 at 21:26 (9:26 pm), the Patient signature on 02/20/22 at 21:26 and Therapist Signature as "Pending Signature" and does not show an evaluation of risk was completed.

D. Record review of P#6 Discharge Continuing Care Plan Assessment shows the RN signature on 03/22/22 at 16:21 (4:21 pm), the Patient signature on 03/22/22 at 16:21 and Therapist Signature as "Pending Signature" and does not show an evaluation of risk was completed.

E. On 05/18/22 at approximately 3 pm, during an interview with S (Staff) #8, Educator and Milieu (patient's social environment) Manager, stated "There is a notification system within the EMR [Electronic Medical Record], that tells them [Therapist] that a note is due to be signed."

F. On 05/19/22 at 2:30 pm, during an interview with S #1, Chief Executive Officer, confirmed that it is a requirement of the facility for the therapist to sign off on the paper forms so it would also be required for the electronic forms.