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Based on review of document and interview, it was determined that the hospital did not have an effective grievance process as evidenced by the following: 1) not ensuring a prompt resolution of all grievances that the facility received: 2) not formally delegating the responsibility to a grievance committee.

Findings include:
1. Staff G (Director of Performance Improvement) was interviewed on 12/3/15 at approximately 12:00 PM. This staff stated that the Performance Improvement (PI) Department is responsible for the coordinating and responding to patients/patients' representatives regarding complaints/grievances; difficult grievances are discussed in the Grievance Committee and complaints/grievances are discussed in the Performance Improvement Council (PIC). She also stated that PIC meets quarterly. There was a meeting of the PIC in the first quarter but not in the second quarter.

Meeting Minutes for the facility's Performance Improvement Council, dated January 8, 2015 was reviewed. It was noted that the data included in this report was for 2nd and 3rd Quarters, 2014. This report indicated that the Performance Improvement Department received 22 grievances; 12 (54%) were handled within 7 business days, and 10 responses to complainants were delayed (delayed letters were sent in 9 of the cases). There was no data on grievances/complaints in year 2015.

2. Staff H was interviewed on 12/3/15 at approximately 12:15 PM. This staff stated that the Board of Trustees approved the Grievance Process; therefore, it approved the Grievance Committee. Review of the Board of Trustees Minutes, dated March 25, 2013 identified that the Board of Trustees approved the Grievance Process and delegated the responsibility for administering this grievance process to the hospital.
The minutes for the facility's Board of Trustees, dated February 23, 2015 was reviewed. It was noted that the data from 2nd and 3rd Quarters of 2014 were presented. There was no evidence that data on complaints/grievances that the facility received in 2015 were presented to the facilities' Board of Trustees in 2015. It was noted that the Board of Trustees approved the revision of the Grievance Policy and Procedure (12/14) and accepted the PI Council Minutes as presented. There was no evidence that the Board of Trustee delegated its responsibility for reviewing and resolving, in writing, to a grievance committee. Therefore, the Board of Trustees is responsible for the prompt resolution of grievances.
During interview with Staff H on 12/4/15, at approximately 3:30 PM, this staff acknowledged that the Board of Trustee did not delegate the responsibility of reviewing and resolving grievances to a Grievance Committee.

Based on document review and staff interview, in nine (9) of thirteen (13) grievance files reviewed, it was determined that the facility did not ensure that the responses provided to patients/patients' representatives, regarding their grievances, were prompt and timely. (Files #A, #B, #C, #D, #E, #F, #G, #H & #I).

Findings include:
File # A: The facility received a complaint, on 4/2/15, from the patient who alleged that the physician stated that he would order medication for chest pain, but this was not administered in a timely manner. The patient was discharged on 4/7/15 and the complaint was converted to a grievance. The Medical Department completed the investigation on 4/13/15. The complaint response tracking form indicated that the response from nursing was dated 4/27/15 and the response letter was sent 4/27/15. The tracking form indicated that response letter was sent within 15 business days. The form also indicated that there was no delay.

File # B: The facility received a complaint, dated 4/17/15, from the patient's family member regarding nursing care and discharge of an elderly patient. The grievance file indicated that Nursing Department investigated the allegations. The date of the investigation was not documented on the investigation. The written response to the complainant, dated 5/7/2015, indicated that nursing already provided an explanation to the complainant. The facility apologize to the complainant on the perception of inappropriate care. It took over 21 days to provide a written response to the complainant.

File # C: The facility received a complaint from the patient's daughter, on 6/16/2015, regarding the treatment that he received in March. The Grievance Committee Meeting dated 7/9/2915 indicated that the committee met to discuss the complaint. It took the Grievance Committee 23 days after the facility received the complaint to meet. The complaint response tracking form indicated that the approval letter sent to the complainant was dated 7/21/15 over 14 days after the Grievance Committee met to resolve this grievance.

Similar findings noted in Grievance files #D, #E, #F, #G, #H, & #I for grievance responses that were not timely.

The facility's policy and procedure titled "Grievance Process/Complaint Management," revised 12/14, stated "a grievance will be completed as soon as possible. If a grievance is minor in nature, the investigation and response should be completed within 7 business days of receipt." This policy does not give examples of a grievance that is "minor in nature."
This policy did not address grievances about situations that endanger the patient, such as neglect or abuse.
During interview with Staff G on 12/3/15 at approximately 12:30 PM, the facility's grievance process was discussed; this staff stated that the facility was following its Grievance Policy.

Based on observation, review document and staff interview, in 1 of 5 applicable medical records reviewed, it was determine the facility did not ensure that patient, who was placed on 1:1 observation, was properly monitored for a safe setting. (Patient MR#2).

Findings include:
During the tour of the CPEP (Comprehensive Psychiatric Emergency Program) on 12/3/15 at approximately 1:00 PM, Staff A was observed sitting outside patient #2's room. This staff was interviewed, on 12/3/15 approximately 1:15 PM, and she stated, she was providing 1:1 monitor to the patient. This staff further stated that the patient was on 1:1 observation as fall precaution.

Review of the medical record for patient #1 identified; 64 year old patient; history of arthritis, coronary artery disease, cirrhosis , alcoholic, cerebral infraction, atrial fibrillation, diabetes, hypertension and dementia; was brought to the Emergency Department on 12/2/2015 by Emergency Medical Services after his daughter called 911, due to aggressive behavior. The physician's order for 1:1 constant observation, on 12/2/15 18:44, indicated the reason for the order was fall risk.

The facility's policy titled "Constant Observation," revised 8/2014, stated, the staff assigned to the patient should be "within no more than arms-length distance from the patient." It was observed that the staff assigned to monitor this patient was not within arms-length distance.
Review of the High Risk Observation worksheet for 12/3/15 identified that the worksheet for this patient was not completed; the staff assigned to monitor the patent did not initial the observation items on the "Do" and "Don't" sections of the form.

Base on document review and interview, it was determined that the hospital did not ensure that all staff who apply restraint or monitor patient, receive first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification.

Findings include:

Staff B (security staff) was interviewed on 12/3/15 at approximately 12:45 PM. The staff stated that security officers do not restrain patients. He explained that sometimes he has to assist clinical staff by holding the patient's limb (arms, legs), while the clinical staff medicate the patient or apply physical restraint.

Staff C (Director of Security) was interviewed on 12/4/15 at approximately 11:30 AM. This staff stated that security officers are not trained in first aid or certification in cardiopulmonary resuscitation. Initially, this staff stated that security officers do not restraint patients. This staff admitted that the security officers do physical take down and hold patients while clinical staff medicate patients. He later agreed that the security officers do physically restrain aggressive patients.

The facility's policy titled "Restraint Use & De-Escalation Strategies for Patient," effective date, June 15, describes the term "Manual Restraint," means and includes term "physical restraint." A physical "take down" to the floor is also considerd a manual restraint.

Personal files for Staff #B, #I, #J, #K, #L, #M, #N & #O (security officers), were reviewed on 12/4/15. These personnel did not have training in first aid techniques and the use of cardiopulmonary resuscitation.

Based on document review and staff interview, it was determined that the hospital did not administer its Quality Assurance (QA) Program to identify opportunities for improvement and the effectiveness of oversight of the grievances process.

Findings include:

Staff G was interviewed on 12/3/15 at approximately 1:30 PM, regarding the oversight on grievance process. This staff stated that the hospital has a Grievance Committee which meets to discuss difficult/complex grievances. A copy of the Grievance Committee Minutes for the year 2015 was requested for review. This staff stated that, although the Grievance Committee meets, there was no minutes. In addition, this staff did not recall when the Grievance Committee had its last meeting. Staff G stated that she reports on patients' complaints quarterly to Performance Improvement Council (PIC). However, she did not report Patient Compliant data to the PIC this year (2015).

The facility's policy titled "Grievance Process/Complaint Management," revised 12/14, stated "all grievances and complaints are logged and tracked. This data is reviewed on an ongoing basis to identify any significant trends that are then reported to the PI Committee." This facility had no data to review since its policy was revised 12/14.

The Meeting Minutes for the facility's Performance Improvement Council, dated January 2015 was reviewed. It was noted that this report discussed the statistics for the 2nd and 3rd Quarter for 2014. Quarter 2 statistics noted, 22 grievances were handled by the Performance Improvement (PI) Department: 12 grievances were responded to within 7 business days (54%); 5 grievances were responded to between 8 and 17 business days (23%) and 5 grievances were responded to after 18 business days (23 %). Quarter 3 statistics noted, 15 grievances were handled by PI: 8 grievances were responded to within 7 business days (53%); 3 grievances were responded to between 8 and 17 business days (20%); 4 grievances were responded to after 18 business days (27%). The "Administrative Grievance Process/Complaint Management Policy" stated that the facility respond to grievances within 7 business days. The facility determined that it was not meeting its mandate of responding to grievances within 7 business days. Therefore, the PI proposed revision to the Administrative Grievance Process/Complaint Management Policy. There was no data or further information to the PIC on complaints/ grievances, from January 2015 to November 2015, neither was there data to determine the implemenation and tracking to determine the success of this action. Therefore, it could not be determined that the facility identifying the problem as changing the policy, was the correct action to ensure that it was responding timely to complainant grievances.

Based on document review, and staff interview, in 1 of 17 medical records reviewed, it was determined this standard is not met, as is evidenced by the lack of patient safety assessment prior to discharge. (MR#1)

Findings include:

Review of MR#1 identified; a 56 year old female was brought to the facility by EMS when her daughter activitated 911 and declared her mother was suicidal. The patient denied suicidal ideation upon assessment. She admitted to having financial diffulties and stated that she was hit by her daughter during an altercation. She was discharged to home in the company of her daughter. There is no documentation in the medical record that a pre-discharge safety assessment was conducted or that the issue of domestic violence was addressed, or that the family was provided with any direction in resolving their issues.