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Based on review of facility documents and staff interviews (EMP), it was determined the facility failed to follow their adopted Grievance process by maintaining the Grievance log for four of the six Grievance documents reviewed. (OTH1, OTH2, OTH3, OTH4)

Findings:

Review of "The Meadows Psychiatric Center Policies and Procedures Section: II Policy: # 16 Function: Patient Rights Subject: Patient Grievance Handling Customer Complaints", reviewed February 2011, revealed "I. policy: there is a process to promptly resolve patient grievances. The process includes informing each patient about whom to contact to file a grievance. II Principle: Patients' grievances will receive prompt review and resolution, by a facility designated patient advocate. ... Definitions/Clarifications: A 'patient grievance' is a formal or informal written or verbal complaint that is made to the hospital by a patient, or patient representative, when a patient issue cannot be resolved promptly by staff present. When a complaint is referred to a patient advocate or to hospital management, it is to be considered a grievance. ... If other staff must call (e.g., the Patient Advocate) to resolve an issue that the staff cannot (or do not) resolve immediately, then it would be considered a grievance in most cases. ... Patient grievances would also include situations where patients and the patient's representatives call or write to the hospital about concerns related to care or services, who were not able to resolve their concerns during their stay or who did not wish to address their issues during their stay. Additionally, whenever the patient's representative request their complaint be handled as a formal complaint or grievance or when the patient request a response from the hospital, then the complaint is a grievance and all requirements apply. V. Process: ... 2. The hospital's governing body approves and is responsible for the effective operation of the grievance process, and has delegated the responsibility for reviewing and resolving grievances to the grievance committee. Committee members include, but are not limited to, the patient advocates, the DON, the Patient Safety Officer and the Director of Clinical Services. The committee reviews and signs off on all grievances. ... 4. The resolution of the grievance, will provide the patient with written notice of the facilities decision that contains the name of the patient advocate, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. 5. Any staff receiving a written or verbal grievance or complaint that cannot be resolved promptly will forward the grievance form to the patient advocate ... 6. A response will be provided for each grievance within 7 days. Grievances about situations that endanger the patient, such as neglect or abuse, will be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient. If the grievance cannot be resolved or if the investigation cannot be completed within 7 days, the hospital will inform the patient or the patient's representative that the hospital is still working to resolve the grievance, and will complete the resolution, including written response as soon as possible. 7. The log of completed grievances is kept for review by the Director of Regulatory Compliance.


1). During review of the "Patient Family Complaint" documents, a random selection of six complaints were reviewed. During review of the Grievance log revealed no evidence that four of the six patients (OTH1-OTH4) had filed a grievance.

2) During an interview with EMP4 on March 23, 2011, at approximately 01:30 PM, it was revealed "... The patient family complaint log book is a disaster. " EMP4 also confirmed the findings.

Based on review of facility documents and staff interviews (EMP), it was revealed that the facility failed to have a grievance committee as delegated by the Governing Body.

Findings:

Review of "The Meadows Psychiatric Center Policies and Procedures Section: II Policy: # 16 Function: Patient Rights Subject: Patient Grievance Handling Customer Complaints ... Revised: ... 1/09 I. policy: there is a process to promptly resolve patient grievances. The process includes informing each patient about whom to contact to file a grievance. II Principle: Patients' grievances will receive prompt review and resolution, by a facility designated patient advocate. ... Definitions/Clarifications: A 'patient grievance' is a formal or informal written or verbal complaint that is made to the hospital by a patient, or patient representative, when a patient issue cannot be resolved promptly by staff present. When a complaint is referred to a patient advocate or to hospital management, it is to be considered a grievance. ... If other staff must call (e.g., the Patient Advocate) to resolve an issue that the staff cannot (or do not) resolve immediately, then it would be considered a grievance in most cases. ... Patient grievances would also include situations where patients and the patient's representatives call or write to the hospital about concerns related to care or services, who were not able to resolve their concerns during their stay or who did not wish to address their issues during their stay. Additionally, whenever the patient's representative request their complaint be handled as a formal complaint or grievance or when the patient request a response from the hospital, then the complaint is a grievance and all requirements apply. V. Process: ... 2. The hospital's governing body approves and is responsible for the effective operation of the grievance process, and has delegated the responsibility for reviewing and resolving grievances to the grievance committee. Committee members include, but are not limited to, the patient advocates, the DON, the Patient Safety Officer and the Director of Clinical Services. The committee reviews and signs off on all grievances. ... 7. The log of completed grievances is kept for review by the Director of Regulatory Compliance. Reviewed: ... 2/11. "

1) During an interview with EMP4, on March 23, 2011, at approximately 10:50 AM, revealed that other than discussing grievances at the Patient Safety Committee, the Grievance Committee does not meet. Continued by stating that there has been no Grievance Committee meetings since July 2010.

2) During an interview with EMP4 on March 23, 2011, at approximately 1:30 PM, it was revealed "We do not have a Grievance Committee, we review grievances quarterly at the Patient Safety Committee. We also discuss grievances daily at the "Flash" meeting. The Flash meeting is a quick summary of what's going on for the day. The patient family complaint log book is a disaster. "

Based on review of facility documents, and staff interviews (EMP), it was determined the facility failed to ensure that a written notice/response was provided to the patient for two of six grievance documents reviewed. (OTH5, OTH6)

Findings:

Review of "The Meadows Psychiatric Center Policies and Procedures Section: II Policy: # 16 Function: Patient Rights Subject: Patient Grievance Handling Customer Complaints", reviewed February 2011, revealed "I. policy: there is a process to promptly resolve patient grievances. The process includes informing each patient about whom to contact to file a grievance. II Principle: Patients' grievances will receive prompt review and resolution, by a facility designated patient advocate. ... Definitions/Clarifications: A 'patient grievance' is a formal or informal written or verbal complaint that is made to the hospital by a patient, or patient representative, when a patient issue cannot be resolved promptly by staff present. When a complaint is referred to a patient advocate or to hospital management, it is to be considered a grievance. ... If other staff must call (e.g., the Patient Advocate) to resolve an issue that the staff cannot (or do not) resolve immediately, then it would be considered a grievance in most cases. ... Patient grievances would also include situations where patients and the patient's representatives call or write to the hospital about concerns related to care or services, who were not able to resolve their concerns during their stay or who did not wish to address their issues during their stay. Additionally, whenever the patient's representative request their complaint be handled as a formal complaint or grievance or when the patient request a response from the hospital, then the complaint is a grievance and all requirements apply. V. Process: ... 2. The hospital's governing body approves and is responsible for the effective operation of the grievance process, and has delegated the responsibility for reviewing and resolving grievances to the grievance committee. Committee members include, but are not limited to, the patient advocates, the DON, the Patient Safety Officer and the Director of Clinical Services. The committee reviews and signs off on all grievances. ... 4. The resolution of the grievance, will provide the patient with written notice of the facilities decision that contains the name of the patient advocate, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. 5. Any staff receiving a written or verbal grievance or complaint that cannot be resolved promptly will forward the grievance form to the patient advocate ... 6. A response will be provided for each grievance within 7 days. Grievances about situations that endanger the patient, such as neglect or abuse, will be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient. If the grievance cannot be resolved or if the investigation cannot be completed within 7 days, the hospital will inform the patient or the patient's representative that the hospital is still working to resolve the grievance, and will complete the resolution, including written response as soon as possible. 7. The log of completed grievances is kept for review by the Director of Regulatory Compliance.

1) During review of the "Patient Family Complaint" documents, a random selection of six complaints were reviewed. During review of the documents, it was noted that two of the six patients did not receive a written response. (OTH5, OTH6) )

2) An interview with EMP4 on March 23, 2011, at approximately 1:30 PM, confirmed the findings.

Based on review of facility documents and staff interviews (EMP), it was determined the facility failed to ensure that a registered nurse (RN) was immediately available for bedside care of a patient for one of one evening.

Findings include:

Review of the policy entitled "The Meadows Psychiatric Center for Provision of Nursing Care", dated January 2009, revealed "... 3.0 Identification of Nursing Care Needs. Nursing care needs of patients shall be identified using the nursing process. Specifically, registered nurses shall use assessment skills initially and on an on-going basis to determine the level of care and necessary interventions to ensure that the identified needs are addressed. The appropriateness of interventions will be evaluated for effectiveness with targeted positive patient outcomes and criteria. Modifications shall be made in treatment strategies based on the nurse's evaluation of the patient's response to interventions; thus ensuring that the delivery of care is representative of the patient's individualized needs. Nurse care needs are identified for all patient populations based on the specialized knowledge of registered nurses ... ."

1) A telephone interview with EMP2, EMP4, and EMP11, on March 31, 2011, at approximately 1:00 PM, was conducted. Related to the evening of the incident, on February 24, 2011, EMP2 stated that EMP14 from the Stabilization Unit building had gone to the Adolescent Unit building to assist. EMP2 confirmed that that left an LPN (Licensed Practical Nurse) in the Stabilization Unit building, and no RN in that building. EMP2 continued by stating that there is typically one RN per unit, per shift. Stated that if a critical incident occurs, the RN responds to provide support, and that phone calls would be made if the RN needs to return to the unit.

Based on review of facility documentation, review of medical record (MR), and staff interview (EMP), it was determined that the facility failed to keep a current treatment plan and failed to follow adopted policies related to elopement precautions for one of one medical record reviewed. (MR1)

Findings include:

Review of facility policy "Treatment Plan" reviewed February 2011, revealed " ... II. PRINCIPLE: ... B. To write patient goals in measurable terms, including interventions, and to document individualized target and completion dates.... ".

Review of facility policy "Elopement / AWOL" reviewed February 2011 revealed " ... It is the policy of The Meadows Psychiatric Center to implement appropriated precautions for any patient who presents as or becomes at risk for elopement (leaving the hospital without physician authorization) ...The staff's awareness of patients exhibiting high risk factors can allow the treatment team to initiate elopement precautions early in the patient's treatment upon written physician order. ... Initiate AWOL Precaution checks to confirm the patient's whereabouts. ... "

Review of facility policy "Special Precautions/Patient Observations" reviewed February 2011 revealed " ... Initiation of precautions should be documented in the physician's orders, Kardex, on the Special Precaution / Observation Level Form and as part of the Treatment Plan. ... ".

1) Review on March 23, 2011 of MR1 dated February 9, 2011 revealed "Physician's Orders ... 0115 AWOL." Further review of MR1 dated February 11, 2011 revealed "Physician Progress Notes Subjective: Once the patient left the building, she went AWOL. This is despite having been on AWOL precautions. The patient was found two hours later by personnel who were looking for her. ... "

2) Review on March 23, 2011 of MR1 dated February 10, 2011 revealed "Interdisciplinary Progress Notes ... February 9 0400 ... pt placed on AWOL ... " Further review of medical record dated February 10, 2011 ... Shift 3-11 ... revealed " ... Summary of Current Status/Response to Treatment/Plan; Pt was AWOL before visitation time and was found on Rt 45 ... ".

3) Review on March 23, 2011 of MR1 "Multidisciplinary Treatment Plan" dated February 9, 2011 revealed no documented evidence of interventions or special precautions/patient observation of patient's physician order of AWOL precautions.

4) Telephone interview on March 31, 2011 at approximately 1:00 PM with EMP4 confirmed the above findings.

5) Telephone interviews with EMP2 and EMP4 on March 31, 2011, also confirmed that the staff didn't follow the policy. Both stated that staff filled out the observation form but did not do the 15 minute checks, as per protocol. Also stated that they found out the patient eloped by another patient's family who had been visiting.