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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 "Conditions of Admission-Inpatient" packet dated 03/06/21 contained a consent for treatment, no contact information for Complaints Department of Health (DOH).

B. On 05/23/22 at 3:05 pm during interview with S(staff)2 (Patient Advocate) who confirmed, "As far as the issue of having contact information for DOH complaints, it is in the policy, but I just put those policies in the binder today. I can get the updated one that has that information on it. The document that contains the DOH contact number is a handout but is only provided on request but will be added to the patient packet, we haven't been doing it but we will start now."

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 facility's grievance log titled "Patient Advocate Log" dated 10/2021 through 04/22, revealed 15 patient grievances and the Facility's response. The response is inadequate with only 9 responses (4 grievance responses left blank, 5 grievance responses of patient property returned or mailed to patient, no mention of actions for any measures taken to prevent repeat instances of grievances). Some have patient signatures others do not. Some have letters sent to patients by certified mail, others do not. One response letter sent on 01/21/22 revealed a response to a patient who had issues regarding infection control practices but the complaint is not attached.

B. Record review of facility's documentation titled "Patient Grievance Information" not dated is a handout that may be provided to patients if requested but is not a part of the patient information packet or patient rights.

C. On 05/23/22 at 2:55 pm during interview with S(staff)2 (Patient Advocate) who confirmed, "I write in the grievance form what I do to resolve the grievance. I respond to many issues and sometimes they are not documented. We send certified letters if the resolution is completed after the patient has been discharged."

Based on observation, record review, and interview, the facility failed to maintain an ongoing process to identify and ensure using medical supplies for direct patient care past expiration dates and not identified as being under an extended use authorization by the United States Food and Drug Administration (FDA). This failed practice is likely to lead to poor treatment and delayed progression to goals using expired medical supplies.
The findings are:

A. On 05/23/22 at 2:30 pm, during a tour of the facility in one of the unit's medical supply room the following expired medical supplies was observed:
1. Busse (product name) Yankauer Suction Instrument w (with)/tubing (used to clear the airway to prevent fluid in the lungs) (2) expired on 11/30/2021.

B. Record review of [name of facility], Policy Area Medication Management, Expired or Unusable Medication, dated 04/2022, revealed, under Procedure section, "Expired or Unusable Medications: will not be distributed or administered, upon identification are returned to pharmacy for proper disposition, are safely and securely stored in designated area separate from active inventory to prevent their distribution."

C. On 05/23/22 at 2:30 pm, during an interview, Staff (S)#6, LPN (License Nurse Practitioner) confirmed S#8 (Infection Control RN( Registered Nurse)) checks the medical supplies weekly to see if expired or need to restock.

D. On 05/24/22 at 11:05 am, during an interview, S#8 (Infection Control RN) confirmed it is the responsibility of all staff to make sure medical supplies are not used if it is expired and to dispose of appropriately.

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Based on record review and interview the facility failed to:
1. Identify, surveil, prevent and control an infection for 1 patient (P15) of 4 (P13, P14, P15, P16) patients;
2. Ensure the oversight of the food and nutritional liquid products by making sure they are used by manufacturer's best use by date and removing expired food items which can affect all patients.
This failed practice could lead to patient harm by allowing an infection to spread amongst patients, lead to poor nutrition and delayed progression to patient's recovery and cause harm from food borne (contaminated) illness from expired food.

The findings are:

1. COVID Screening
A. Record review of P15 Nursing Reassessment dated 01/16/22 23:49 [11:49 pm] COVID Screening: Does the patient have any of the below symptoms? "No" box is marked. "Patient anxious and medication pass, she complained of nausea and vomiting. Gave Phenergan [medication to prevent vomiting] and was effective. Patient denies SI [Suicidal Ideation], HI [Homicidal Ideation], AVH [Auditory and Visual Hallucinations] she endorses depression. Encouraged shower and group attendance. Continue to monitor for safety."

B. Record review of P15 Nursing Reassessment dated 01/17/22. 0818 [8:18 am] COVID screening: Does the patient have any of the below symptoms? "No" box is marked. "Patient tells this RN (Registered Nurse) that patient feels a little nauseated and relates this to not drinking. Patient request PRN [as needed] nausea med, PRN given as prescribed. Patient requests to hold off on scheduled AM meds for now.
0852 [8:52 am] Patient currently at nurse's station patient reports nausea better AM scheduled meds given. Patient encouraged to attend group, patient tolerated, will continue to monitor."

C. Record review of P15 Psychiatric Progress Note dated 01/17/22. Chief complaint: "I am having stomach problems."

D. Record review a P15 Nursing Reassessment dated 01/17/22 2259 [10:59 pm]. COVID screening: Does the patient have any of the below symptoms? "No" box is marked. "Patient complained of nausea and vomiting gave comfort meds as needed and were effective ... Attended group. Continued to be supportive and monitor for safety."

E. Record review of P15 Nursing Reassessment dated 01/18/22 0807 [8:07 am]. COVID screening: Does the patient have any of the below symptoms? "Yes" box is marked. "Patient previously noted in bed eyes closed resting. Patient complaints of nausea and wanted anti-emetic [prevent vomiting] before her meds. Vitamins held per provider due to patient complaint of nausea. Patient encouraged to attend group. 1248 [12:48 pm] Patient currently at nurses' station with complaint of cough. Provider notified, orders obtained and carried out. Patient moved to private room. Patient tolerated well. Continue to monitor."

F. Record review of P15 Psychiatric Progress Note dated 01/18/22. Chief complaint: "I am feeling sick."

G. Record review of P15 Nursing Reassessment dated 01/18/22 2216 [10:16 pm]. COVID screening: Does the patient have any of the below symptoms? "No" box is marked. "Patient was isolated to self. Complained of nausea and back pain so ibuprofen and Phenergan [medication to prevent vomiting] given per patient request."

H. Record review of P15 Nursing Reassessment dated 01/19/22 1100 [11:00 am]. Contacted [name of facility] ER and spoke with RN [name] who stated patient had tested positive for COVID-19 and has been admitted."

I. Record review of P15 medical chart dated 01/14/22 to 01/19/22 revealed no evidence of COVID tests being offered or administered to patient.

J. On 05/24/22 in an interview with S(staff)4, Director of Nursing, confirmed that the nurses should have documented nausea and vomiting in the COVID Screening portion of the Nurse Reassessment so that a trend may have been noticed.

K. On 5/25/22 in an interview with S1, Chief Executive Officer, confirmed that the trend of the patient's regression of health should have been identified and treated as an isolation situation.

2. Expired Food and Nutritional Liquid Products
L. On 05/23/22 at 2:15 pm, during observation of the medical supply room in the unit the following expired nutritional supplies was revealed:
1. Kikkoman (product name) Pearl Organic Soymilk (4 carton boxes) expired 02/01/22
2. Premium (product name) Saltine Crackers (6 packages) 04/17/22.

M. On 05/23/22 at 2:20 pm, during an interview, Staff (S)#6 Registered Nurse confirmed S#8 (Infection Control RN) checks the nutritional supplies weekly to see if expired or need to restock.

N. On 05/24/22 at 11:00 am, during an interview, S#8 (Infection Control RN) confirmed it is the responsibility of all staff to make sure nutritional supplies are not used if it is expired and to dispose of in the trash.

O. Record review of [name of facility], Policy Area Provision of Care, Dietary Services, dated 09/2021, revealed, under Procedure section, "Food/drinks will be discarded immediately if expired."

Based on record review and interview the facility failed to meet the Condition of Participation (COP) for discharge planning by failing to comply with the requirements as evidenced by the following:

A. The facility failed to update the discharge plan based on the re-evaluation of the patient's high-risk condition. See tag 0802.

Based on record review and interview the facility failed to ensure an effective transition from hospital to post discharge care. The facility failed to update the discharge plan based on the re-evaluation of the patient's condition for 1 (P14) of 4 patients (P13, P14, P15, P16). This deficient practice would likely lead to patient harm by not ensuring safeguards were implemented before discharge.

The findings are:

A. Record review of P14 Nursing Reassessment dated 01/16/22 0735 [7:35 am]. "Nursing staff notified by CSW (Certified Social Worker) that patient is Covid positive and patient informed discharge on hold. Patient isolated to room on droplet precautions and will wear a mask and maintain social distancing and hand hygiene. 1100 [11:00 am]: Patient assessed from hallway, he is pacing inside room and is agitated and anxious. He requests meds [medications] for anxiety and meds given... He is upset with news of COVID positive result. He does have a cough and a sore throat but mostly upset about quarantine and lack of socializing. He indicates positive suicidal ideations. No plan. But states he would rather not be alive than be like this and alone, feels ignored."

B. Record review of P14 Discharge Order dated 01/17/22. Stated, "Discharge patient to Hotel" Signed by DNP (provider, Doctorate of Nurse Practitioner) at 7:00 AM.

C. Record review of P14 Discharge/Aftercare Instructions dated 01/17/22 1540 [3:40 pm]. C-SSRS (Columbia Suicide Severity Rating Scale) shows patient is assessed by Social Worker as high risk for suicide. Form also indicated that Social Worker notified Provider on 01/17/22 1700 [5:00 pm]. Outcome/Justification for Discharge (from Provider) section is not completed.

D. Record review of P14 medical chart shows no note from provider that Social Worker notified Provider of high risk for suicide.

E. Record review of P14 Social Services Progress Note dated 01/17/22 at 1607 [5:07 pm] stated "Patient stated he is suicidal and stated he has a plan, but would not disclose plan ... Patient was unable to identify any supportive people in his life. Patient is discharged to [motel] to quarantine."

F. Record review of P14 Face Sheet stated discharge date and time as 01/17/22 at 1727 [5:27 pm]

G. On 05/24/22 at 3:00 pm, during an interview with S(staff) 4, Director of Nursing, confirmed that when a patient is assessed as high risk on the C-SSRS before discharge, the provider must be notified and give a justification for the discharge. S4 went on to state that this notification and justification should be documented in the chart.