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Based on record review and interview, the hospital failed to ensure in its resolution of patient grievances to provide four of four patients (Patients #16, #12, #13, #15) with written notices regarding their complaints.

Findings included:

Patient #16 filed a written complaint with staff on 07/29/15. A letter dated 07/30/15 acknowledged the "receipt of grievance" and noted to "continue to look into this matter." The space provided for the resolution of the patient concern was left blank.

Hospital Personnel #3 reviewed the patient advocacy documentation and denied that there was "anything in writing after 07/07/15."

Patient #12 filed a written complaint dated 03/26/15. A letter dated 03/31/15 noted the patient advocate's intention to "...continue to look into this matter." The space provided for date and time of complaint resolution was left blank.

Patient #13 filed a written complaint dated 02/21/15. The space provided for date and time of complaint resolution was left blank.


Patient #15 filed a written complaint dated 02/21/15. The space provided for date and time of complaint resolution was left blank.


Record review of a patient advocacy log provided to the surveyor on 10/09/15 did not reflect the complaints filed by Patients #16, #12, #13, #15. There was no entry of patient complaints dated after 07/07/15.

Based on record review and interview the hospital failed to ensure that a registered nurse evaluated the nursing care for one of one patient (Patient #4) who was admitted with severe panic attacks. The patient's anxiety did not diminish throughout her hospitalization. Although the clinician assessed Patient #4 to have severe anxiety symptoms shortly before discharge, nursing failed to reevaluate the patient's anxiety level.

Findings included:

Patient #4's Intake Assessment dated 04/08/15 at 06:31 (not specified AM or PM) noted the patient arrived as a memorandum of transfer from an acute care hospital with complaints of anxiety and "jerking" like in a "seizure," panic attacks, tremors, crying spells, and nightmares. The patient had a plan to overdose on medication in a suicide attempt.

Psychiatric Progress Notes dated 04/10/15 at 15:00, 04/11/15 at 09:00, 04/12/15 at 10:10 reflected that Patient #4 was physician assessed to be anxious. The patient stated she was anxious. On 04/13/15 at 12:00 the physician noted the patient's mood was anxious.


Patient Data and Assessment documentation dated 04/09/15, 04/10/15, 04/11/15, 04/12/15, and 04/13/15 (the day of discharge) reflected nursing staff assessed Patient #4 to be anxious for at least 16 hours a day. On 04/10/15 at 11:00 the patient complained to nursing staff that she was anxious. One hour later, on 04/10/15 at 12:00 Patient #4 had an anxiety attack and "started twitching." On 04/11/15 at 18:30 nursing received a complaint from the patient that her anxiety level was "9 to 10" on a scale with "10" as the highest score.

On the day of discharge (04/13/15) at 10:40, Patient #4 complained to nursing staff of increased anxiety and lability. Approximately one hour later during a coping skills group, the therapist noted that the patient was "anxious, trembling, reporting panic attacks daily." Nursing documented that Patient #4 was discharged home on 04/13/15 at 17:20. Forty minutes later, nursing noted that the patient was "anxious" during the 15:00 to 23:00 shift.

Hospital Personnel #2 reviewed Patient #4's medical record on 10/13/15 at 14:10 and agreed that Patient #4 was admitted and discharged with severe anxiety.