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Based on review of the hospital policy, video surveillance, medical record review, and patient and staff interviews the hospital staff failed to treat a patient concern as a grievance for 1 of 2 patient (Patient #1).

Findings included:

Review of the facility policy titled "Patient Complaint & Grievance Management approved 11/21/2019" revealed, " ...GRIEVANCES Complaints meeting any of the following criteria are considered a grievance and require a written response. 1. A written or verbal complain that cannot be resolved at the time of the complaint by staff present and requires further investigation and/or related actions for resolution. The complaint will be referred to the appropriate staff for resolution. 2. Complaints regarding the patient's care or with allegation of abuse, neglect, patient harm, or failure of the hospital to comply with one or more COPs, or other CMS requirements. A. Grievances involving situations that potentially endanger the patient such as harm or neglect should be reviewed immediately. Upon notification, the patient will be immediately removed from any situation that may endanger the patient ..."

Review of video surveillance on the Behavioral Health Unit on 07/03/2021 at 1416, revealed Patient #1 witnessed Patient #3 enter a common dining area and hit Patient #5 seven times with the closed fist to the head and face. Patient #1 was sitting within arms distance of the traumatic event.

Closed medical record review revealed Patient #1 was a 69-year-old female who was admitted after a fall with recent alcohol consumption related to 6-7 weeks of depression. Record review of the H&P (History and Physical) documented by MD #8 on 07/01/2021 at 1434, revealed Patient #1 had an admission diagnosis of " ...Bipolar II disorder. Patient requires inpatient treatments, expected > 2 midnights due to depression with SI (suicidal ideation) and recent suicide attempts and high-risk behaviors." Review of Nursing Flowsheet documentation on 07/03/2021 at 2106 by RN #9 revealed, " ...Patient appearing anxious about incident of violence on unit, able to voice her emotions with writer ..." Review of Nursing Flowsheet documentation on 07/04/2021 at 1328 by RN #10 revealed, " ...expressing anger over things that she observed yesterday on the unit, able to process her feelings logically and appropriately ..." Review of Nursing Flowsheet documentation on 07/07/2021 at 1607 by RN #11 revealed, " ...During team meeting she appeared more frustrated and voiced her concern over safety issues on unit. She indicated she did not feel comfortable in the same room with one of our patients, and incicated (sic) [indicated] she did not feel this was an appropriate place for him based upon his behaviors. Staff provided reassurance that safety was of utmost importance to staff, and that we continue to address this on a consistent basis ..." Review of the "Discharge Summary" documented on 7/08/2021 at 1400, by MD #8 revealed, on 07/04/2021 " ...She reports that overall she is feeling 'good' but says that she had trouble sleeping following the events yesterday. She spent some time in debriefing, discussing what she saw, and her concerns for everyone's safety. She says that she does not currently feel safe in the hospital and notes that she is experiencing higher level of anxiety ..." Further review of note documented by MD #8 on 07/06/2021, revealed " ...She has some anxiety b/c (because) of an agitated patient on the unit ...." Record review revealed Patient #1 did not have a documented grievance of record entered. Patient #1 was discharged on 07/08/2021 to her home with family.

Interview with NM #4 (Nurse Manager) on 08/12/2021 at 1445, revealed " ...it is my expectation of staff to bring concerns of patient to my attention. It is my expectation that the concern of (Patient #1) brought to RN #11's attention (on 07/07/2021 at 1559) documented in her nursing note be treated as a grievance ...." Interview revealed the concerns of Patient #1 brought to the attention of RN #11 should have been treated as a patient grievance according to the facility's policy.

Requested interview with RN #11 on 08/12/2021 at 1500 was unavailable.

Based on facility policy review, medical record review, and staff interview, the facility failed to maintain a complete and accurate medical record by failing to retain patient safety attendant documentation for 1 of 11 patients (Patient #3) with a behavioral health patient monitoring order.

Findings included:

Review of the facility policy, "Patient Safety Attendant: Standards for Patient Observation" approved 04/01/2018, revealed, "PROCEDURE... E. The PSA/OTT (Patient Safety Attendant/Other Trained Teammate) is to complete ongoing monitoring during observation using the Patient Safety Observation Monitoring Form... DOCUMENTATION. A. Patient Observation Monitoring Form hourly or as directed and scan into EMR (Electronic Medical Record) daily. B. Document room safety check as completed in the EMR each shift..."

Review of the facility policy, "Monitoring Levels and Suicide Precautions" approved 06/30/2021, revealed, "1.PL-1(Precaution Level 1): ...If on PL1 for any other purpose staff's position must be close enough to the patient so staff can intervene immediately if necessary, to prevent harm, and document at least every 15 minutes. The assigned staff person will have no other responsibilities."

Closed medical review of Patient #3 revealed a 35-year-old male was admitted to the Behavioral Health (BH) unit at the facility on 06/30/2021 at 0323 with admitting diagnosis of schizophrenia and substance abuse disorder. Review of the Physician Orders revealed, "Precaution Level 1 (PL1) - 07/02/2021 at 1523 - Dangerous contraband found, predatory behavior, sexual tendencies, and entering other pt (patient) rooms." Review of the Physician Orders revealed the PL1 order was modified on 07/03/2021 at 2131 to "Precaution Level 1 - Assault." Review of the Physician Orders revealed the PL1 order was discontinued at the time of discharge, 07/14/2021 at 1259. Review of Room Safety Checks revealed documentation on the following dates and times: 06/30/2021 1630, 07/01/2021 0945, 07/02/2021 1345, 07/07/2021 0730, 07/13/2021 1215. Medical record review revealed Patient #3 was discharged into custody of the police on 07/14/2021 at 1259. Review of medical record failed to reveal documentation of room safety checks for each 12-hour shift for 23 of 28 room checks. Review of the medical record failed to reveal Patient Observation Monitoring Forms for the following dates and times:
07/02/2021 1523 through 07/04/2021 0659 (39 hours),
07/06/2021 1100 through 07/08/2021 0659 (44 hours),
07/09/2021 1901 through 07/10/2021 0659 (12 hours),
07/11/2021 0701 through 07/12/2021 0659 (24 hours),
07/12/2021 1800 through 07/13/2021 0659 (13 hours),
07/13/2021 1901 through 07/14/2021 0659 (12 hours).

Interview on 08/11/2021 at 1320 with RN #1 revealed they provided supervision of care for Patient #3 during his time on the BH unit. Interview revealed Patient #3 had a sitter due to predatory female behaviors and patient to patient assault. Interview revealed the sitter role was filled with PSAs (Patient Safety Attendants) or the Psych (Psychiatric) Techs, depending on staffing availability. Interview revealed the documentation for the sitter role should be located in the medical record.

Interview on 08/12/2021 at 1150 with Nurse Supervisor #3 revealed the expectation was that PSAs documented their observations on the Patient Observation Monitoring Form. Interview revealed the PSAs were expected to turn the forms into the nurse before leaving the unit. Interview revealed reconciliation of the form was to be performed by the nurse.

Interview on 08/12/2021 at 1050 with NM (Nurse Manager) #4 revealed the expectation was that staff document every 15 minutes on patients with PL1 orders. Interview revealed Patient Observation Monitoring Forms would not be present in Patient #3 ' s medical record, if the patient was being monitored by a Psych Tech. Interview revealed the documentation from the Psych Tech was located in the electronic medical record. Interview revealed a Psych Tech worked as a sitter for Patient #3 on the following dates and times: 07/02/2021 1523 through 07/04/2021 0659, 07/06/2021 1100 through 07/06/2021 1900, 07/07/2021 0700 through 07/07/2021 1900, 07/09/2021 1901 through 07/10/2021 0659, 07/11/2021 0701 through 07/12/2021 0659, 07/12/2021 1901 through 07/13/2021 0659, 07/13/2021 1901 through 07/14/2021 0659. Interview revealed a PSA worked as a sitter for Patient #3 on the following dates and times: 07/06/2021 1901 through 07/07/2021 0659 (PSA #5), 07/07/2021 1901 through 07/08/2021 0659 (PSA #6), 07/12/2021 1800-1900 (PSA #7). Interview revealed the nursing staff were expected to document room checks each 12-hour shift. Interview revealed the documentation for room checks was missing.

Interview on 08/12/2021 at 1445 with PSA #5 revealed they were unsure of what happened to their documentation. Interview revealed that the Patient Observation Monitoring Form was given to the front desk.

Interview on 08/12/2021 at 1453 with PSA #6 revealed PSA #6 was not given a Patient Observation Monitoring Form upon arrival to the BH unit. Interview revealed, "there may have been another staff member that documented the observations in the computer (EMR)". Interview revealed the PSA was reassigned after 3 hours on the BH unit and did not turn in any documentation.

NC00179085