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Based on observation, clinical record review, interview, policy and procedure review the Governing Body failed to effectively discharge it's oversight responsibilities to assure quality health care was provided in a safe environment in that 1( #6) of 10 (#1-#10) patients was not protected from abuse or harassment and failed to protect, identify, investigate and report allegations of abuse or harassment by Patient #6. The failed practice did not assure Patient #6's emotional health and safety were protected. The failed practice created an Immediate Jeopardy to the health and safety of Patient #6 and had the likelihood of affecting any patient in the Facility. See CMS A-0115

Based on observation, clinical record review, policy and procedure review and interview the Facility failed to assure 1( #6) of 10 (#1-#10) patients was protected from abuse or harassment in that the Facility failed to protect, identify, investigate and report allegations of abuse or harassment made by Patient #6. The failed practice did not assure Patient #6's emotional health and safety were protected. The failed practice created an Immediate Jeopardy to the health and safety of Patient #6 and had the likelihood of affecting any patient in the Facility. The findings were:

A. Observation on Units 1 - III on 04/08/15 began at 0930 and patients were present on each Unit. There were no patients in seclusion at the time of the observations. The census for Unit 1 and Unit 2 was 11 for each Unit. Both Units had adult patients. Unit 3 was Adolescents (ages 11-18) and children (10 and under). The patient census for Unit 3 was 27. Unit IV census was 11 and Unit 5 was 28. Patient #6 was a 17 year old patient on Unit 3.

B. The clinical record for Patient #6 was reviewed on 04/08/15. A handwritten note (undated) was noted in the clinical record and identified by staff as Patient #6. The note was between 03/31 and 04/01/15 Group Progress Notes. The note contained the statement "So yesterday, I was playing ball w (with)/(Named) and (Named). Well (Named) rapped [sic] his arms around me and grabbed my boobs. I feel very uncomfortable around him. I told Mrs. (Named) but she just said to stay away from him. He also stuck his hands between (Named) legs. I'm just letting you know so you can be aware of it." There was no documentation staff acted to protect Patient #6, identify or investigate and report the allegation as a complaint or grievance.

C. The Director of Quality was interviewed 04/8/15 at 1530 and stated she was not aware of the existence of the handwritten note from the Patient #6 and concluded the note was from 03/31-04/01/15 due to it's location in the clinical record. Review of the Grievance Log 04/08/15 with the Director of Quality revealed there was no evidence a grievance was reported for the allegations in the handwritten note.

D. The Patient Advocate was interviewed on 04/08/15 at 1545. She reviewed the complaint by Patient #6 in the clinical record. She confirmed she had no prior knowledge of the complaint.

E. On 04/08/15 the Facility policy "Patient Grievance" stated "any patient complaint that calls into question the quality of care that was received while in the hospital is managed and resolved immediately by the nurse at the bedside, the Patient Advocate or the front line Supervisor. Complaints that cannot be managed by front line staff are resolved through the Grievance Committee." The Facility definition of a Patient Grievance is: "A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, if the patient's representative regarding the patient's care, abuse or neglect, issues related to the hospitals' compliance with the CMS Hospital's Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489."

F. The Director of Nursing provided on 04/08/15 the patient rights pamphlet that is given to patients/families upon admission to the Facility. The pamphlet contains the statement: "You have the Right: to have personal privacy, dignity, and safety and to be free from all forms of abuse or harassment during your stay."

G. The Director of Nursing was interviewed on 04/08/15 at 1015 and reviewed the clinical record. She confirmed there was no documentation staff intervened or acted on the allegation by Patient #6.

H. After a written plan was received from the Facility on 04/09/15 at 1020, the Immediate Jeopardy was abated. On 04/09/15 at 1215, the Administrator requested to submit a revised plan to remove the Immediate Jeopardy and this was received and accepted 04/09/15 at 1522. The plan "Since the allegations were reported, the accused patient has been discharged from the Facility without further incident. Additionally, no further concerns or issues have been identified by the patient since this time. However, because we failed to document the incident and our interventions, we have implemented several corrective actions to prevent any further concerns. The following corrective Action Plan has been immediately implemented to correct the Immediate Jeopardy situation identified during the survey. 1) Clinical Services Director (DCS) will conduct individual interview with patient to ensure the patient feels safe and to address any prior allegations or concerns. (04/09/15); 2) Licensed Social Services and Nursing staff, under the close supervision of the DCS and Chief Nursing Officer (CNO), will provide ongoing therapeutic interactions with the patient to address the patient's needs, ensure safety and adherence to patient rights. These will occur at least weekly or more frequently at the request of the entire treatment team. (04/09/15, On-going); 3) All Nursing and/or Social Services staff involved in this incident will be counseled and disciplinary action will be documented where warranted. (04/10/15; 4) Social Services and Nursing staff, including Mental Health Technicians, will be provided mandatory education from an outside source (such as the Disability Rights Center) regarding patient rights and potential abuse warning signs ( 04/13/15 and 04/15/15); 5) All patient care staff will be provided mandatory education on the necessity of incident reporting (HPRR) and the process for their appropriate use. (04/20/15); 6) Non-licensed staff will be provided mandatory education regarding appropriate and timely documentation in the medical record pertaining to patient incidents and concerns. (04/20/15)."

Based on review of clinical records, Patient Complaint/Grievance Log, complaint forms and interview, the Facility failed to adhere to their policy for identifying and responding to patient complaints and grievances for 1 (#6) of 10 (#1-#10) patients selected for review and 4 (#11-#14) patients who completed a Patient Complaint Form. Patient rights were not assured in that patients were not assured protection from abuse or harassment or that complaints and grievances would be identified, investigated or resolved. The failed practice affected Patients #6, #11-#14 and had the potential to affect any patient in the Facility. The findings were:

A. The clinical record for Patient #6 was reviewed on 04/08/15. A handwritten note (undated) was noted in the clinical record and identified by staff as Patient #6. The note was between 03/31 and 04/01/15 Group Progress Notes. The note contained the statement "So yesterday, I was playing ball w/ (Named) and (Named). Well (Named) rapped (sic) his arms around me and grabbed my boobs. I feel very uncomfortable around him. I told Mrs. (Named) but she just said to stay away from him. He also stuck his hands between (Named) legs. I'm just letting you know so you can be aware of it." There was no documentation staff intervened or acted on the allegation by Patient #6.

B. The Director of Quality was interviewed 04/8/15 at 1530 and stated she was not aware of the existence of the handwritten note from the Patient #6 and concluded the note was from 03/31-04/01/15 due to it's location in the clinical record. Review of the Grievance Log 04/08/15 with the Director of Quality revealed there was no evidence a grievance was reported for the allegations in the handwritten note.

C. The Patient Advocate was interviewed on 04/08/15 at 1545. She reviewed the complaint by Patient #6 in the clinical record. She confirmed she had no prior knowledge of the complaint.

D. On 04/08/15 at 1535, the "Patient/Family Rights, Complaint Grievance Log" was reviewed. The last entry on the log was dated 03/19/15. The notebook also included five "Patient Complaint Form" completed by patients with dates of the complaint listed as 03/14/15, 03/18/15, 03/19/15 and 03/23/15. These were not included on the Patient/Family Rights, Complaint Grievance Log. The Patient Advocate was interviewed on 04/08/15 at 1545. The Patient Advocate confirmed the last entry on the log was 03/19/15. Regarding the five complaint forms completed by patients, but not logged or acting upon, the Patient Advocate stated the following:
1) (Patient #11, complaint date 03/23/15) "He was discharged before I could see him." The Director of Quality confirmed the patient was admitted on 03/19/15 and was discharged on 04/07/15.
2) (Patient #12, complaint date 03/18/15) "I don't believe anyone would have told him that."
3) (Patient #13, #14) "The patients were already gone when I got the complaint."

E. On 04/08/15 the Facility policy "Patient Grievance" stated "any patient complaint that calls into question the quality of care that was received while in the hospital is managed and resolved immediately by the nurse at the bedside, the Patient Advocate or the front line Supervisor. Complaints that cannot be managed by front line staff are resolved through the Grievance Committee." The Facility definition of a Patient Grievance is: "A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative regarding the patient's care, abuse or neglect, issues related to the hospitals' compliance with the CMS Hospital's Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489."

F. The job description for the Patient Advocate ws provided by the Director of Nursing on 04/09/15 at 0910 and contained the statement "As patient Advocate, is knowledgeable of all standards and regulations governing patient rights and the grievance process. Responds to and documents all contacts and interventions related to patient complaints/grievances per policy/procedure/standards. Provides reports as requested related to complaints/grievances.

G. The Patient Advocate and the Director of Quality confirmed there was no evidence the Facility's policy was followed for Patient #11 - #14 in that the complaints were not resolved at the time of the complaint and there was no evidence the complaints were forwarded for resolution to the Grievance Committee.