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Based on staff interview, and review of the facility's Complaint Log, Patients' Grievance files, Patient Grievance Mechanism Policy, Patient Relations Reports to the Performance Improvement Committee 2012, and Board of Trustees Meeting Minutes, it was determined that the facility failed to ensure that it has an effective grievance process which included prompt resolution of all grievances that it received. This was evident in twelve (12) of thirty one (31) Grievance Files reviewed (Files: #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12).

Findings include:

Staff #9 was interviewed on 10/6/2014. This staff reported that the facility does not have a grievance committee. She also stated that the Patient Relations Department reports quarterly to the Performance Committee.

Thirty one (31) patients' grievances files were reviewed. It was noted that twelve (12) of thirty one (31) grievance files reviewed lacked written responses to the complainant on the outcome of the investigations.

For example:

Grievance file #1 was reviewed on 10/7/2014. It was noted that the patient's niece filed a complaint with the facility on 2/11/2013 alleging that her aunt had staples removed on 1/9/2013 without the use of anesthesia and the staple removal was very painful; her aunt had to be held down. The file indicated that a telephone call was made to the niece on 2/26/2013 regarding the physician's reply. It was noted in the file that the complainant was not happy with the facility's response. There was no evidence that the complainant was provided with a written response on the steps taken to resolve the grievance. The file did not indicate that if the complainant was not satisfied with the facility's response that she may contact the state agency.

Grievance file #2 was review on 10/7/2014. It was noted that the patient's son filed a complaint with the facility on 2/25/2014 alleging patient abuse. The file indicated the Spanish speaking patient informed her son that a nurse hit her on her hand. It was noted that the facility investigated the allegation and concluded, on 3/17/2014, that there was no evidence of inappropriate touching of the patient's hand. The grievance file indicated that a letter was sent to the son on 3/18/2014. The facility was unable to produce a copy of the written response to the complainant. In addition, if the response was sent to the complainant on 3/18/2014, then this was not timely.

Grievance file #3 was reviewed on 10/7/2014. It was noted that the facility received a complaint from a patient on 3/7/2014 alleging patient abuse. The patient alleged that she was hit by a nursing assistant. The following was documented in the file, "comments: 3/10/14 . . . Print the ID pictures of everyone who was working on Wednesday and Thursday. She did not identify any of the employees as the one who alleged hit her. We are not able to corroborate her complaint". It was noted that there was no other investigation conducted. There was no evidence that the complainant was provided with a written response on steps taken to resolve the grievance.

Grievance #4 was reviewed on 10/7/2014. It was noted that the facility received a complaint from the patient in grievance file #4 on 9/2/2014. In this grievance, the complainant (patient's mother) alleged that the patient was allergic to penicillin and medicine derived from penicillin. However, penicillin was administered to the patient. As of the date of the surveyor, on 10/7/2014, there was no evidence that the complaint was provided with a written response on the outcome of the investigation.

Similar findings were noted in grievances files (#5, #6, #7, #8, #9, #10, #11 & #12) where the complainants were not provided with written responses on the outcome of investigation.

Staff #9 submitted "Patient Relations Report 4th Quarter 2012 on 10/7/6/14" and "Patient Relations Report 3rd and 4th Quarters 2012" were reviewed 10/7/2014. This staff reported that there were no reports to the Performance Committee for the year 2013 and 2014. It was noted that the Patient Relations Reports discussed what is considered a grievance. It was noted that this report did not include that a grievance can be verbal or written. It was noted that lack of written responses and timely responses were not discussed in the Performance Committee for 2012. What is considered a grievance was discussed with staff #9 on 10/7/2014. This staff acknowledged that the facility was not classifying all complaints that required further follow up as grievances.

The Board of Trustees Meeting Minutes for December 2013 through August 2014 were reviewed on 10/7/2014. It was noted that patients' grievances were not discussed in any of these meetings. The hospital governing body is responsible for reviewing and resolving grievances as it has not delegated the responsibility to a grievance committee. Therefore, the facility is not in compliance with this regulation.

Based on staff interview, review of Patients' grievance files, and Patient Grievance Mechanism policy, it was determined that the facility's specified time frame for reviewing and investigating the provision of responses to patients' /patients' representatives was not within a reasonable time frame. This was evident in eighteen (18) of thirty one (31) grievance files reviewed (files: #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 & #31)

Findings include:

Grievance file #13 was reviewed on 10/7/2014. It was noted that the facility received complaint from a parent on 3/8/2013. The parent alleged that the 4 year old patient had an outpatient surgery on his webbed toes. This parent believed that the surgery was not done properly. The file indicated that on 6/16/2013 the facility informed the complainant that the facility was investigating the issue. It was noted as of the day of this review, on 10/7/2014, the complaint had not been provided with a written response on the outcome of the investigation.

Grievance file #14 was reviewed on 10/7/2014. It was noted that on 3/26/2014 the facility received a complaint from a patient regarding an outpatient surgery on 11/26/2013. The patient alleged that he went to the facility for surgery on his nose and left with a scratched cornea. It was noted that, on 4/2/2014, the patient was informed that the concern was brought to the attention of the Chief of Anesthesiologist, who will follow-up. It was noted as of the day of this review, 10/7/2014, over seven months later, this patient was not provided with a written response on the outcome of the investigation.

Grievance #15 was reviewed on 10/7/2014. It noted that the facility received a complaint from the patient's daughter on 11/15/2013. The complainant alleged that the 75 year old patient with dementia was brought to the Emergency Department on 11/11/2013 at 5:00 AM for suspected stroke. At about 6:00 or 7:00 PM that night the patient was found at the daughter's doorstep with heplock in and EKG sensors attached to his chest. The written response on the outcome of the investigation was dated 1/3/2014, two months later.

Grievance file #16 was reviewed on 10/7/2014. It was noted that the patient's wife filed a complaint with the facility on 1/20/2014. The complainant alleged that her husband was sent from the hospital, without her knowledge, wearing only a hospital gown and sneakers. The comments on the file dated 3/12/2014 indicated that social work notes were reviewed on 3/12/2014. However, a copy of the written response to the complainant on the outcome of the investigation was dated 4/2/2014. It was noted that it took the facility two months to review the social workers notes. In addition, the written response to the complainant was dated 4/16/2014. Three months after the facility received the complaint.

Grievance #17 was reviewed on 10/7/2014. It was noted that the patient's daughter filed a grievance with the facility alleging that her father was unnecessarily restrained and he was demeaned by the Registered Nurse (RN) when he was in the emergency room. The file indicated that the facility received the complaint on 2/22/2014. The written response to the complaint was dated 4/17/2014.

Similar findings for grievance files (#18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 & #31) with responses to patients' / patients' representatives which were not timely.

Staff #9 was interviewed on 10/7/2014. This staff reported that the facility's responses to grievances were according to the facility's grievance policy.

The facility's policy titled: Patient Grievance Mechanism policy number: RI-24 reviewed 5/12, was reviewed by surveyor on 10/7/2014. This policy indicated that "a final written response will be sent to the complainant within thirty (30) days of receipt of the complaint". Based on CMS guidelines, "On average, a time frame of 7 days for the provision of the response would be considered appropriate". It was noted that thirty one (31) grievances files were reviewed and only three (3) of the thirty one (31) contained responses to complainant within the CMS guidelines.

Cross reference Tag # A 119

Based on staff interviews, grievance files and the review of incident reports, it was determined that the facility failed to effectively identify the need for improvement in the management of incidents of patient's aggressive behavior or sexual contact, in order to ensure a safe environment for all patients. In addition, the facility failed to have an effective system in place to address all allegations made from its patients concerning abuse (physical and sexual), neglect, and harassment of all forms, whether from staff, other patients, visitors or other persons.

Findings include:

1) Incidents
The incident logs for October 2013 through October 2014 were reviewed on 10/6/2014. The surveyor tallied up the number of: patient physical - verbal abuse, patient to patient altercations, and patient to patient sexual assault listed on the log. It was noted there were three (3) patient to patient sexual abuse, three (3) abuse - physical or verbal, and forty seven (47) patient to patient altercations for that period. It was noted that these incidents took place in the psychiatric units.

A request was made to staff #2 for the department of Psychiatry Quality Assurance Minutes / Reports for the year 2013 to present. This staff reported that there was no departmental Quality Assurance minutes. Staff #2 stated that there is a Special Incident Review Committee which meets to discuss the reportable incidents. According to this staff, if the incident is not reportable, then it is not discussed in the Special Incident Review. It was noted that of the fifty three (53) incidents reviewed only three were discussed in the Special Review Committee. Therefore, all patients' behavior on the unit was not analyzed, tracked, and trended in order to determine if there was need for improvement. Additionally, for the cases discussed in the Special Incident Review Committee, there was no follow up on the committee's recommendations.

For example:
Incident report 2014-3388 dated 3/5/2014 was reviewed on 10/8/14. This report was concerning a patient who was assaulted by another patient. It was noted that the patient was unconscious for approximately 2 minutes and with active bleeding. The Special Incident Review (Just Center) dated March 5, 2014 was reviewed on 10/8/14. It was noted that the committee met to discuss the patient that was hit by another patient in the face and head four or five times rapidly. The committee recommended: communication be improved between security and nursing staff, revised 1:1 watches and room restriction requirements, clarification of the policy, and in-service of staff. It was noted that there was no follow up on the Special Committee recommendation as this was not discussed in subsequent meetings.

2)
Review of Grievance file #2 & Grievance file #3 on 10/7/2014 noted that patient's / patient's represented filed complaints with the facility alleging patient abuse. The facility's policy in place regarding protecting patients from abuse (physical and sexual), neglect, and harassment of all forms, whether from staff, other patients, visitors or other persons was requested from staff #4 on 10/7/2014. This staff reported that the facility does not have such a policy.