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Based on record review, interview and policy review, the facility failed to ensure patient grievances were investigated by the facility. This affected two (Patients #5 and #8) of ten patient records reviewed. The census was 14.

Findings include:

1. Record review revealed Patient #8 was admitted on 05/05/21 and discharged on 05/12/21 with diagnoses including anxiety, depression, mania, and substance abuse.

Review of the complaint log revealed on 05/11/21 Patient #8 submitted a handwritten complaint alleging Staff F embarrassed her in front of other patients after an episode of incontinence and did not provide assistance with hygiene as requested after the incident occurred.

On 05/13/21, Staff E interviewed Patient #8; she summarized her findings and provided a typed report to the Staff D and Staff H and reported the incident to Ohio Mental Health and Addiction Services as an "alleged abuse of patient, verbal".

Staff F received disciplinary action on 05/17/21 and was placed on 30-day probation for safety issues, abusive language/conflict and work quality as a result of the aforementioned complaint . The complaint form was not completed in its entirety in that the "Required Corrections and Timeline for Corrections" on the form was left blank. As a result, there was no evidence of any education provided to either Staff F or Nursing staff in general.

During email exchange on 12/09/21 at 2:00 P.M., Staff A documented education had not been completed per facility protocol after the event had occurred.

During telephone interview on 12/09/21 at 3:04 P.M., the acting Director of Nursing stated that nothing could be found in regard to resolution presented to the patient or education of staff.

2. During interview on 12/07/21 at 10:36 A.M., Patient #5 stated she had chosen to shower in the evening on 12/03/21 because it may help her sleep better. She recalled while in the shower she heard what she thought was a male voice and she noticed the door from the hall had opened more than once. She said she didn't actually observe anyone because of her position in the shower stall. However, when she completed bathing and stepped out to the sink, there was a bag of candy that was part of the snack pass by activities department in the evening. She began to think that a male activity staff person, Staff J, had been in the bathroom to place the candy package on the sink. She said the events that she experienced troubled her, and she reported her concerns to staff on either 12/03/21 or 12/04/21.

Review of the facility's incident log revealed no documentation of Patient #5's concern about an event on 12/03/21.

During interview on 12/07/21 at 10:15 A.M. , Staff I stated there was a report by Patient #5 of an alleged event involving being in the shower and hearing a male's voice and finding a bag of candy on the sink counter after her shower. Staff I said Patient #5 had reported her concern, but Staff I didn't know if anything had been resolved related to the allegations. Staff I said the activity staff person, Staff J, would have no reason to enter the patient bathroom. Staff I said the incident had created some talk among staff and potentially other patients at the facility.

During interview on 12/07/21 at 3:36 P.M., Staff A stated there was a report of a concern by Patient #5 about an event on 12/03/21 that had not been investigated until she began a review on 12/07/21. Staff A said any allegation by a patient about safety on the unit should be immediately investigated per facility protocols. Staff A confirmed the incident investigation had not been initiated within 24 hours with appropriate documentation and action per facility policy and procedure for an allegation of potential abuse.

Review of the policy titled "Patient Grievance", effective 11/01/21 revealed it is the responsibility of the Patient Advocate to implement this policy and procedure and to disseminate this information to all staff members under their direction. The facility shall provide a system whereby patients and/or their significant others or services received at the facility. The procedure is including the patient will receive a written notice of grievance determination, all grievances are to be submitted verbally or in writing to the Grievance Coordinator, either by the patient, the patient's representative, or a staff member to whom the grievance was reported. The Grievance Coordinator will conduct an investigation of the grievance, reviewing the patient's medical record, to obtain information regarding the patient's clinical condition. All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance that requires immediate redress. All grievances receive immediate priority and must be investigated with effort made toward resolution within 24 hours. The organization will make every attempt to provide a response within seven days of receiving a grievance. The patient will be provided within 24 hours the name of the Grievance Coordinator, steps taken to investigate and resolve the grievance, final result of the complaint and grievance process and the date of completion of the complaint and grievance process. Written notice will be provided to the patient in a language and manner the patient/representative can understand.

Based on observation and interview, the facility failed to ensure bathroom surfaces were maintained from growths of mold/ mildew, peeling paint and rusting metal surfaces. This affected three of five shower rooms on Unit 53. This had the potential to affect all patients in the facility. The census was 14.

Findings include:

During tour on 12/06/21 at 12:10 P.M., a shower fixture was not operational in shower room 557. In shower room 513, there was steadily dripping water from the shower fixture, a rusted metal door frame, two tiles missing in the shower area below the water on/off fixture, black splotches on the white painted ceiling, a rusted surface of a metal wall mounted radiator/ heat-cool fixture with peeling paint, and metal framed hampers with rusted frames and lids. In shower room 566 there was a wall mounted metal radiator with surface rust and peeling paint. The shower water temperature felt lukewarm to touch.

During interview at the time of the observations, Staff L confirmed findings of rust, peeling paint, black splotchy growths on painted surfaces, especially ceilings, and missing tiles.

During interview on 12/06/21 at 1:38 P.M., Staff A stated the bathrooms are not well ventilated. She said an inspector in a prior inspection required the facility to close off the louvers at the bottom of the bathroom doors to the hallways. The rooms had never been equipped with exhaust fans.