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Based on interview and record review the facility failed to follow their procedure for complaints and grievances for two (#1 and #2) of four patients reviewed for complaints and grievances out of a total sample of 10, resulting in the potential for decreased patient satisfaction and missed opportunities for quality improvement. Findings include:

On 8/11/20 at approximately 1300 the facility Complaints/Grievance log and the Office of Recipient Rights (ORR) complaints/grievance log were reviewed with the ORR advocate Staff D and revealed no documentation of any complaints or grievances related to Patient #1.

On 8/11/20 at approximately 1400 Patient #1's clinical record was reviewed with the Director of Nursing Staff B and revealed the following information:

Patient #1 was a 29 year old female who was admitted for lithium (medication) titration for Bipolar Disorder on 7/9/20. Patient #1 did not have a physician order for a source control/ personal protective mask to prevent transmission of Covid-19 infection, and there is no documentation to indicate that one was provided or that she was ever asked if she wanted to wear one.

There was no documentation in Patient #1's clinical record, the Office of Recipient Rights (ORR) complaint/grievance log or the facility complaint/grievance log of any complaint made by Patient #1 or any of her family members.

Review of Patient #1's clinical record revealed loose papers documenting a preliminary facility investigation of an undated complaint made to the facility Corporate Compliance hotline by Patient #1's husband. Pages 1-3 were missing and not provided. The undated form entitled "Compliance Investigation Hotline Report Summary" documented that the facility received a complaint made by Patient #1's husband which alleged, "patients do not wear masks and he was concerned that his wife might get infected with Covid-19 in the facility because patients do not wear masks." The corporate compliance complaint form also noted that Patient #1's husband complained that he had a hard time getting in touch with someone regarding his concerns. Staff B said that she received this complaint referral from Corporate Compliance on July 26 and was in the process of investigating it.

There was no documentation that Patient #1 or her husband were sent a complaint acknowledgement letter or complaint resolution letter. There was no documentation to indicate that either Patient #1 or her husband were informed that the facility had received their complaint or that they were investigating it.

Staff B was asked about this during review of this document but did not explain why this complaint was not included on the facility Complaints/Grievances log, or why the facility timeframe and process for Complaints and Grievances was not followed. Staff B said that the investigation was not completed yet because she received it one day before she went off work on leave.

On 8/11/20 at approximately 1500 Patient #2's clinical record was reviewed with Staff B who was also interviewed at that time. The following information was revealed:

Patient #2 was a 28 year old female who was admitted into the facility by petition and certification on 7/12/20 for diagnoses of Major Depressive Disorder, Bipolar II, Post Traumatic Stress Disorder (PTSD), Narcolepsy, Asthma, Borderline Personality Traits, Obesity and Sclerosing mesenteritis (a rare disorder where the tissue (mesentery) that holds the small intestines in place becomes inflamed and forms scar tissue).

Patient #2's Admission Psychiatrist History and Physical (H&P) dated 7/12/20 at 2230 documented, "She is afraid of being infected with Covid-19 in the hospital." Patient #2's medical physician H&P dated 7/13/20 at 1215 noted, "Patient is concerned for Covid. Patient says that she might get exposed here."

A Nursing note for Patient #2 dated 7/14/20 at 1445 noted, "Patient is upset about mask guidelines. Patient expressed concern about Covid-19 policies. Staff assisted patient to write to ORR advocate. Staff left a voice mail to ORR advocate to notify them of patient concerns. Risk manager notified."

There was no documentation of Patient #2's written complaint regarding facility Covid-19 policies or the Nurse voicemail notification to the Risk Manager and the ORR Patient Advocate regarding Patient #2's complaint/grievance.

On 8/11/20 at approximately 1300 review of the facility Complaints/Grievance log and the Office of Recipient Rights (ORR) complaints/grievance log with the ORR advocate Staff D revealed no documentation of any complaints or grievances related to Patient #2.

On 8/11/20 at approximately 1520 the ORR advocate and Staff B were interviewed regarding patient #2's complaint/grievance documented in her clinical record and both stated that they couldn't remember any complaints made by Patient #2 and did not remember receiving any complaints regarding facility Covid-19 policies. Staff D reported that he kept no phone log and that he did not document patient/family complaints that he resolved immediately. Staff D reported that he was on vacation for most of July, but had staff covering ORR complaints/grievances in his absence.

On 8/12/20 at approximately 1400 review of the facility policy entitled, "Patient complaint and Grievance Policy", revised 11/2014 revealed the following statements:

"A patient grievance is a formal or informal written or verbal complaint that is filed by a patient when a patient issue cannot be resolved promptly by staff present."

"The Patient Advocate or designee responding to the grievance should speak with the patient or patient's representative within 24 hours of the receipt of the complaint to clarify the issues and inform the patient of the time frame for investigation and written response."

"The Patient Advocate documents each step in the investigation thoroughly on the Grievance/Complaint investigation form."

"Grievances are expected to be resolved within seven days with the provision of a written response."

"The Grievance will be logged into the Grievance log by the Patient Advocate or designee."

Based on observation, interview and record review the facility failed to implement Covid-19 infection prevention patient source control per facility policy and per guidelines from the nationally recognized scientific resource the facility infection prevention program was based on, for three (#1, #2, and #6) of three patients reviewed for Covid-19 infection prevention source control out of a total of 182 patients in the facility, resulting in the potential for transmission of Covid-19 in the facility from asymptomatic infected patients. Findings include:

On 8/11/20 at 0830 a tour of the facility was conducted with the Director of Nursing Staff B and the Associate director of Nursing Staff C. Patients were observed without masks in the common areas and dayrooms . Observation revealed that patients did not consistently maintain social distancing between patients. Staff redirection to remind patients to socially distance was not consistently noted.

On 8/11/20 at approximately 0900 Staff B and Staff C were interviewed said that all patients were offered masks on admission and could ask for masks at any time during admission unless they were at high risk for suicide. Staff B said that the facility relied on twice daily temperature checks and screening questions to detect infected patients and prevent the spread of Covid-19 in the facility.

On 8/11/20 at approximately 0910 Staff Nurse K and House Supervisor L were interviewed and reported that a physician order was required in order for a patient to be allowed to wear a mask (source control device) in the facility and that patients who were at risk for self harm were not allowed to have masks.

On 8/11/20 at approximately 1050 Patient #7 was overheard complaining to staff that the facility was not allowing her to wear a mask and that the facility was not following current guidance related to Covid-19 prevention.

On 8/11/20 at approximately 1100 patient #7 was interviewed. Patient #7 said that she "came from a family of physicians" and she was very worried about contracting Covid-19 infection in the facility because the facility was not following the Centers for Disease Control (CDC) guidelines and State mandates for mask wearing indoors. Patient #7 said, "They never asked me if I wanted a mask. When I asked for one, they could never find one to give me."

On 8/11/20 at approximately 1115 Patient #7's clinical record was reviewed with Staff B and revealed the following information:

Patient #7 was a 43 year old female who was admitted into the facility by petition and certification on 8/4/20 for "unspecified psychosis." Her admission suicide risk screening assessment dated 8/4/20 revealed that she was not actively suicidal with a low Columbia suicide risk score. Patient #7's daily suicide risk screenings indicated that she was at low risk for self harm .

Patient #7's medical physician admission history and physical examination dated 8/4/20 at 1820 noted that she was medically compromised with a heart murmur and history of syncope. There was no documentation in the clinical record that she was asked if she wanted to wear a mask in the facility or that the physician was asked to prescribe her a mask. There was no prescription for a mask in her clinical record, and no Nursing documentation or rounding sheet to indicate that she was ever given one or asked if she wanted one.

On 8/11/20 at approximately 1400 Patient #1's clinical record was reviewed with Staff B and revealed the following information:

Patient #1 was a 29 year old female who was admitted for lithium (medication) titration for Bipolar Disorder on 7/9/20.

Patient #1 did not have a physician order for a mask and there is no documentation to indicate that one was provided or that she was ever asked if she wanted to wear one. There was no Nursing documentation or patient mask rounding documentation to indicate that Patient #1 was ever provided with a mask.

Review of Patient #1's clinical record at that time revealed loose papers documenting a preliminary investigation of an undated complaint made to the facility Corporate Compliance hotline by Patient #1's husband. The undated form entitled "Compliance Investigation Hotline Report Summary" documented a complaint made by Patient #1's husband that, "patients do not wear masks and he was concerned that his wife might get infected with Covid-19 in the facility because patients do not wear masks."

On 8/11/20 at approximately 1500 Patient #2's clinical record was reviewed with Staff B who was also interviewed at that time. The following information was revealed:

Patient #2 was a 28 year old female who was admitted into the facility by petition and certification on 7/12/20 for diagnoses of Major Depressive Disorder, Bipolar II, Post Traumatic Stress Disorder (PTSD), Narcolepsy, Asthma, Borderline Personality Traits, Obesity and Sclerosing mesenteritis (a rare disorder where the tissue (mesentery) that holds the small intestines in place becomes inflamed and forms scar tissue).

Patient #2's Admission Psychiatrist History and Physical (H&P) dated 7/12/20 at 2230 documented, "She is afraid of being infected with Covid-19 in the hospital." Patient #2's medical physician H&P dated 7/13/20 at 1215 noted, "Patient is concerned for Covid. Patient says that she might get exposed here."

A Nursing note for Patient #2 dated 7/14/20 at 1445 noted, "Patient is upset about mask guidelines. Patient expressed concern about Covid-19 policies."

On 8/11/20 at approximately 1530 Staff B was interviewed regarding source control patient masks for prevention of Covid-19 transmission in the facility. Staff B reported that the facility had (source control) paper masks for patient use that were provided by the local county health department. Staff B said that the facility could not force patients to wear masks or social distance in the facility as they had the right to refuse treatment. When asked if court ordered (petitioned and certified) patients had the right to refuse treatment or if patients who were a danger to self or others had the right to refuse chemical or physical restraints, Staff B said they did not.

On 8/11/20 at approximately 1545 a patient source control mask was provided for inspection, and the manufacturer's product information was reviewed. The mask was observed to be made of three ply woven paper with holes for ear loops and heat sealed seams. There were no ligatures, strings, elastics, sharp edges, or metal on the mask. When pressure was applied to the mask or to the ear loops, the mask tore. Staff B was asked if patients had access to toilet paper, napkins, or tissues. Staff B answered yes. Staff B was asked how the masks were more dangerous than these commonly accessible toiletry items and was unable to explain.

On 8/11/20 at approximately 1550 review of the facility Infection Prevention Program and Infection Prevention policies revealed the facility based their Infection Prevention program and Infection Prevention policies on Center for Disease Control (CDC) guidelines.

On 8/12/20 at approximately 1330 review of the facility policy entitled "Infection Disease Outbreak/Pandemic" dated 6/2020 noted that staff should follow strict guidelines during an infectious disease outbreak as defined by the CDC which included the following:

2. The Infection preventionist or designee will implement appropriate control measures immediately using CDC guidelines with established criteria, and at a minimum:
d. The facility will follow CDC guideline for personal protective equipment (PPE) and transmission precautions.

On 8/12/20 at approximately 1500 review of the CDC guidelines for Covid 19 prevention in Healthcare facilities, updated 6/28/20 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-hcf.html) revealed the following guidelines,

" To prevent SARS-CoV-2 transmission by symptomatic and pre-symptomatic persons, healthcare facilities should use source control for all persons entering a healthcare facility (e.g., staff, patients, visitors).
Source control helps prevent transmission from infected individuals who may or may not have symptoms of COVID-19.
Cloth face coverings are not considered personal protective equipment (PPE); they are source control. "

On March 11, 2020 the Novel Coronavirus Disease, COVID-19, was declared a pandemic by the World Health Organization. On March 13, 2020 a national public health emergency was declared in the United States concerning the COVID-19 Outbreak.