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Based on interview and record review, the facility failed to protect and promote patient rights for 2 of 3 (#16, 17) patients who were to receive an Important Message from Medicare; for 2 of 3 (#12, 15) patients who made grievances to the facility; and for 1 of 2 (#6) restrained patients requiring a 1-hour face-to-face assessment resulting in the potential loss of patient rights for all patients served by the facility. Findings include:

See Specific Findings:

A-117 Failure to inform patients of their rights
A-118 Failure to identify and resolve grievances
A-182 Failure to conduct a timely 1-hour face-to-face assessment

Based on interview and record review, the facility failed to ensure the Important Message from Medicare documents for 2 of 3 (# 16, 17) patients were accurate and given at the appropriate times resulting in the potential for the loss of patient or patient representative rights to appeal discharge. Findings include:

On 6/2/2022 at 0937, review of Patient #16's medical record revealed an Important Message from Medicare (IMM) form with the Quality Improvement Organization (QIO) listed as "KEPRO" instead of Livanta. Livanta was designated the QIO for facilities in this geographic region in 2019.

On 6/2/2022 at 0939, Chief Nursing Officer (CNO) Staff D, who was present during the record review, stated old forms must still be "out there somewhere" and that staff would be educated on the proper IMM form to use.

On 6/2/2022 at 0941, review of Patient #17's medical record revealed she was a 79 year old female who was admitted from 2/11/22-3/10/2022. Review of the IMM's revealed there was only one given which was on admission. No IMM within 48 hours of discharge was present. This was confirmed by Staff C at the time of discovery.

Based on interview and record review, the facility failed to log and follow policy for 2 of 3 (#12, 15) patients reporting grievances received by the facility resulting in the potential denial of all patients to have grievances investigated and addressed by the facility. Findings include:

On 6/2/2022 at 0846, files chosen from the Complaint and Grievance Log were reviewed with Patient Experience Manager/Recipient Rights Officer Staff U electronically beginning with Patient #12. Review of the file revealed Patient #12 had written a negative review on the facility's website on 5/9/2022. Review of the investigation revealed a brief note that the behavioral health manager had spoken with the physician and nurse practitioner. No details were given. The behavioral health manager was unavailable for interview.

On 6/2/2022 at 0852, Staff U was queried as to the negative review of the patient and the investigation of his allegations. She stated, "all of his concerns were medical. He had medical clearance so there was no further follow up." Staff U was then asked if the case was opened or closed to which she stated it was considered closed. She was then asked to show the closing letter to which she stated this case was considered a complaint and no letter had been sent.

On 6/2/2022 at 0925, review of the file for Patient #15 revealed she was a visitor to the facility and had made a phone call on 3/10/2022 stating she had brought her fiancee to the emergency department on 3/10/2022 with nausea/vomiting and staff had made her wait in the lobby.

On 6/2/2022 at 0928, Staff U was queried as to the investigation that ensued to which she stated staff had asked her to wait in the lobby until they could "get his vomiting under control... They did eventually come and get her from the lobby." Staff U was queried as to the follow-up with Patient #15 to which she stated she attempted to call her on three different days with no answer. The file was considered closed. Staff U stated this was considered a complaint and denied any letters of acknowledgement or closure had been sent to Patient #15.

Review of facility policy #MHC_SE004 titled "Patient Complaint and Grievance Policy" effective 9/1/2021 states, "Grievance-A written or verbal expression of dissatisfaction with the resolution of a complaint or communication received after discharge... A grievance ordinarily requires a written response to the patient. A grievance shall also be defined as: 3.2.1. Instances where the Patient Experience Department, staff, and/or management is contacted after failure to resolve initial complaint. 3.2.2. Any written complaint including email, or fax... All grievances ordinarily shall require a written response to the patient/representative acknowledging receipt of the complaint/concern within 7 calendar days of original receipt. The response ordinarily shall be written in clear and easily understandable language, and tailored to the complaintant's age, language, and ability to understand. 5.2.3. A second written communication will be sent to the patient/representative outlining the resolution of the grievance upon completion within a reasonable time frame, but no longer than 30 calendar days. 5.2.4 If the grievance will not be resolved within the initial 30 calendar day time line, the patient/representative ordinarily shall receive written communication that the hospital or medical practice is still working to resolve the concern and identify the number of days before a response should be expected."

Based on interview and record review, the facility failed to conduct a timely 1-hour face-to-face assessment for 1 of 2 (#6) patients reviewed for restraint use resulting in the potential for unidentified patient needs and unnecessary restraint. Findings include:

On 6/1/2022 at 1501, review of the medical record for Patient #6 revealed she was a 36 year-old female who was admitted to the facility from 4/6/2022-4/11/2022 for schizoaffective disorder bipolar type (a combination of symptoms of schizophrenia and mood disorder).

Behavioral Health Progress note dated 4/10/2022 at 2111 revealed Patient #6 became "severely violent" and injured multiple staff members and was causing "significant stress amongst the milieu." Attempts were made to discharge her to the local sherriff; however, they "declined to accept her stating there was a placement issue." The document further stated the patient had been in 4-point restraints since 1245 that afternoon and indicated reasons for the progess note to be face-to-face assessment (listed twice as the order for restraint had to be renewed within this time frame).

On 6/1/2022 at 1510, Staff C, who was assisting with the eletronic medical record review, stated when a face-to-face was done, it was documented in a progress note. She stated the only progress note for a face-to-face assessment present was dated 4/10/2022 at 2111.

Review of facility policy #BH-RI-110 titled "Restraint and Seclusion, Use Of in the Behavioral Health Unit" effective 7/23/2021 states, "Specific Provisions when Using Restraints or Seclusion on the for Violent or Licensed Psychiatric Unit for Self-Destructive Behavior. 5.1.1.1. The following should be assessed and documented by the physician for the one hour face-to-face evaluation: 5.1.1.2. The patient's immediate situation. 5.1.1.3. A description of the patient ' s behavior and the intervention used; 5.1.1.4. Alternatives to restraint or seclusion attempted (as applicable); 5.1.1.5. The patient's reaction to the intervention; 5.1.1.6. The patient's medical and behavioral condition; and 5.1.1.7. The rationale for the need to continue or terminate the restraint or seclusion... The patient must be seen face-to-face within 1 hour after the initiation of the restraint by a physician. The evaluating physician must contact the attending physician to discuss the patient condition at the time of the evaluation. The following should be evaluated and documented in the EMR: 5.1.7.1. The patient's immediate situation. 5.1.7.2. The patient's reaction to the intervention. 5.1.7.3. The patient's medical and behavioral condition; and 5.1.7.4. The need to continue or terminate the restraint or seclusion."

This citation has two deficient practice statements

Deficient Practice Statement #1

Based upon observation and interview the facility failed to maintain the facility with respect to building finishes
resulting in penetrations and other unrepaired damages that make it difficult to clean and provide potential access to insects and vermin into the patient environment resulting in the potential for unsanitary environment and less than optimal outcomes for all patients.

Findings include:

On 06/02/2022 at 1115 AM observed a hole in the wall just above the baseboard in the shower room on the Adult Psychiatric Unit. At this time Staff R was queried if the facility had a work order on this damaged wall. Staff R explained staff had not reported this so maintenance was not aware of this damage. Staff R was also queried if the facility conducted any routine rounds to help identify physical plant issues. Staff R explained that they did monthly rounding. The monthly rounding is not frequent enough for this area to effectively keep up with needed repairs due to physical damage created by patients. Staff R confirmed this observation at the time of the finding.


38269

Deficient Practice Statement #2

Based on observation and interview the facility failed to ensure that outdated supplies are maintained at an acceptable level of safety and quality resulting in the potential for poor patient outcomes. Findings include:

On 06/02/22 at at 1035 during a tour of the supply room 6045 sixth floor medical surgical unit a box (quantity 30) of clean catch urine kits were labeled with an expiration date of 2022-04-02 and available for patient use.

On 06/02/22 at 1035 during an interview with staff H, the Manager of the sixth floor medical surgical unit it was confirmed that the clean catch urine kits (quantity 30) were expired and available for use. When asked how the supplies were rotated, who was responsible for removing outdated supplies from the available for use cart and if there was a policy related to removing outdated supplies from the ready for use locations, Staff H stated, "we don't use those anymore. I am not sure if there is a policy, I will have to research".

A policy for expired supplies was requested at the time of tour and not received prior to survey exit.

Based upon observation, interview, and record review the facility failed to ensure proper ventilation including proper exhaust from the building which could result in higher concentration of odors and air contaminants causing adverse health effects and affecting the well being of all staff and all Adult psychiatric patients.

Findings include:

1. On 06/02/22 at approximately 1205 during a tour of the East tower roof, observed exhaust Fan 45 was not operating properly. The fan was noisy and when the housing was removed, observed that the belt was still intact but was very loose.

2. On 06/02/22 at approximately 1210 observed that exhaust fan EF 40 was not operating properly. Maintenance staff removed the fan housing and noted that the belt was all chewed up. It was missing most of the V portion of the belt which was causing the belt to slip.

3. During document review at approximately 1530 staff W provided the printout of the preventive maintenance for EF 40 for the past year (09/01/21, 12/01/21, and 03/01/22) which indicated that the exhaust fan maintenance checks were completed and no problems were found. Since the belt was so badly worn, the poor condition should have been noticed in March 2021 had the inspection been done properly.

Staff R & W confirmed these observations at the time of the findings.