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Based on document review, and interview, the facility failed to ensure that a verbal complaint by a patient, regarding possible staff abuse, was treated as a grievance for patient #8.

Findings:
1. Review of the policy Consumer Complaint and Grievance Policy, H-2200.3.2, last approval date of 11/18/14, indicated:
a. In the section "VI. Procedures and Responsibilities", it reads: "A. Complaint:...2. The consumer may use the client Team Communication form to ask a question, communicate a concern, or register a complaint with the consumer's treatment team...".
b. In the section "VI. Procedures and Responsibilities", it reads: "B. Grievance: 1. A person who wishes to file a grievance may contact the hospital Superintendent....using a grievance form or other medium..she or he may dictate her or his grievance for another person to write. 2. If the consumer cannot write her or his grievance in English...the hospital will provide an appropriate interpreter to help the consumer write her or his grievance. 3. Grievance forms are available from the unit nurse...4. A written grievance should be sealed in an envelope, addressed to "Superintendent", and delivered to the Superintendent's office...Grievances that indicate abuse, neglect...are referred to the consumer's Division Director for investigation and action...8. From the time it is logged in by the superintendent's Office, the resolution facilitator will complete the Grievance Response form within 10 Business Days and return it to the Superintendent's Office...13. The resolution facilitator will ask the consumer to sign, date, and rate her or his level of satisfaction with the resolution of the Grievance and will provide a copy of the completed resolution to the consumer....".

2. Review of a file titled: "Reportable Events" dated from 8/1/14 to 3/18/15, indicated pt. #8 filed a verbal complaint of staff abuse. Documentation indicated that on 11/1/14, pt. #8 reported allegations that agency staff member N8 followed the patient into their room, closed the door and had struck the patient and threw him/her on his/her bed.

3. A file of "Reportable Events" was reviewed and one related to patient #8 was noted. The event was noted to have been alleged on 11/1/14 at 7:20 PM...CPS (child protective services) was contacted as was the patient's family. We will be investigating and staff member N8 will remain off duty until this issue is resolved.

4. At 4:30 PM on 3/19/15, interview with staff member #59, the facility superintendent, indicated:
a. The current complaint and grievance policy does not indicate that a verbal complaint may also be considered a grievance if the allegations are serious enough.
b. Currently, the facility is requiring a particular form to be completed to consider an allegation to be a grievance.

Based on document review, and interview, the facility failed to ensure that a verbal complaint by a patient, regarding possible staff abuse, was treated as a grievance and followed up within the time frames of the facility policy for patient #8.

Findings:
1. Review of the policy Consumer Complaint and Grievance Policy, H-2200.3.2, last approval date of 11/18/14, indicated:
a. In the section "VI. Procedures and Responsibilities", it reads: "A. Complaint:...2. The consumer may use the client Team Communication form to ask a question, communicate a concern, or register a complaint with the consumer's treatment team. 3. The treatment team must respond to issues from a client Team Communication form, in writing, within 5 business days of receipt. 4. Client Team communication forms are available from the unit nurse, ...".
b. In the section "VI. Procedures and Responsibilities", it reads: "B. Grievance: 1. A person who wishes to file a grievance may contact the hospital Superintendent....using a grievance form or other medium..she or he may dictate her or his grievance for another person to write. 2. If the consumer cannot write her or his grievance in English...the hospital will provide an appropriate interpreter to help the consumer write her or his grievance. 3. Grievance forms are available from the unit nurse...4. A written grievance should be sealed in an envelope, addressed to "Superintendent", and delivered to the Superintendent's office...Grievances that indicate abuse, neglect...are referred to the consumer's Division Director for investigation and action...8. From the time it is logged in by the superintendent's Office, the resolution facilitator will complete the Grievance Response form within 10 Business Days and return it to the Superintendent's Office...13. The resolution facilitator will ask the consumer to sign, date, and rate her or his level of satisfaction with the resolution of the Grievance and will provide a copy of the completed resolution to the consumer....".

2. Review of a file titled: "Reportable Events" dated from 8/1/14 to 3/18/15, indicated pt. #8 filed a verbal complaint of staff abuse. Documentation indicated that on 11/1/14, pt. #8 reported allegations that agency staff member N8 followed the patient into their room, closed the door and had struck the patient and threw him/her on his/her bed.

3. A file of "Reportable Events" was reviewed and one related to patient #8 was noted. The event was noted to have been alleged on 11/1/14 at 7:20 PM...CPS (child protective services) was contacted as was the patient's family. We will be investigating and staff member N8 will remain off duty until this issue is resolved.

4. Review of the medical record for pt. #8 indicated: Nursing wrote on 11/2/14 at 1846 hours, family member called r/t (related to) concern pt. #8 had been hit by staff last evening. Consulted with RN (registered nurse) supervisor. Notified family member that matter is being investigated and Div. Director will call them tomorrow."

5. Interview on 3/19/15 at 12:05 PM and 4:00 PM with staff member #53, the Division Director for pt. #8's unit, indicated: This staff member was never notified that they needed to return a call to pt. #8's family regarding notes written by nursing on 11/2/14.

6. Interview with the medical director, staff member #66, at 4:30 PM on 3/19/15, indicated: With the lack of documentation, it appears that the "loop was not closed" in that the family of pt. #8 was contacted that the pt. alleged an assault by a staff member and there was an appropriate investigation, but the family was not contacted regarding the results of the investigation, causing concern related to this incident.

7. At 4:30 PM on 3/19/15, interview with staff member #59, the facility superintendent, indicated the current complaint and grievance policy does not indicate that a verbal complaint may also be considered a grievance if the allegations are serious enough.

Based on document review and interview, the facility failed to ensure that the specific type of restraint was ordered for 6 of 8 patients who had restraint events, (Pts. #2, #3, #6, #7, #8, and #10).

Findings:
1. Review of the policy "Seclusion and Restraint Policy", no policy number, with last revision and approval dates of 6/16/08, indicated:
a. On page 3, in section IV., (3), it reads: "The type or technique of restraint or seclusion used must the least restrictive...".

2. Review of the policy "Therapeutic Crisis Intervention Policy", policy number H-2400.15.5, last approved on 3/19/13, indicated:
a. On page 7, the "Approved List of Mechanical Devices" were: "Wrist to waist Velcro, Four-way Velcro, Helmets, Mitts, Spit Guards, Blocking Pads, Emergency Restraint Chair".

3. Review of the "Bridge Building" training document, (no policy number or date of approval), with attached photo page of types of restraint, indicated the types of holds/restraints included: "Come Along" (escort technique), "Hug", and floor restraint called "Full Bridge Building Restraint".

4 Review of medical records indicated:
a. Pt. #2 had:
A. Physician orders on 8/25/14 at 1700 hours to: "Place pt. in restraints for behavior dangerous to self & others for up to 2 hrs...", and lacked the form "Seclusion/Restraint Nursing Assessment Interventions/Observations" that would have documentation as to the type of restraint utilized.
B. A physician order on 10/29/14 at 1235 hours to: "Restrain for up to 2 hours for behavior dangerous to others and self...", with the patient noted on the "Seclusion/Restraint Nursing Assessment Interventions/Observations" form with the "Interventions Type" of restraint noted as: "restraint", but lacking a specific type.
C. Physician orders on 11/3/14 at 0947 hours to: "Restrain patient for behavior dangerous to others...", with the "Seclusion/Restraint Nursing Assessment Interventions/Observations" form noting that the "ERC" (emergency restraint chair) was utilized.
b. Pt. #3 had:
A. An order written on 11/22/14 at 1815 hours to: "Place pt in restraints for up to 2 hrs...", with the "Seclusion/Restraint Nursing Assessment Interventions/Observations" form with the "Interventions Type" of restraint noted as: "restraint", but lacking a specific type.
B. Orders written on 1/24/15 at 0140 hours to: "...Place pt in physical hold for up to 1 minute for behavior dangerous to others...", with the "Seclusion/Restraint Nursing Assessment Interventions/Observations" form with the "Interventions Type" of restraint noted as: "restraint", but lacking a specific type.
c. Pt. #6 had: Orders written on 2/12/15 at 1920 hours to: "Place pt. in physical hold for up to 30 minutes for behaviors dangerous to self or others,...", with documentation on the form titled: "Seclusion and Restraint Critical Incident Report", under the "Patient Debriefing" section, that the "Type of Incident" was a "Physical Hold", but was not specific as to the type.
d. Pt. #7 had: Physician orders written on 11/11/14 at 1445 hours to: "1) Restrain for up to 2 hours for dangerousness to others...", with the "Seclusion/Restraint Nursing Assessment Interventions/Observations" form with the "Interventions Type" of restraint noted as: "restraint", but lacking a specific type, and the narrative portion of that form noting the patient was in an ERC.
e. Pt. #8 had:
A. A physician order written on 9/4/14 at 1835 hours to: "1. Place pt in a physical hold for up to 1 hr for behavior dangerous to others...", with the "Seclusion/Restraint Nursing Assessment Interventions/Observations" form with the "Interventions Type" of restraint noted as: "restraint", but lacking a specific type.
B Orders written on 12/16/14 at 2000 hours to: "Place pt. in restraints for up to 2 hrs for behavior dangerous to self and others,...", with the "Seclusion/Restraint Nursing Assessment Interventions/Observations" form with the "Interventions Type" of restraint noted as: "restraint" and "ERC" noted in the same area.
f. Pt. #10 had: Physician orders written on 1/16/15 at 1545 hours to: "Place patient in physical hold for up to 5 minutes for behavior dangerous to others...", with the "Seclusion/Restraint Nursing Assessment Interventions/Observations" form with the "Interventions Type" of restraint noted as: "restraint".

5. Interview with staff member #50, a division director, at 2:45 PM on 3/18/15, indicated:
a. There are 2 types of physical holds used in the Bridge Building restraint program used at the facility: a supine/floor restraint, and a wall restraint.
b. The orders for holds/restraints for patients as written in 4. above, are not specific to the type of hold, or restraint, utilized by staff.

6. Interview on 3/19/15 at 10:50 AM and 12:05 PM, with staff member #53, a division director and Bridge Building trainer, indicated:
a. Staff also may use a "come along", escort hold, with patients at times, as well as the floor/supine hold/restraint.
b. The orders for holds/restraints for patients as written in 4. above, are not specific to the type of hold, or restraint mechanism, utilized by staff.

Based on document review and interview, the facility failed to ensure that one of two BHRA (behavioral health recovery attendant) staff had documentation of current therapeutic crisis intervention training, called Bridge Building by this facility (Staff member N8).

Findings:
1. Review of the document for "Specific Requirements for Bridge Building", no policy number, no date of approval, indicated:
a. Under the heading, it reads: "Current BB (Bridge Building) certification is required for certain job classifications. Currently those classifications are:...All BHRAs regardless of level...BB is required annually."

2. Review of employee files for BHRA staff member N8 indicated:
a. Staff member N8 was an agency BHRA with a first date worked of 1/9/10, and a last date worked of 2/8/15.
b. Staff member N8's only Bridge Building documentation of training/competency was noted as 1/2011.

3. Interview on 3/19/15 at 4:30 PM with staff member #53, a division director and Bridge Building trainer, indicated:
a. The document provided shows a facility requirement for BB certification for BHRAs.
b.. All agency staff must meet the same training requirements, including Bridge Building therapeutic crisis intervention, to work at the facility.
c. Current Bridge Building training could not be found, prior to exit, for agency BHRA staff member N8.

4. At 3:40 PM on 3/19/15, interview with staff member #54, the HR (human resources) Director, indicated:
a. Current Bridge Building training could not be found, prior to exit, for agency BHRA staff member N8. The only Bridge Building documentation in the file for agency BHRA staff member N8 was dated 1/2011.

5. At 4:30 PM on 3/19/15, interview with staff member #57, the DON (director of nurses), indicated:
a. Agency staff are supposed to be required to have current Bridge Building training prior to work at the facility.

Based on document review and interview, the facility failed to ensure that one of two BHRA (behavioral health recovery attendant) staff had documentation of current CPR (cardio pulmonary resuscitation)competence. (Staff member N8.)

Findings:
1. Review of the document for "Specific Requirements for Bridge Building", no policy number, no date of approval, indicated:
a. Under "Specific Requirements for CPR", it reads: "Current CPR certification is required for certain job classifications. Currently those classifications are:...All BHRAs regardless of level...".

2. Review of employee files for two BHRA staff members indicated:
a. Staff member N8 was an agency BHRA with a first date worked of 1/9/10, and a last date worked of 2/8/15.
b. Staff member N8 had no documentation of any CPR competence in their file.

3. Interview on at 4:30 PM with staff member #53, a division director and Bridge Building trainer, indicated:
a. The document listed in 1.a. above indicates the facility staff requirements for CPR competence.
b.. All agency staff must meet the same training requirements, including CPR competency certification, to work at the facility.
.
4. At 3:40 PM on 3/19/15, interview with staff member #54, the HR (human resources) Director, indicated:
a. Current CPR certification, or any CPR certification, for agency BHRA staff member N8, could not be found prior to exit.

5. At 4:30 PM on 3/19/15, interview with staff member #57, the DON (director of nurses), indicated:
a. Agency staff are supposed to be required to have current CPR prior to the start of work at the facility.