HospitalInspections.org

Based on review of the Governing Body (GB) Bylaws, GB meeting minutes, hospital documents, medical records, policies and procedures, and staff interviews, it was determined that the Governing Body was not effective in carrying out the functions of the hospital to ensure compliance with the Conditions of Participation for Patient Rights and Quality Improvement Activities (QAPI) as evidenced by failure to:

Patient Rights:

(A0116) ensure all patients were informed of all their rights. This deficient practice poses the potential risk to the health and safety of patients when they were not fully informed of all aspects of their rights as a patient.

(A0123) ensure all patients were provided with a written response to their grievance. This deficient practice poses the potential risk to the health and safety of patients when hospital staff failed to document how/ if / when a grievance was resolved, and communicated this to patients per facility policies and procedures.

(A0144) ensure all patients received care in a safe setting when 1. Fifty three (53) of 70 toilet seats pose a ligature risk to patients. This deficient practice poses a risk to the health and safety of patients when the hinges on the toilet seats are not identified as a ligature risk.

2. Contraband and potential hazards were identified while on tour and the Incident Report Log from 05/01/19-10/04/19 included a total of 28 incidents involving self harm with contraband. This deficient practice poses a risk to the health and safety of patients when potential hazards are not identified during environmental rounds.

3. The emergency cart on the Catalina unit was kept in the locked medication room, making it inaccessible to any staff other than licence nurses in an emergency. This deficient practice poses a risk to the health and safety of patients when there is a potential delay in emergency medical care due to the inaccessibility of emergency equipment.

(A0160) ensure chemical restraints were documented per hospital policies and procedures. This deficient practice poses the potential risk to the health and safety of patients when patients were not monitored and assessed per facility policies and procedures for a chemical restraint.

(A0194) ensure all Registered Nurses were properly trained in seclusion and restraint implementation. This deficient practice poses the potential risk to the health and safety of patients when staff who initiated seclusion and/or restraints were not properly educated regarding the rules and regulations related to seclusion and restraint.

QAPI: Quality Assessment Performance Improvement

A-283 require hospital staff investigate patient incidents to identify the source of hazardous items obtained by patients while in the hospital;

A-286 require hospital staff identify appropriate actions to resolve patient complaints and grievances; and

A-309 require evaluation and oversight related to the patient complaint / grievance process.

The cumulative effect of these systematic deficient practices resulted in the Governing Body's inability to ensure the provision of quality care in a safe environment related to Patient Rights and QAPI.

Based on review of hospital documents, medical records, policies and procedures, observations on tour, and staff interviews, it was determined the facility failed to:

(A0116) ensure all patients were informed of all their rights. This deficient practice poses the potential risk to the health and safety of patients when they were not fully informed of all aspects of their rights as a patient.

(A0123) ensure all patients were provided with a written response to their grievance. This deficient practice poses the potential risk to the health and safety of patients when hospital staff failed to document how / if / when a grievance was resolved, and communicated this to patients per facility policies and procedures.

(A0144) ensure all patients received care in a safe setting when 1. Fifty three (53) of 70 toilet seats pose a ligature risk to patients. This deficient practice poses a risk to the health and safety of patients when the hinges on the toilet seats are not identified as a ligature risk.

2. Contraband and potential hazards were identified while on tour and the Incident Report Log from 05/01/19-10/04/19 included a total of 28 incidents involving self harm with contraband. This deficient practice poses a risk to the health and safety of patients when potential hazards are not identified during environmental rounds.

3. The emergency cart on the Catalina unit was kept in the locked medication room, making it inaccessible to any staff other than licence nurses in an emergency. This deficient practice poses a risk to the health and safety of patients when there is a potential delay in emergency medical care due to the inaccessibility of emergency equipment.

(A0160) ensure chemical restraints were documented per hospital policies and procedures. This deficient practice poses the potential risk to the health and safety of patients when patients were not monitored and assessed per facility policies and procedures for a chemical restraint; and

(A0194) ensure all Registered Nurses were properly trained in seclusion and restraint implementation. This deficient practice poses the potential risk to the health and safety of patients when staff who initiated seclusion and/or restraints were not properly educated regarding the rules and regulations related to seclusion and restrainst.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights; which poses a potential risk to the health and safety of patients if patients are not maintained free from potential harm.

Based on review of facility policies and procedures, observations on tour, and staff interviews, it was determined the hospital failed to ensure that the current patient rights for the State of Arizona were posted on the hospital premises, when an out of date version was found on all patient care units. This deficient practice poses a risk to the health and safety of patients when they are not fully informed of all aspects of their rights as a patient.

Findings include:

The current version of Arizona's patient rights posted on patient care units, as well as in the lobby, were not up to date as far as including reference to sexual abuse and sexual assault. The patient rights forms that were handed out upon admission were also out of date.

Observation on tour with Employee #2 on 10/08/19(1230), revealed that the patient rights on display in the lobby, as well as on all patient care units, had not been updated to include the language about sexual abuse and sexual assault.

Employee #2 explained that updated signage had been received, but had not yet been hung on the walls.

Based on review of policies and procedures, hospital documents and staff interviews, it was determined the hospital failed to require staff provide 7 of 7 patients with written notice of the facility's decision regarding a grievance, the hospital staff contact person, the steps taken to investigate a complaint, the results of the investigation, and date of completion/ resolution. This deficient practice poses a potential risk to patient health and safety when hospital staff failed to document how/if /when a grievance was resolved, and communicate this information to patients per facility policies and procedures.

Findings include:

The "Grievance-Patient" policy requires the following: "...When grievances are received, the Patient Advocate will review, investigate, and resolve grievances and determine the appropriate response to the complainant...The Patient Advocate will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance...if a written response cannot be made within (7) calendar days, the Patient Advocate will inform the patient or his/her representative that the organization is still working to resolve the grievance and that a written response will be made within thirty (30) calendar days of receipt of the grievance...."

Seven (7) of seven (7) "Patient Concern Notification" forms, did not identify "actions to resolve" the complaint or grievance.

Employee #25 documented the following on the Patient Concern Notification Form:

Actions Taken to Resolve Concern by Staff Present:
- Five (5) of the forms contained: "...writer to forward concern to [name of ADON]"
- One (1) form contained: "Email sent to RN Director advising her of the issue".
- One (1) form contained: "writer informed nursing staff and they agreed to look into the incident".

Employees #16 and #17 confirmed in an interview conducted on 10/16/2019, they are not required to respond to the grievance in writing. Employee #16 and #17 were unable to identify what actions were taken to resolve the patient complaints/grievances.

Employee #25 confirmed in an interview conducted on 10/16/2019, the s/he did not know how the grievances were resolved.

Based on review of the medical record, facility documents, observations on tour, and staff interviews, it was determined the hospital failed to ensure that all patients received care in a safe setting when:

1. Fifty three (53) of 70 toilet seats pose a ligature risk to patients. This deficient practice poses a risk to the health and safety of patients when the hinges on the toilet seats are not identified as a ligature risk.

2. Contraband and potential hazards were identified while on tour and the Incident Report Log from 05/01/19-10/04/19 included a total of 28 incidents involving self harm with contraband. This deficient practice poses a risk to the health and safety of patients when potential hazards are not identified during environmental rounds.

3. The emergency cart on the Catalina unit was kept in the locked medication room, making it inaccessible to any staff other than licence nurses in an emergency. This deficient practice poses a risk to the health and safety of patients when there is a potential delay in emergency medical care due to the inaccessibility of emergency equipment.

Findings include:

1. The Incident Report log for 05/01/19-10/07/19 was reviewed. The following was documented on the log regarding Patient #18. "Patient [#18] was let into his room to go to the bathroom. Patient [#18] started slamming toilet seat and the toilet seat broke in 2 pieces. Patient [#18] was moved from his room, directed to take space in the quiet room."

A tour of the patient care units was conducted on 10/10/19, with Employee #5. Santa Rita unit, had toilets with seats that could be lifted because the toilet seats were connected to the toilet via a hinge. The hinge creates a ligature risk as it is possible to slip a cord, shoe lace, ect. through the opening. Tortolita unit had toliet seats that could not be lifted. Because there was a discrepancy between the two units, the remainder of the units in the hospital were toured as well.

The following units have toilets with seats that can be lifted: Santa Rita, Rincon, Madera, Havasu, Pima, and Sabino, for a total of 53 toilets.

Employee #43 documented the following regarding Patient #18 in Nursing Reassessment Progress Note on 07/05/19: "...Pt was labile and disruptive all day...pt continued to escalate, was asked to take space,...one other episode of agitation in the evening, went to room and yelled started slamming toilet seat, broke toilet seat...maintenance notified, toilet seat repaired...."

An incident report completed by Employee #43 on 07/05/19, revealed: "Pt was let into his room to go to the bathroom. Pt started slamming toilet seat and then toilet seat broke into 2 pieces. Pt was moved from his room, directed to take space in the quiet room."

In the box titled "Actions Taken/Follow-Up/Recommendations as a result of the incident" the following unsigned and undated statement was written: "Pt was noted to be labile and disruptive all day; physical restraint initiated earlier due to imminent DTS. Pt became agitated in evening, slammed toilet seat, was redirected to quiet room, self-soothed; Maintenance notified of toilet seat being broken, repaired/fixed."

Employee #5 did not know why two units had toilet seats without hinges, while the other six units had toilet seats with hinges.

Employee #6 provided an "Environmental Risk Assessment" dated 08/22/19, which identifies toilets as an "Issue/Concern" due to "ligature risk." The following is documented under "Mitigation of Issue": "toilets are floor mounted with enclosed piping to prevent an anchor point for hanging. Staff checks regularly throughout the day on environmentals. Housekeeping inspects on daily cleaning." No further action is indicated. The toilet seat hinge was not identified as a ligature risk.

The "Environmental Check List" (aka "environmentals") are completed by the BHTs twice daily. Toilets are referred to once on this form "Faucets, toilet and/or pipes not leaking"

Employee #6 provided an updated "Environmental Risk Assessment" on 10/11/19. "Issue/Concern" is "Ligature risk/seats." "Mitigation of Issue" has been updated to add the following: "Policy exists for assessing self harm behaviors, completed in admission. We continue to monitor resources and events from multiple groups i.e; FGI. CMS, TJC standards regarding risk levels. Currently CMS and other AHJ findings, resources, assessments for toilet seats as ligature provide guidance as minimal risk." An additional item was also added to the risk assessment. The "Issue/Concern" is listed as "toilet seat used as a weapon." "Mitigation of Issue" states "Damage to physical environment requires a work order to be submitted. Facilities to investigate, test and identify the most secure way to secure the seats to limit the risk of removal or damage." "Further Action Required, Who's Responsible" states "DPO, Increase unit tours to quarterly over the next 12 months." "Time Frame for Action or Completion" states "Assessment of all toilets/seats completed 10/11/19. All corrective actions completed during assessment. Additional fastening equipment to be installed 11/11/19."

Employee #46 revealed during an interview conducted on 10/10/19, that all of his/her other facilities had toilets with seats that could be lifted.

Employee #47 confirmed during an interview conducted on 10/11/19, that [name of another Behavioral Health facility] (also owned by Acadia) does not have any toilets with seats that can be lifted.

2. The following was observed while on tour with Employee #2 and #8 on 10/15/19.

Santa Rita unit:
*The restroom in the seclusion area had a paper towel dispenser that was partially coming off the wall. Additionally, there was an accessible screw in the area where paper towels would come out.

*A storage cupboard door in the patient group room was attached by only one (1) of three (3) hinges. The other two (2) hinges were missing screws, and this surveyor was able to remove a screw from the hinge.

Tortolita unit:
Exposed and accessible upholstery staples were found on the underside of approximately 25 chairs in activity/art room.

The form titled "Environment of Care (EOC) New Form Attestation" indicates that "...each staff member responsible for the EOC rounds each shift are to check thoroughly ALL items on the NEW EOC form...EOC form MUST be completed by each shift in the beginning and turned into the supervisor at the end of shift. Any deficiencies are to be reported to Facilities Director and to the supervisor...."

None of the above items were found to be documented on recently completed Environment of Care forms.

An incident report from 06/25/19 revealed the following: " Patient #1 was found to be in possession of a long screw and washer on 06/25/19. Employee #7 signed off on the incident report on 06/26/19. The "Actions Taken/Follow-up Info" section was left blank.

Employee #7 was asked what was done to investigate how and where Patient #1 came to possess the screw and washer during an interview conducted on 10/16/19. Employee #7 stated that because the incident involved contraband, it was not investigated.

The Incident Report Log was reviewed from 05/01/19-10/04/19. Four (4) incidents involving self harm with a staple were found. A total of 28 incidents involving self harm with contraband were found.

3. The following was observed while on tour with Employee #2 and #8 on 10/15/19.

The code cart maintained on the Catalina unit was kept in the medication room, making it inaccessible to anyone besides a licensed nurse in an emergency.

Employee #8 confirmed that the cart should not be kept in the medication room.

Based on review of medical records, policies and procedures, and staff interviews, it was determined that the hospital failed to ensure emergency medications were recognized, documented, and assessed as chemical restraints. This deficient practice poses a risk to the health and safety of patients when patients were not monitored and assessed per facility policies and procedures for a chemical restraint.

Findings include:

The policy titled "Restraint, Chemical" defines a chemical restraint as: "...a drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. These medications are used in addition to or in replacement of the patient's regular drug regimen to control extreme behavior during an emergency...."

Medical record review revealed that Seclusion/Restraint packets were not always completed when the medication and indication were identical to times when a Seclusion/Restraint packet was completed.

Patient #2 was administered Zyprexa and Benadryl, which was documented as a chemical restraint in a Seclusion/Restraint packet on the following dates: 06/29/19, 08/04/19, and 08/12/19.

Patient #2 was administered Zyprexa and Benadryl for agitation and aggression on the following dates: 07/30/19, 07/26/19, 07/17/19, 07/14/19, 07/13/19, 07/12/19 (x 2), 07/07/19, 06/30/19, and 06/28/19 (x 2). On these dates, a Seclusion/Restraint packet was not completed, although the medications and indications were identical to those that were documented as chemical restraints in a Seclusion/Restraint packet on the three (3) previous occasions.

Patient #1 was administered Haldol and Benadryl, which was documented as a chemical restraint in a Seclusion/Restraint packet on 07/09/19.

Patient #1 was administered Haldol and Benadryl for agitation and aggression on the following dates: 06/21/19, 05/30/19 (x 2), 05/26/19, and 05/06/19. On these dates, a Seclusion/Restraint packet was not completed, although the medications and indications were identical to those that were documented as chemical restraint in a Seclusion/Restraint packet previously.

Additionally, Patient #1 was administered an antipsychotic with Benadryl for agitation and aggression on the following dates without a Seclusion/Restraint packet being completed: 06/21/19, 06/20/19 (x 2), 06/18/19, 06/10/19, 06/08/19 (x 2), 06/06/19, 05/28/19, 05/27/19, and 05/26/19 (x 3).

Medical Staff #4 acknowledged during an interview conducted on 10/15/19, that the documentation of emergency medications as chemical restraints was not consistent.

The "New Employee Orientation-Nurses Completing the Seclusion and Restraint Packet" defines a chemical restraint as: "...a drug or medication, or a combination, when it is used as a restriction to manage the patient's behavior, restrict the patient's freedom of movement, or to impair the patient's ability to appropriately interact with their surroundings-and is not standard treatment or dosage for the patient's condition...." Additionally, the document includes the following statement: "Note: The typical PRN's we give at Sonora (Haldol, Ativan, and Benadryl, etc.) do not constitute a chemical restraint."

Employee #7 revealed in an interview conducted on 10/15/19, that they were told by insurance companies that if a patient willing takes an emergency medication, even if it's IM, then it's not considered a chemical restraint.

Employee #3 revealed during an interview conducted on 10/16/19, that a medication is a chemical restraint if given while a patient is being physically held.

Medical Staff #2 explained during an interview conducted on 10/17/19, that a chemical restraint is any medication given to change the patient's behavior in an emergent situation.

Based on review of hospital policies and procedures, hospital documents, and staff interviews, it was determined that the hospital failed to ensure staff were properly trained in the implementation of seclusion and/or restraint. This deficient practice poses a risk to the health and safety of patients when the staff who initiated seclusion and/or restraint were not properly educated regarding the rules and regulations related to seclusion and restraint.

Findings include:

The policy titled "Restraint" requires: "...the attending/covering Practitioner will be contacted during the initiation of restraint or immediately after...." The policies for chemical restraints and seclusion use the same language.

The "New Employee Orientation-Nurses Completing the Seclusion and Restraint Packet" PowerPoint used to educate registered nurses during new employee orientation contains the following statement: "...you have up to 1 hour to get the order...."

The policy titled "Restraint" reads in part: "...a practitioner or trained Registered Nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention...."

The "New Employee Orientation-Nurses Completing the Seclusion and Restraint Packet" PowerPoint used to educate registered nurses during new employee orientation contains the following statement: "...Also, you have 1 hour to do the face to face and report that. To help decrease phone calls to the doc, call for the order at the same time that you call to report the face to face...."

Employee #3 confirmed in an interview conducted on 10/16/19, that the PowerPoint presentation titled "New Employee Orientation-Nurses Completing the Seclusion and Restraint Packet" is what s/he is currently using to teach during new employee orientation.

Employee #3 revealed during an interview conducted on 10/16/19, that s/he was not aware that the order for seclusion/restraint could not be obtained at the same time the nurse face to face was reported to the physician.

The policy titled "Restraint, Chemical" defines a chemical restraint as: "...a drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. These medications are used in addition to or in replacement of the patient's regular regimen to control extreme behavior during an emergency...."

Employee #3 during an interview conducted on 10/16/19, described a chemical restraint as when a patient is held against their will in order to receive medications intramuscularly.

Based on review of the hospital's policies and procedures, hospital documents, staff interviews, and surveyor observations, it was determined the Governing Body:

A-283: failed to require hospital staff investigate patient incidents to identify the source of hazardous items obtained by patients while in the hospital;

A-286: failed to require hospital staff identify appropriate actions to resolve patient complaints and grievances; and

A-309: failed to require evaluation and oversight related to the patient complaint / grievance process.

The cumulative effect of these systematic deficient practices resulted in the hospital's inability to ensure the provision of Quality Assessment Performance Improvement was maintained to ensure patient incidents were investigated, appropriate action was taken related to patient complaints and grievances, and evaluations and oversight was completed to ensure patients received quality health care in a safe environment.

Based on review of policies and procedures, hospital documents and staff interviews, it was determined the Governing Body failed to require hospital staff identify resolutions to patient grievances for seven (7) of seven (7) complaints/grievances reviewed. This deficient practice poses a potential risk to patient health and safety when hospital staff failed to resolve patient complaints and identify areas of improvement.

Findings include:

The "Grievance-Patient" policy, reviewed 2/08/2019, requires the following: "...All complaints (verbal, written, email, and fax) brought to the attention of the Patient Advocate are considered grievances with the exception of complaints that can be resolved quickly...If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, the complaint is a grievance...When grievances are received, the Patient Advocate will review, investigate, and resolve grievances and determine the appropriate response to the complainant...The Patient Advocate will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance ...if a written response cannot be made within (7) calendar days, the Patient Advocate will inform the patient or his/her representative that the organization is still working to resolve the grievance and that a written response will be made within thirty (30) calendar days of receipt of the grievance...The Patient Advocate maintains a record of all complaints and grievances received, including issues addressed...."

Seven (7) of seven (7) "Patient Concern Notification" forms, did not identify "actions to resolve" the complaint or grievance.

Employee #25 documented the following on the Patient Concern Notification Form:

Actions Taken to Resolve Concern by Staff Present:
- Five (5) of the forms contained: "...writer to forward concern to [name of ADON]"
- One (1) form contained: "Email sent to RN Director advising her of the issue".
- One (1) form contained: "writer informed nursing staff and they agreed to look into the incident".

Employee #25 confirmed in an interview conducted on 10/16/2019, the s/he did not know how the grievances were resolved.

Employees #16 and #17 confirmed in an interview conducted on 10/16/2019, they are not required to respond to the grievance in writing. Employee #16 and #17 were unable to identify what actions were taken to resolve the patient complaints/grievances.

Hospital staff was unable to provide documentation related to how the grievances were resolved.

Based on review of policies and procedures, hospital documents, staff interviews, and surveyor observations, it was determined hospital staff failed to identify the source of hazardous items confiscated from patient #15 and patient #1. This deficient practice poses the risk of patient harm and resulted in patient #15 using the hazardous items to inflict self harm.

Findings Include:

The "Incident Reporting--Risk Management Program" policy, reviewed 1/1/2019, requires the following: "...It is the policy of [Name of Hospital] to utilize the Risk Management Program techniques to promote safety, pro-actively focus on loss prevention, and detection of hazardous event and circumstances...The Incident Report will help the various facility committees and administration in identifying potential areas of risk and implementing measures to improve the overall quality of care throughout the facility ...it is the expectation that part of reporting the incident includes describing the actions taken to mitigate damages and/or prevent further loss. Every incident reported requires that the interventions be identified ...."

The "Risk Management Incident Investigation" policy, reviewed 1/1/2019, requires the following: "... it is the policy of [Name of Hospital] to utilize investigation as a preventive tool to avoid incidents from reoccurring to improve quality of care. Additionally, investigations help to cultivate an educational mindset of safety amongst all levels of employees at this facility...."

Patient #15

Hospital staff completed three (3) incident reports related to patient #15 from 8/08/2019 through 8/09/2019.

The first incident report, completed on 8/08/2019 at 15:50, contained the following: "Pt came to nurse station stating intent to cut self. Presented metal object - large U-shaped staple to nurse." The report was labeled as "safe catch". Hospital staff informed the provider and continued to observe patient on 5 minute checks. The "ACTIONS TAKEN" section of the report contained the following: "ADON & Facility Director conducted unit sweep & determined source to be the upholstery on the chairs on the unit." No other actions were identified.

The second incident report was completed 8/08/2019 at 22:40. It contained the following documentation: " ...Pt approached the med window and stated, 'I did something but I don't know how it happened.' Pt showed RN his R forearm with gray metal piece appearing to be an open staple imbedded in skin ...Pt pulled the staple out of his skin. Staple was in open position but had been pushed in forearm flush with skin. Site did not bleed ...Pt was asked if he had a current Tetanus shot and he responded, 'yes' ...." The "Actions Taken" section of the form contained the following: "Pt refused first aid". No further information was documented.

The third incident report was completed on 8/09/2019 at 15:50, and contained the following: "...3 u-shaped staples in Pt mouth under tongue. [Title and name of provider] visualized 3 (upholstery staples) under pt's tongue while he was speaking. Pt gave them to her upon request. Pt refuses to state where he is obtaining them from...." The incident was labeled as a "Safe Catch."

Hospital staff was unable to provide documentation that the source of the staples was removed from the unit.

While on tour of the Tortolita Unit (with Employee #2 and #8), on 10/15/2019, the surveyor identified multiple exposed and accessible upholstery staples on the underside of approximately 25 chairs in activity/art room.

Patient #1

The hospital incident report, 6/25/2019, contained the following: "...Patient said a screw was loose so he took it out and was showing another patient and the other patient took it from him and put it in his room, peers told on him and I found it in the bed in his room...Interventions: Explained importance of not having contraband...Actions Taken / Follow-Up Info / Recommendations as result of the Incident: Contraband retrieved, no harm to patient or others...."

Employee #7 was unable to identify where the screw came from, and was unable to provide documentation that staff performed a unit sweep in attempt to identify the source of the contraband.

While on tour of the Santa Rita unit, (with Employee #2 and #8), on 10/15/2019, the surveyor identified the following:
· The restroom in the seclusion area had a paper towel dispenser that was partially coming off the wall with an accessible screw in the area the paper towels would come out.
· A storage cupboard door in the patient group room was attached by one (1) of three (3) hinges.
· The surveyor was able to remove a screw from the hinge.

Based on review of policies and procedures, hospital documents, and staff interviews, it was determined the Governing Body failed to evaluate and resolve the patient complaints and grievances for seven (7) of seven (7) reviewed. This deficient practices poses the potential risk to patient health and safety when the hospital fails to evaluate opportunities for improvement related to the quality of patient care.

Findings include:

The "Grievance-Patient" policy, reviewed 2/08/2019, requires the following: "...The Patient Advocate maintains a record of all complaints and grievances received, including issues addressed, and reports to the Risk Management on a monthly basis, the Quality Committee on a quarterly basis then on to the Governing Board on a quarterly basis...The Governing Board shall have final authority and responsibility in resolving grievances...."

The Quality Committee meeting minute notes 10/17/2018 through 9/25/2019, were reviewed. One of eleven meeting minute notes contained a quarterly report related to patient complaints (1/24/2019). The other ten documents did not address patient complaints.

The "Clinical and Compliance Report, Board of Directors Meeting" March 2019, contained the following: "...Patient Grievances/Complaints - For Q1 there were 23 patient grievances/complaints. All concerns were resolved either on the unit or through the Patient Advocate...."

The "Clinical and Compliance Report, Board of Directors Meeting" for Quarter 2 of 2019 contained the following: "...For Q2 there were 69 patient grievances/complaints. This is a 67% increase compared to Q1 (23 patient grievances/complaints). All concerns were resolved either on the unit or through he Patient Advocate...Highest Area: 48% of patient complaints were categorized as Care and Treatment...."

Employee #25 confirmed in an interview conducted on 10/16/2019 that patients submit complaints and grievances on the "Patient Concern Notification" form while in the hospital.

Seven (7) of seven (7) "Patient Concern Notification" forms did not contain "actions" to resolve the complaint or grievance.

Hospital staff was unable to provide documentation identifying "how" the patient complaint and grievances were addressed by Risk Management on a monthly basis or by the Quality Committee or Governing Body on a quarterly basis.