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Based on document review and interview, the facility failed to follow the grievance process and failed to ensure care in a safe setting for 1 of 10 patient (Patient 7) medical records reviewed. (See tags 0118 and 0145)

The cumulative effects of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, the facility failed to follow the grievance process for 1 out of 10 patient (Patient 7) medical records reviewed.

Findings Include:

1. Facility policy titled, Grievance, Patient, last reviewed 01/2023, indicated under Policy, all patient grievances will be investigated and the results of the investigation reported back to the complainant; under Procedure 1. Staff who present who receive a grievance/concern from a patient/patient's legal representative will take the following steps: a. Acknowledge receipt of the grievance/concern by documenting the time and date of the grievance on the Patient Concern Notification Form. b. Attempt to resolve the issue at the time of receipt. c. Document actions taken, on the Patient Concern Notification Form. d. Forward Patient Concern Notification Form to the Patient Advocate.

2. Review of Patient 7's medical record indicated on 09/29/2024 A4 (Assistant Director of Nursing) documented they came in to meet with family to address concerns and indicated they would address concerns and make management team aware.

3. Review of Complaint and Grievances from 05/01/2024 through 10/28/2024 lacked documentation of complaints and grievances related to patient 7.

4. Interview with A4 (Assistant Director of Nursing) on 10/30/2024 at approximately 2:00 p.m. confirmed they spoke with Patient 7's family, investigated the allegations, and that they did not complete a grievance report detailing the allegations and findings.

Based on document review and interview, the facility failed to ensure care in a safe setting for 1 of 10 patient (Patient 7) medical records reviewed.

Findings Include:

1. Facility policy titled, Abuse and Neglect, last reviewed 01/2023, indicated under Policy, It is the policy of the Hospital that any staff who witness or suspect a patient has been abused either physically or verbally will report such abuse to the appropriate authority IMMEDIATELY. This includes patient-to-patient, staff-to-patient or suspicion that a patient may have been or is at risk for abuse, neglect and/or exploitation from caregivers, family or others outside of the hospital. This suspicion may be based on verbal report, visual observation, physical evidence or upon behaviors which provides reasonable belief that a patient may have been or may become a victim. And under Procedure, 2. Notifications: When there is a suspected case of abuse or neglect, the appropriate regulatory agency will be notified.

2. Facility policy titled, Incident Reporting, Policy: RM 15.03, last reviewed 01/2023, indicated under 4.0 Procedure: Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/work day. An "incident" is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety. Any harm caused can be temporary, long term, or permanent and range in severity from no obvious or significant injury, up to death.

3. Review of Patient 7's medical record indicated on 09/26/2024, the medical record intake form completed at 5:00 p.m., patient was worried about going home, Family Member #1 (patient's parent) had physically abused them, and Family Member #3 (patient's step grandparent) had sexually assaulte them. Medical record intake form lacked documentation if the abuse had been reported or if protective services was involved. Psychiatric evaluation on 09/27/2024 documented at 9:47 a.m. indicated that patient 7 reported that Family Member #3 sexually assaulted them, and Family Member #1 physically abused them. Medical record indicated the patient's psychosocial assessment was completed on 09/27/2024 at approximately 4:49 p.m. and indicated patient 7 had suffered physical, emotional, and sexual abuse and listed Family Member #1 and Family Member #3 involved in the abuse; the assessment indicated that the abuse had been reported and that a report was not indicated; MR lacked documentation of an abuse report and/or that facility confirmed a report had been filed. Patient was discharged to home with Family Member #1 on 09/29/2024. Medical record lacked documentation that patient 7 had water thrown on them.

4. Interview with A4 (Assistant Director of Nursing) on 10/30/2024 at approximately 2:00 p.m. confirmed that patient 7 had water thrown on them by an unidentified patient and there was no incident report filed.

5. Interview with A5 (Director of Clinical Services) on 10/30/2024 at approximately 2:35 p.m. indicated that there was not a DCS (Department of Child Services) report made regarding patient 7's reported abuse that was documented in the medical record; A5 indicated a report should have been filed