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Based on document review and interview, the facility failed to ensure staff followed their policy and procedures for investigating a grievance regarding allegations of abuse for 1 (#12) of 4 patients alleging abuse, resulting in the potential for less than optimal outcomes. Findings include:
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A-118
Failure to document investigation of a grievance for allegations of abuse for 1 (#12) of 4 patients that alleged abuse.

Based on document review and interview, the facility failed to ensure staff implemented their policy and procedure to document investigation of a grievance for allegations of abuse for 1 (#12) of 4 patients that alleged abuse, resulting in the potential for less than optimal outcomes. Findings include:

On 2/7/23 at approximately 0930, review of the Grievance Log with Recipient Rights Advisor Q revealed that there were no entries for patient #12. During an interview on 2/7/23 at 1000, Staff Q verified that there were no complaints or grievances logged for patient #12. Staff Q recalled that she had gotten a phone call from patient #12's significant other which stated that another patient hit the patient of concern. Staff Q stated that she had investigated the grievance, which she stated was not substantiated after camera video footage review and interview with patients and staff. Staff Q had not documented the investigation or sent a letter regarding findings, stating "I didn't open a case file." On 2/7/23 at approximately 1100, interview with the Chief Nursing Officer R revealed that she was not aware of any abuse complaint regarding patient #12, or any documented correspondence.

On 2/7/23 at approximately 1400, review of the facility policy titled "Patient Complaints and Appeal Process, MH-01, effective 1/4/23" documented:

"IV Procedures B.
1. Patient Rights Advisor will:
f. Logs each complaint upon receipt and sends a letter of Acknowledgment of Receipt with a copy of the complaint within 5 business days to the complainant.
g. Initiates investigation of the complaint in a timely and efficient manner.
h. Sends a Status Report to the complainant, the respondent, and hospital CEO..."

The addendum to this policy titled "Patient Concerns and Grievances, MH-01.1, effective September 2021" also documented:

"4. The Recipient Rights Advisor, with the help of the appropriate Clinical Manager or Coordinator will further investigate the grievance and will have no more than seven (7) days of the filed grievance to provide a resolution to the grievant. The Advisor will be sending out a Grievance Summary Response Letter to the grievant. The Grievance Summary Response Letter will include the following criteria:
a. Name of the Hospital Representative: Recipient Rights Advisor and Clinical Manager or Coordinator involved in the grievance resolutions
b. Steps taken on behalf of the grievant to investigate the grievance
c. Results of the grievance process
d. Date of completion."

These steps had not been documented and correspondence had not been issued regarding findings as required.

Based on observation and interview the facility failed to properly clean the facility, resulting in the potential for less than optimal outcomes for all patients served by the facility.

On 2/6/2023 at 10:15 AM during a tour of the B-wing resident laundry room B 378, excessive built-up of lints and grime were observed on the floor behind the washers and dryers, on the walls, and on the ventilation grilles. An ice making machine was also observed inside the residents' laundry room. It was adjacent to the dirty equipment in the room, subjecting the ice and it's consumers to cross contamination.

On 2/6/2023 at 10:50 AM during a tour of the B-wing Janitor closet B 375 it was confirmed that this janitor closet room had not been used for a very long time (years) as janitor closet room B 379 is utilized instead. Also, the existing central tub room B 371 had not been used as a central tub and currently is used as equipment storage, leaving the existing plumbing fixtures for both rooms not used which could promote bacterial growth and contamination of the entire potable water system.

On 2/6/2023 at 11:07 AM during the tour of the B-wing clean supply room, observation revealed 7 out 7 light plastic storage racks had a surface that was not fully cleanable and the bottom shelves sat directly on the floor, preventing proper cleaning of the room.

On 2/6/2023 at 12:10 PM during the tour of the central space between both A and B wings, both janitor closet room C 379 and storage room C 382 had floors and walls with excessive filth, lints, and dusty surfaces.

On 2/6/2023 at 12:19 PM during the tour of the A-wing two full boxes of 10 OZ cups are observed on the floor of the janitor closet A 326. The floor of the janitor closet and bottom of the sink exhibited dirt. These cups are for patient use and were subject to cross contamination.

On 2/6/2023 at 12:48 PM during the tour of the A-wing medication room A 320 and the clean linen room had flooring, top of cabinets, and ventilation grilles with excessive dirt and lints build-up, subjecting all contents of the room to contamination.

On 2/6/2022 at 3:15 PM the Environmental Services and Security Manager Staff G, was queried regarding the above findings. Staff G confirmed that high surface cleaning is required throughout the facility. He stated "the environmental services department is currently experiencing staff shortages and that is one contributing factor to the lack of the proper high surfaces cleaning" and cleaning in general. All above findings were also confirmed by accompanying staff members G and I at the time of the observations.