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Based on document review and interview the facility failed to ensure that a patient, or their representative, received a copy of their Patient Rights and Responsibilities form for 4 of 10 patients (Patients #1, #3, #7, and #8.) (see tag A117), failed to ensure that grievances were recognized as such for three of three complaints that were related to patient care and submitted after discharge of a patient (see tag A118), failed to follow its policy time frame for 2 of 3 complaints/grievances reviewed (see tag A122), failed to ensure that patients, or their representative, had the opportunity to participate in the development and implementation of the patient's care plan/treatment plan for 6 of 10 patient records reviewed (Patients #1, #2, #3, #4, #8 and #10), and failed to ensure that physicians noted participation in the development and approval of a treatment plan within 72 hours for 3 of 10 patients, (Patients #5, #9 and #10) (see tag A130), and failed to ensure the employment of staff in accordance with their policy for background checks for 1 of 1 MHT (mental health tech) with indications with the employees background check, (staff member P5) (see tag A144).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure patient rights were promoted and protected.

Based on document review and interview the facility failed to ensure that a patient, or their representative, received a copy of their Patient Rights and Responsibilities form for 4 of 10 patients. (Patients #1, #3, #7, and #8.)

Findings Include:
1. Review of the policy Psychiatric Patient Rights, policy number RE 16, last approved 1/2015 (sic), indicated under "Procedure", "A. The document outlining patient rights and responsibilities shall be given to patients, family and/or guardian at the time of admission."

2. Review of the policy Psychiatric Patient Rights, policy number RE 16, last approved 1/2015 (sic), indicated under the section "You have the right to.:" "..16. Be informed of your rights promptly at the time of your admission to the facility and periodically thereafter...".

3. Review of medical records indicated:
a. Patient #1 was admitted on 1/27/17 and had admission consent forms signed by a family member with no documentation that the Patient Rights and Responsibilities form was presented to the family as there was no signature on the form.
b. Patient #3 was admitted on 12/3/16 (and discharged on 12/9/16) and had no Patient Rights and Responsibilities form in their medical record.
c. Patient #7 was admitted on 12/7/16 (and discharged on 1/6/17) and had admission consent forms signed by a POA (power of attorney) with the Patient Rights and Responsibilities form left unsigned so that it could not be determined that it was presented to the patient and/or their responsible party at the time of admission.
d. Patient #8 was admitted on 12/27/16 (and discharged on 1/18/17) and had their admission consents signed by a POA. The Patient Rights and Responsibilities form was unsigned so that it could not be determined that it was presented to the patient and/or their responsible party at the time of admission.

4. At 8:45 AM on 2/7/17, interview with the Regional Chief Clinical Officer, staff member #53, confirmed that the Patient Rights and Responsibility forms for patients #1, #3, #7 and #8 were either missing from the records or unsigned so that it cannot be determined that the Rights and Responsibilities were presented to the patient and/or family/POA at the time of admission, as required per facility policy.

5. At 11:10 AM on 2/7/17, interview with the Quality and Risk staff person #50, confirmed that:
a. Patient #1 had documentation that they were "Unable to sign" their patient rights, but there was no documentation that the patient's POA/family member was given the Patient Rights information if the patient was unable to sign/understand them.
b. If a family member/POA signs consent for admssion and treatment, the staff have not been giving the Patient Rights and Responsibilities form to them. It was thought that this was only for the patient, and if they couldn't sign the document, it was left blank.

Based on document review and interview, the facility failed to ensure that grievances were recognized as such for three of three complaints that were related to patient care and submitted after discharge of a patient.

Findings Include:
1. Review of the policy Compliments, Concerns, and Grievances, policy number RE 11, last approved 8/2016, indicated a Grievance was: "A formal verbal or written complaint that is not able to be resolved to the patient's satisfaction through the hospital's concern resolution process is a grievance and will require a letter of resolution as defined by policy...", in section E.: "...2. For grievances involving quality of care or medical staff performance issues:...".

2. Review of the 2016 and 2017 complaint log indicated:
a. A complaint was filed on 12/6/16, after a patient's discharge, related to a family member reporting they were "not happy with how [their family member] was treated...[pt.] reported a fall...had bruises all over [pt's] body and...was worried [pt.] was not treated appropriately...was never notified of the fall."
b. A complaint was filed on 12/11/16 that family was "upset about [pt.] having a black eye" which was noticed after discharge.
c. A complaint was filed on 12/15/16 by family who complained of "scratches on pt. arms" that were noted after discharge from the facility.

3. Interview with staff member #53, the Regional CCO (chief clinical officer), confirmed that:
a. The compliment/concerns/grievances policy does not specifically state that complaints related to patient care issues, when lodged after discharge of the patient, are to be considered grievances.
b. The complaints listed in 2. above were handled as simple complaints and not as grievances, as they should have been.

Based on document review and interview the facility failed to follow its policy time frame for 2 of 3 complaints/grievances reviewed.

Findings Include:
1. Review of the policy Compliments, Concerns, and Grievances, policy number RE 11, last approved 8/2016, indicated under section C. Initial Handling of Concerns and Grievances, in item 3.d.: "...A concern or grievance that is not immediately resolved will be reviewed and an initial response provided to the consumer within 2 weeks. All issues shall be investigated and resolved by the Department Director/Manager within 30 days of receipt, if possible...".

2. Review of the 2016 and 2017 complaint log indicated:
a. A complaint was filed on 12/6/16 with response to the complainant on 12/20/16 with more investigation needed. The final attempted call was noted on 1/13/17 which was beyond 30 days for completion of the investigation.
b. A complaint was filed on 12/11/16 with the complainant called on 1/20/17 with information related to the investigation. This was beyond the 30 days required by policy.

3. Interview with staff member #53, the Regional CCO (chief clinical officer), confirmed that two complainants (as listed in 2. above) were not notified within 2 weeks of the initial complaint with an "initial response", nor was the complainant notified within 30 days of the receipt of the complaint as to the complaint resolution, as required by facility policy.

Based on document review and interview the facility failed to ensure that patients, or their representative, had the opportunity to participate in the development and implementation of the patient's care plan/treatment plan for 6 of 10 patient records reviewed (Patients #1, #2, #3, #4, #8 and #10), and failed to ensure that physicians noted participation in the development and approval of a treatment plan within 72 hours for 3 of 10 patients, (Patients #5, #9 and #10).

Findings Include:
1. Review of the policy Treatment Plan, policy number NU 58, last approved 8/2016, indicated under "Policy": "...Every patient shall be encouraged and allowed to participate in the development and review of their treatment plan...The organization documents family participation, (if any) in the patient's medical record..." and, under "Procedure": "...The patient and/or primary caregiver (legal guardian, POA (power of attorney), Temporary Healthcare Representative), if indicate, will actively participate in the development and any changes to the treatment plan and their signature on the treatment plan and any updates will serve to signify their awareness and understanding...".

2. Review of the "Patient Handbook" indicated in the section "The Treatment Plan", "...You will be a part of this process...When the plan is complete, you will be asked to review and sign it...".

3. Review of patient medical records indicated:
A. Patient #1 was admitted on 1/27/17 with consent for admission and treatment signed by a family member. There was no documentation in the medical record that indicated the patient and/or family had active participation and involvement in the development and implementation of the treatment plan.
B. Patient #2 was admitted on 1/11/17 and signed their admission forms voluntarily. There was no documentation in the medical record that indicated the patient had active participation and involvement in the development and implementation of the treatment plan.
C. Patient #3 was admitted on 12/3/16 (and discharge on 12/9/16) and had their consent for admission and treatment signed by their POA. There was no documentation in the medical record that indicated the patient and/or family had active participation and involvement in the development and implementation of the treatment plan.
D. Patient #4 was admitted on 12/22/16 (and discharged 12/26/16) and hod admission consent signed by the patient voluntarily. There was no documentation in the medical record that indicated the patient had active participation and involvement in the development and implementation of the treatment plan.
E. Patient #8 was admitted on 12/27/16 and discharged on 1/18/17. Their consent for admission and treatment was by their POA. There was no documentation in the medical record that indicated the patient and/or POA had active participation and involvement in the development and implementation of the treatment plan.
F. Patient #10 was admitted on 1/26/17 and had admission consents signed by family members. There was no documentation in the medical record that indicated the patient and/or family had active participation and involvement in the development and implementation of the treatment plan.

4. At 8:45 AM on 2/7/17, interview with the Regional CCO (Chief Clinical Officer), staff member #53 confirmed that there is no documentation in the medical records of patients indicating active participation by either the patient or their family member/POA.

5. At 2:10 PM on 2/7/17, interview with SW (social worker) #P7 confirmed that:
A. Patients and families are not invited to treatment planning meetings.
B. The treatment plan is presented to patients after staff create/develop it.
C. Per the Patient Handbook, given to all patients and families, the patient and family are to be a part of the develpment of the treatment plan and to sign the document as proof of that.
D. None of the patients listed in 2. above had signatures of patients or their family/POA members in the signature area of the treatment plans.
E. There is no documentation in the medical records for Patients #1, #2, #3, #4, #8 and #10 regarding active participation by family and/or the patient in the development and implementation of the treatment plan.

6. Review of the policy Treatment Plan, policy number NU 58, last approved 8/2016, indicated under "Procedure": "...Within 72 hours of admission, members of the treatment team shall further develop the Treatment Plan that is based on a comprehensive assessment of the patient's presenting problems, physical health, emotional and behavioral status. The team will consist of the physician, the R.N. (registered nurse), social worker, and other members, as appropriate...".

7. Review of patient medical records indicated:
A. Patient #5 was admitted on 12/12/16, discharged on 12/30/16 and lacked a signature by the physician on the Master Treatment Plan to show involvement in the creation and approval of the plan.
B. Patient #9 was a current patient admitted on 1/24/17 who lacked a signature by the physician on the Master Treatment Plan to show involvement in the creation and approval of the plan.
C. Patient #10 was a current patient admitted on 1/26/17 who lacked a signature by the physician on the Master Treatment Plan to show involvement in the creation and approval of the plan.

8. At 2:10 PM on 2/7/17, interview with SW (social worker) #P7 confirmed that the physician failed to sign the Master Treatment Plan within 72 hours, as required by facility policy, indicating their involvement and approval of the treatment plan.

Based on document review and interview, the facility failed to ensure the employment of staff in accordance with their policy for background checks for 1 of 1 MHT (mental health tech) with indications with the employees background check, (staff member P5).

Findings include:
1. Review of the policy Criminal Background Checks, policy number HR 67, last approved 9/2016, indicated:
A. Under "Policy": "Assurance Behavioral Health System is committed to providing a safe environment for both patients and staff...".
B. Under "Procedure": "...If at any time the employee does not meet the conditions of the background checks or any standard given by the licensing body, it is the policy of Assurance Behavioral Health System to terminate employment."
C. under "Applicant Review": "Assurance Health System believes in giving potential employees a second chance, therefore in the event a manager believes an applicant with something in their background requires reconsideration they may appeal to the Director of Human Resources or the Chief Executive Officer. The employee will be reviewed for past work history, current living situation, age of incident, type of incident and any other elements to determine if potential employee is worthy of consideration for employment. No employee shall be hired that has information in their background check that hiring the employee would put the hospital in violation of any federal or state law."

2. Review of employee files indicated that MHT P5 was hired 9/9/16 and had a background check that indicated arrests and felony convictions for assault and/or battery in 2011 and 2012, including attack of a police officer. There was no documentation in the file that a special consideration, related to those listed in the facility policy, had been made to hire this MHT for direct patient care services. It could not be determined that the facility policy was followed in relation to an Applicant Review.

3. At 1:40 PM on 2/7/17, interview with the HR (human resources) staff member #56 confirmed that it was unknown by them that this staff member had a felony conviction for assault/battery and was unsure why then had been offered employment.

4. At 2:00 PM on 2/7/17, interview with the Regional CCO (Chief Clinical Officer), staff member #53, confirmed that:
A. The facility policy is not specific as to what "Not meeting the conditions of the background checks" consisted of, or which types of offenses would keep the facility from hiring a potential employee.
B. There was no documentation in the personnel file for P5 that indicated special consideration had been made in hiring this staff member who would be giving direct patient care to facility patients.

Based on document review and interview, the nursing supervisor failed to ensure the implementation of the daily nursing assessment form completion for 6 of 10 patients (Patients #1, #2, #6, #7, #9 and #10), and failed to ensure that an incident report was completed after 1 of 2 patients (Patient #1) fell (see tag A395), failed to ensure the implementation of the daily nursing assessment form completion for 6 of 10 patients (Patients #1, #2, #6, #7, #9 and #10); failed to ensure the orientation of nursing staff. per policy, for 3 of 6 nursing staff files reviewed, (Staff P1, P2 and P6); failed to ensure that an incident report was completed after 1 of 2 patients (Patient #1) fell (see tag A397), failed to follow its policy related to the the need for consent to be given prior to the administration of certain psychotropic medications for 8 of 10 patients, (Patients #1, #3, #5, #6, #7, #8, #9 and #10) (see tag A405), and failed to ensure that nursing staff documented telephone and verbal orders as per policy requirements for 5 of 10 medical records reviewed, (Patients #1, #3, #4, #5 and #8) (see tag A408).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure it had an organized nursing service.

Based on document review and interview, the nursing supervisor failed to ensure the implementation of the daily nursing assessment form completion for 6 of 10 patients (Patients #1, #2, #6, #7, #9 and #10), and failed to ensure that an incident report was completed after 1 of 2 patients (Patient #1) fell.

Findings Include:
1. Review of the policy Nursing Assessments, policy number CC.11, last approved 8/2016, indicated in "Procedure", in section B.: "Reassessments will be done each shift and PRN (as needed). The licensed nurse will complete and document a patient-specific assessment."

2. Review of patient medical records indicated:
a. Patient #1 had shift nursing notes that were missing for one shift on each of the following days: 1/29/17, 1/31/17, 2/5/17 and 2/6/17.
b. Patient #2 had shift nursing notes that were missing for one shift on each of the following days: 1/19/17, 1/20/17, 1/21/17, 1/25/17, 1/29/17, 2/5/17 and 2/6/17.
c. Patient #6 had shift nursing notes that were missing for one shift on each of the following days: 12/16/16, 12/18/16, 12/22/16, 12/23/16, 12/27/16 and 12/31/16.
d. Patient #7 had shift nursing notes that were missing for one shift on each of the following days: 12/8/16, 12/13/16, 12/15/16, 12/18/16, 12/19/16, 12/22/16, and were not present for either shift on 12/23/16, 12/28/16 and 1/4/17.
e. Patient #9 had shift nursing notes that were missing for one shift on each of the following days: 1/26/17, 1/27/17, 1/30/17, 2/2/17, 2/4/17, 2/5/17 and 2/6/17 and none was present for either shift for 1/28/17, 1/31/17 and 2/1/17.
f. Patient #10 had shift nursing notes that were missing for one shift on each of the following days: 1/29/17, 2/1/17, 2/5/17 and 2/6/17 with no shift note for either shift on 1/31/17, 2/2/17, 2/4/17 and 2/6/17.

3. At 1:30 PM on 2/6/17, interview with the Quality and Risk staff member, staff #50, confirmed that:
a. Nursing staff work two 12 hour shifts each day.
b. Nursing is to complete an assessment form for each shift, so that two per day should be in each patient medical record.
c. This staff member agreed that the medical records listed in 2. above were missing a nursing assessment for at least one shift, and sometimes two shifts, for the days listed.

4. Review of the policy Incident Reports, policy number EOC 11, last approved 8/2016, indicated an incident report should be completed immediately when an incident occurs: "...1...Incident Reports are completed following any situation where there has been harm or potential for harm of a patient...The following are some instances when an Incident Report would be completed...a. falls...".

5. Review of patient medical records indicated that nursing wrote for Patient #1 at 1925 hours on 1/28/17 that: "Pt. had a fall at 7:10 PM during shift change. [Pt.] tried to stand up from chair and sat down on the floor. [Pt] hit his/her buttock...".

6. Review of incident reports lacked any documentation that an incident report was completed for the patient in 5. above.

7. At 2:45 PM on 2/7/17, interview with staff member #53 confirmed that no incident report could be found related to the documented fall of patient #1 on 1/28/17 and that nursing should have completed one.

Based on document review and interview, the nursing supervisor failed to ensure the orientation of nursing staff per policy for 3 of 6 nursing staff files reviewed, (Staff P1, P2, and P6).

Findings Include:
1. Review of the policy Employee Orientation, policy number HR 23, last approved 8/2016, indicated under "Purpose": "Employee orientation is a continuous and systematic process beginning from the time the employee begins working through at least the first ninety (90) days of employment. The primary purpose of orientation is to ensure that all employees develop and/or enhance the skill and competence necessary to effectively and safely perform their duties and responsibilities...".

2. Review of the policy Employee Orientation, policy number HR 23, last approved 8/2016, indicated under "Department/Unit Orientation": "1. The department/unit's Director and/or Manager (or specific designee) orients new employees or newly transferred employees to his/her department...2. Each Department/unit is responsible for developing and maintaining a department checklist which provides general guidelines which ensure that all new employees are properly welcomed to the organization, and made aware of departmental procedures...4. Proof of departmental orientation is required and will be maintained in the department/unit's personnel file. The original shall be maintained in the employees Human Resource file. The Departmental Orientation checklist serves as proof of orientation, which includes signature of the employee and Director and/or Manager This must be completed by the department/unit Director and/or Manager within 90 days of hire."

3. Review of the policy Staff Compentencies (sic), policy number HR 24, last approved 8/2016, indicated in "Policy": "...An evaluation of each Staff (sic) member's competence is conducted during the orientation process, three months post employment and annually thereafter...".

4. Review of the policy Staff Compentencies (sic), policy number HR 24, last approved 8/2016, indicated in the section "Orientation": "...2. Core Competencies are given to CNAs (certified nursing assistants), LPNs (licensed practical nurses), and RNs (registered nurses) along with an orientation packet provided by the appropriate supervisor/director. 3. All newly hired personnel complete an orientation program consisting of unit based training with assigned employee(s)...5. Initial skills check lists and/or competencies are completed by employees during orientation as assigned...6. Each individual department is responsible for devising department specific competencies and maintaining records...".

5. Review of employee files indicated:
a. P1 and P2 were RNs hired 11/28/16 who lacked documentation in their files of unit/department orientation and competencies related to their duties on the nursing unit.
b. P6 was a MHT hired 9/9/16 who lacked documentation in their files of unit/department orientation and competencies related to their duties on the nursing unit.

6. At 11:40 AM on 2/7/17, interview with the Regional CC) (chief clinical officer), staff member #53, confirmed that after the previous DON (director of nursing) left, orientation and competency documentation has been lacking.

7. At 1:40 PM on 2/7/17, interview with the HR (human resources) staff person, staff member #56, confirmed that:
a. P6 is beyond their 90 day orientation time frame and lacked any documentation in their HR file related to orientation and competencies for their job on the nursing unit.
b. P1 and P2 have completed their orientation even though they are within 90 days of hire and should have had documentation of orientation and competency in their files.
c. The former DON left employment the first of January and it was found after they left that some orientation and competency documentation was never completed or provided to HR for placement in employee files.

Based on document review and interview the facility failed to follow its policy related to the the need for consent to be given prior to the administration of certain psychotropic medications for 8 of 10 patients, (Patients #1, #3, #5, #6, #7, #8, #9 and #10).

Findings Include:
1. Review of the policy Psychotropic Medication Consent, policy number MM.21, last approved 8/2016, indicated:
A. Under "Purpose": "This policy has been established to provide guidelines for administration of psychotropic medications that are in compliance with the Department of Health."
B. Under "Statement of Policy": "...To ensure that the patient/designee has received specific information regarding the nature and effect of antipsychotic medications, to enable him/her to make an informed decision. To ensure that the patient/designee has signed or verbal consent is obtained and documented on a Medication Information Consent Antipsychotic Major Tranquilizers, form prior to administering the medication(s) to the patient."
C. Under "Procedure": "Written documentation of the patient's decision to consent must be maintained, and the patient may withdraw consent at any time...The patient must be provided with sufficient information by the physician prescribing the medication or the nurse, in order to make an informed consent...The facility will utilize the form whereby the patient signs with each new psychotropic medication prior to its admission."

2. Review of medical records indicated:
A. Patient #1 had Zyprexa and Risperdal ordered during their hospitalization and there was no document signed indicating the patient or their guardian/family member had given permission for these medications to be administered.
B. Patient #3 was given Zyprexa during their hospitalization and there was no document signed indicating the patient or their POA (power of attorney) had given permission for this medication to be administered.
C. Patient #5 was given Thorazine and Zyprexa during their hospitalization and there was no document signed indicating the patient or their POA had given permission for these medications to be administered.
D. Patient #6 was given Haldol during their hospitalization and there was no document signed indicating the patient or another responsible party had given permission for this medication to be administered.
E. Patient #7 was given Risperdal during their hospitalization and there was no document signed indicating the patient or their POA had given permission for this medication to be administered.
F. Patient #8 was given Risperdal during their hospitalization and there was no document signed indicating the patient or their POA had given permission for this medication to be administered.
G. Patient #9 was given Haldol during their hospitalization and there was no document signed indicating the patient or their POA had given permission for this medication to be administered. (A blank form was found in the chart.)
H. Patient #10 was given Zyprexa, Risperdal and Seroquel and there was no document signed indicating the patient or their guardian/family member/POA had given permission for these medications to be administered.

3. At 2:45 PM on 2/7/17, interview with the Regional CCO (Chief Clinical Officer), Staff member #53, confirmed that:
A. Certain psychotropic medications such as Zyprexa, Risperdal, Seroquel, Haldol and Thorazine require consent for administration from either the patient, or if they are not competent to make an informed decision regarding their medications, their representative/POA/guardian.
B. Review of the medical records for patients #1, #3, #5, #6, #7, #8, #9 and #10 indicated nursing failed to follow the facility policy in acquiring approval from patients or family prior to the administration of certain psychotropic medications, as policy requires.

Based on document review and interview the facility failed to ensure that nursing staff documented telephone and verbal orders as per policy requirements for 5 of 10 medical records reviewed, (Patients #1, #3, #4, #5 and #8).

Findings Include:
1. Review of the policy Validating the Accuracy of Verbal or Telephone Orders, policy number NU 49, last approved 8/2016, indicated under "Verbal Orders": "...4. Simply repeating back the order is not sufficient. Whenever possible, the receiver of the order should write down the complete order, then read it back, and receive confirmation from the individual who gave the order...", Under "Procedure": "...6. Verbal or telephone orders and critical lab results shall be "read back" to the practitioner to confirm the accuracy and completeness, using the following steps:...9. The health care professional shall sign, date, and time when the order was obtained and also document the "read back verified order"...".

2. Review of medical records indicated:
A. Patient #1 had a telephone order written on 1/30/17 at 1943 hours for 5 mg of Zyprexa IM (intramuscular) 1x (one time) dose that did not indicate a read back and verify check by the nurse.
B. Patient #3 had a telephone order written on 12/4/16 at 0930 hours for a change in Depakote, Trazadone 25 mg at bedtime as needed and Zyprexa as needed that did not indicate a read back and verify check by the nurse.
C. Patient #4 had telephone orders on 12/22/16 at 11:10 AM and 12/26/16 at 12:00 PM written as: "TO [MD1]" with no nurse name/title after and no documentation of read back and verify.
D. Patient #5 had a telephone order for 75 mg Thorazine IM x 1 now written on 12/17/16 at 0140 hours that had no documentation of a read back and verify.
E. Patient #8 had a telephone order written on 12/27/16 at 2200 hours that included 25 mg Trazadone orally at bedtime that had no documentation of a read back and verify.

3. At 8:45 AM on 2/7/17, interview with the Regional CCO (Chief Clinical Officer), staff member #53, confirmed that medical records #1, #3, #4, #5 and #8 had telephone/verbal orders written incorrectly by nursing staff and that the nurse(s) failed to document read back and verify of the orders, as per policy requirements.