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Based on observation, record review, document review and staff interview it was determined the facility failed to ensure patient's rights were protected and promoted by all facility staff by not having a clear policy for grievances that ensures prompt resolutions for patient grievances (See Tag A 118); failed to ensure the resolution was provided to the patient in written notice (See Tag A 123); failed to ensure patient privacy was provided for medication administration, laboratory specimen collection or vital sign assessments (See Tag A 143); and, failed to ensure care was rendered in a safe setting related to infection control surveillance and control (See Tag A 144).

Based on record review, document review and interviews it was revealed the facility failed to ensure all staff follow the hospital's own grievance policy by documentation, investigation and written resolution provided to the patient concerning patient grievances in one (1) of one (1) patient's who voiced a grievance to facility staff. Staff failed to follow facility policy to document, investigate and send a written response to the patient (patient #1). This failure to ensure all facility staff have clear knowledge to follow the grievance policy that is based on regulation and ensure the policy is clear for staff to understand has the potential for a large negative impact if patient rights are not followed by facility staff. This will also impact the numbers for quality tracking if grievances are not reported.

Findings include:

1. The medical record for patient #1 on the identifier list was reviewed. She was admitted to psychiatric unit A of the facility on 9/1/19 with diagnoses that included depression. The therapy note dated 9/4/19 documented the patient to have said to the therapist, "This is the nastiest place I've ever seen, it never gets cleaned. My bathroom is filthy. All they do is pick up trash."

2. In an interview conducted on 9/24/19 at about 3:00 p.m. with the therapist who documented the above note was asked about the note. She stated, "Yes, the patient did complain a lot." When asked if she had completed a grievance form per hospital policy she stated, "No. The patient said she was going to call the administrator after she was discharged. I thought that was right where it needed to go." I asked if she was aware of the facility complaint/grievance policy and she said, "Yes, I guess." She could not remember ever filling out a complaint/grievance.

3. In an interview conducted on 9/24/19 at about 11:00 a.m. with the therapy team leader, the finding of the therapy note was discussed. She stated, "The therapist should have reported this."

4. In an interview with the head of the Behavior Science Center on 9/23/19 at about 10:30 a.m. the issue of patient #1's grievance was discussed. He was asked if there was a complaint/grievance documented and investigated by the facility and he said no. He said he did recall speaking to the patient by telephone the day after she was discharged. He stated he did listen to her complaint and after talking with her felt the issue was resolved so did not document the grievance.

5. A review of the facility policy entitled Patient Grievance Policy, last reviewed/revised 5/12 revealed in part: "The definition of complaint as a written or verbal concern...from a patient...regarding patient care services that can be effectively addressed and resolved by informal means.... A grievance is defined by the policy as a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) that is made by a patient...regarding the patient's care, abuse or neglect, privacy or issues related to the organization's compliance with the CMS Conditions of Participation( CoP).... It further goes on to explain "complaints vs grievance as: a patient issue is not a grievance if the patient issue can be resolved promptly, on the spot by staff present." It also states "if a verbal complaint cannot be resolved at the time of the complaint by staff present, it is postponed for later resolution, referred to other staff for later resolution, requires investigation and/or requires further actions for resolution, then the complaint is a grievance for the purpose of these requirements." These statements are unclear about when to report, what to report and if it should be reported. The policy further states: "Patient grievances also include situations where patients...phone or write to [the facility] about concerns related to care or services,...or failure of the organization to comply with one or more CMS CoPs..." It further states, "Patient complaints, concerns or expressions of dissatisfaction communicated to [facility] staff that can be resolved promptly by the staff present in the facility shall be resolved at that level. Staff shall address the complaint with the patient and collect pertinent information concerning the complaint. Measures taken to resolve the complaint will be documented..." Lastly, the policy states in part: "A complaint that is not resolved promptly by staff present or is referred to facility administration is considered a grievance..."

6. In an interview with the Community Chief Regulatory Affairs Officer/Risk Management conducted on 9/23/19 at about 10:15 a.m. she was asked if a grievance was documented, investigated and a written resolution sent to the patient and she responded, "No." She agreed the facility had not documented, investigated nor sent a written resolution to the patient for this grievance.

Based on record review, document review and interviews it was revealed the facility failed to ensure all staff follow the hospital's own grievance policy by documentation, investigation and written resolution provided to the patient concerning patient grievances in one (1) of one (1) patient's who voiced a grievance to facility staff. Staff failed to follow facility policy to document, investigate and send a written response to the patient (patient #1). This failure to ensure all facility staff have clear knowledge to follow the grievance policy that is based on regulation and ensure the policy is clear for staff to understand has the potential for a large negative impact if patient rights are not followed by facility staff. This will also impact the numbers for quality tracking if grievances are not reported.

Findings include:

1. The medical record for patient #1 on the identifier list was reviewed. She was admitted to psychiatric unit A of the facility on 9/1/19 with diagnoses that included depression. The therapy note dated 9/4/19 documented the patient to have said to the therapist, "This is the nastiest place I've ever seen, it never gets cleaned. My bathroom is filthy. All they do is pick up trash."

2. In an interview conducted on 9/24/19 at about 3:00 p.m. with the therapist who documented the above note was asked about the note. She stated, "Yes, the patient did complain a lot." When asked if she had completed a grievance form per hospital policy she stated, "No. The patient said she was going to call the administrator after she was discharged. I thought that was right where it needed to go." I asked if she was aware of the facility complaint/grievance policy and she said, "Yes, I guess." She could not remember ever filling out a complaint/grievance.

3. In an interview conducted on 9/24/19 at about 11:00 a.m. with the therapy team leader, the finding of the therapy note was discussed. She stated, "The therapist should have reported this."

4. In an interview with the head of the Behavior Science Center on 9/23/19 at about 10:30 a.m. the issue of patient #1's grievance was discussed. He was asked if there was a complaint/grievance documented and investigated by the facility and he said no. He said he did recall speaking to the patient by telephone the day after she was discharged. He stated he did listen to her complaint and after talking with her felt the issue was resolved so did not document the grievance.

5. A review of the facility policy entitled Patient Grievance Policy, last reviewed/revised 5/12 revealed in part: "The definition of complaint as a written or verbal concern...from a patient...regarding patient care services that can be effectively addressed and resolved by informal means.... A grievance is defined by the policy as a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) that is made by a patient...regarding the patient's care, abuse or neglect, privacy or issues related to the organization's compliance with the CMS Conditions of Participation( CoP).... It further goes on to explain "complaints vs grievance as: a patient issue is not a grievance if the patient issue can be resolved promptly, on the spot by staff present." It also states "if a verbal complaint cannot be resolved at the time of the complaint by staff present, it is postponed for later resolution, referred to other staff for later resolution, requires investigation and/or requires further actions for resolution, then the complaint is a grievance for the purpose of these requirements." These statements are unclear about when to report, what to report and if it should be reported. The policy further states: "Patient grievances also include situations where patients...phone or write to [the facility] about concerns related to care or services,...or failure of the organization to comply with one or more CMS CoPs..." It further states, "Patient complaints, concerns or expressions of dissatisfaction communicated to [facility] staff that can be resolved promptly by the staff present in the facility shall be resolved at that level. Staff shall address the complaint with the patient and collect pertinent information concerning the complaint. Measures taken to resolve the complaint will be documented..." Lastly, the policy states in part: "A complaint that is not resolved promptly by staff present or is referred to facility administration is considered a grievance..."

6. In an interview with the Community Chief Regulatory Affairs Officer/Risk Management conducted on 9/23/19 at about 10:15 a.m. she was asked if a grievance was documented, investigated and a written resolution sent to the patient and she responded, "No." She agreed the facility had not documented, investigated nor sent a written resolution to the patient for this grievance.

Based on observation and interviews it was revealed the facility failed to ensure all patient's rights to physical privacy on psychiatric unit A of the facility. This failure to ensure patient privacy during administration of patient medications, laboratory specimen collection and vital sign collection has the potential to negatively impact all patients who receive care at the facility's psychiatric unit A if staff administer patient's treatments and medications publicly in the lounge area of the unit.

Findings include:

1. A physical tour was conducted on 9/23/19 at about 10:25 a.m. of the facility's psychiatric unit A. A nurse was in the lounge with a medication cart and computer. Two (2) patients were around her with several other patients in various positions in the room. She was administering medications, assessing medication effectiveness and educating the patients in full view of each other and any one else in the lounge area.

2. In an interview conducted with the Clinical Nurse Manager of psychiatric unit A on 9/23/19 at about 1:45 p.m. she was asked about the unit procedure for medication administration and other like treatments such as laboratory specimen collection and vital sign collection. She stated the staff will call the patients to the lounge area to administer medications, for phlebotomists to collect laboratory specimens in a collection chair in the lounge or for vital sign collections. She did not perceive this to be a violation of patient privacy. She said they didn't offer privacy to patients unless they requested to have these done in their room.

Based on observation and interviews it was revealed the facility failed to ensure a safe environment related to infection control on the facility's psychiatric unit A where an unknown orange, rust colored substance was observed in the patient shower stalls about one third (1/3) of the way up from the bottom of the shower. This failure to adequately provide infection control for patient showers has the potential to negatively impact all patients if the facility does not provide adequate disinfection of patient shower facilities.

Findings include:

1. A physical tour was conducted of psychiatric unit A on 9/23/19 at about 10:30 a.m. along with the Clinical Nurse Manager and the head of the psychiatric units. Patient rooms 142, 145 and 155 were inspected due to patients not occupying them. The shower area was about six (6) feet by three (3) feet with a light bluish green tile. The grout was a grayish color. Tiny areas of grout were missing in some spots. About one third (1/3) of the way up from the shower floor an orange, rust colored substance was on the tiles and the grout.

2. An interview was conducted on 9/23/19 at about 1:25 p.m. with the housekeeper for the day's routine cleaning of the unit. The above finding was discussed. She stated she followed the facility policy for daily and terminal cleaning. She uses the approved neutral cleanser and/or hydrogen peroxide in the showers. She sprays the walls then wipes them down with a long handled mop with a microfiber head. She does not clean the bathrooms daily, only if a patient is discharged.

3. An interview was conducted on 9/23/19 at about 2:48 p.m. with the housekeeping supervisor. The above findings were discussed. He stated the facility does not do any deep cleaning due to it was combined with the terminal cleaning procedure. He said he did not know what the orange substance was in the showers on the unit.

4. An interview and tour were conducted on 9/24/19 at about 1:00 p.m. with the head of maintenance and the head of psychiatric unit A. Patient room 142 was revisited and the shower was observed. The orange, rust color was still present. The head of maintenance stated it was difficult to repair items on the locked unit, rooms had to be closed. He reached over and wet a piece of toilet paper with water and rubbed the grout with it. The orange, rust colored substance came off. He stated, "This is a housekeeping issue."

5. An interview was conducted on 9/24/19 at about 2:00 p.m. with the infection control person of the facility. The above findings were discussed. She stated she does do environment rounds and produced the last dated infection control rounds for the unit on 6/24/19. She stated she did not go into the patient rooms and do any observations there.

Based on record review, a review of documents and staff interviews it was revealed the facility failed to ensure orders were obtained when a patient was placed in restraints. This failure was identified in three (3) of three (3) restraint records reviewed (patient #2, 3 and 21). This failure has the potential to adversely affect all patients.

Findings include:


1. A review of the medical record for patient #2 revealed patient #2 was placed in four (4) point restraints on 9/19/19 at 5:35 p.m. and on 9/20/19 at 4:40 p.m. No orders for four (4) point restraints were noted in the medical record for these episodes.

2. A review of the medical record for patient #3 revealed patient #3 was placed in open seclusion on 9/22/19 at 11:37 a.m. No order for seclusion was noted in the medical record for this seclusion episode.

3. A review of the medical record for patient #21 revealed patient #21 was noted in open seclusion on 9/8/19 from 12:00 a.m. to 12:30 a.m., 9:00 a.m. to 10:30 a.m., 11:00 a.m. to 11:30 a.m., 12:00 p.m., 12:30 p.m., 1:00 p.m. to 3:00 p.m., 3:30 p.m. to 3:45 p.m., 4:15 p.m., 4:45 p.m. to 7:45 p.m. and 8:15 p.m. to 10:30 p.m. No orders for seclusion were noted in the medical record for 9/8/19. Patient #21 was noted in seclusion on 9/9/19 from 12:00 a.m. to 1:15 a.m., 1:45 a.m. to 3:00 a.m., 3:30 a.m. to 6:30 a.m., 8:15 p.m. to 9:00 p.m. and 9:30 p.m. to 11:45 p.m. No orders for seclusion were noted in the medical record for 9/9/19. Patient #21 was noted in seclusion on 9/10/19 from 12:00 a.m. to 12:30 a.m., 1:00 a.m. to 5:00 a.m., 5:30 a.m. to 6:15 a.m. and 7:30 a.m. to 8:00 a.m. No orders for seclusion were noted in the medical record for 9/10/19. Patient #21 was noted in open seclusion on 9/18/19 from 9:15 a.m. to 2:15 p.m. and 2:45 p.m. to 11:45 p.m. No orders for seclusion were noted in the medical record for 9/18/19. Patient #21 was noted in open seclusion on 9/19/19 from 12:00 a.m. to 11:15 a.m. and 12:00 p.m. No orders for seclusion were noted in the medical record for 9/19/19. Patient #21 was noted in seclusion on 9/21/19 from 9:30 p.m. to 10:45 p.m. No orders for seclusion were noted in the medical record for 9/21/19.

4. A review of the policy titled Restraints and Seclusion, updated 3/01/2019, revealed in part: "Any order for restraint or seclusion must be given by the attending physician or LIP [Licensed Independent Practitioner] or designated physician or LIP credentialed at this facility."

5. An interview was conducted with the Nurse Manager on 9/24/19 at approximately 1:00 p.m. She concurred there were no orders for the four (4) point restraint episodes for patient #2 and seclusion episode for patient #3.

6. An interview was conducted with the Chief Nursing Assistant on 9/25/19 at 1:30 p.m. She concurred there were no orders for the seclusion episodes for patient #21.

Based on a review of documents, medical record review and staff interviews it was revealed the facility failed to ensure a face to face was completed per policy. This failure was identified in one (1) of four (4) face to face assessments reviewed (patient #2). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #2 revealed a face to face assessment was not completed as per policy for the restraint episode on 9/19/19 at 5:35 p.m.

2. A review of the policy titled Restraints and Seclusion, updated 03/01/2019, revealed in part: "The in-person evaluation, conducted within one hour of the initiation of restraint or seclusion for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff, or others includes the following: An evaluation of the patient's immediate situation. The patient's reaction to the intervention. The patient's medical and behavioral condition. The need to continue or terminate the restraint or seclusion."

3. An interview was conducted with the Nurse Manager on 9/24/19 at approximately 1:00 p.m. She concurred the face to face assessment was not completed as per policy.

Based on a review of documents, medical record review and staff interviews it was revealed the facility failed to ensure patient care provided by the nursing staff was being provided as ordered. This failure was identified in three (3) of three (3) restraint charts reviewed (patient #2, 3 and 21). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #2 revealed patient #2 was placed in four (4) point restraints on 9/19/19 at 5:35 p.m. and on 9/20/19 at 4:40 p.m. No orders for four (4) point restraints were noted in the medical record for these episodes.

2. A review of the medical record for patient #3 revealed patient #3 was placed in open seclusion on 9/22/19 at 11:37 a.m. No order for seclusion was noted in the medical record for this seclusion episode..

3. A review of the medical record for patient #21 revealed patient #21 was noted in open seclusion on 9/8/19 at 12:00 a.m. to 12:30 a.m., 9:00 a.m. to 10:30 a.m., 11:00 a.m. to 11:30 a.m.,12:00 p.m., 12:30 p.m., 1:00 p.m. to 3:00 p.m., 3:30 p.m. to 3:45 p.m., 4:15 p.m., 4:45 p.m. to 7:45 p.m., and 8:15 p.m. to 10:30 p.m. No orders for seclusion were noted in the medical record for 9/8/19. Patient #21 was noted in seclusion on 9/9/19 at 12:00 a.m. to 1:15 a.m., 1:45 a.m. to 3:00 a.m., 3:30 a.m. to 6:30 a.m., 8:15 p.m. to 9:00 p.m., and 9:30 p.m. to 11:45 p.m. No orders for seclusion were noted in the medical record for 9/9/19. Patient #21 was noted in seclusion on 9/10/19 at 12:00 a.m. to 12:30 a.m., 1:00 a.m. to 5:00 a.m., 5:30 a.m. to 6:15 a.m. and 7:30 a.m. to 8:00 a.m. No orders for seclusion were noted in the medical record for 9/10/19. Patient #21 was noted in open seclusion on 9/18/19 at 9:15 a.m. to 2:15 p.m., and 2:45 p.m. to 11:45 p.m. No orders for seclusion were noted in the medical record for 9/18/19. Patient #21 was noted in open seclusion on 9/19/19 at 12:00 a.m. to 11:15 a.m. and 12:00 p.m. No orders for seclusion were noted in the medical record for 9/19/19. Patient #21 was noted in seclusion on 9/21/19 at 9:30 p.m. to 10:45 p.m. No orders for seclusion were noted in the medical record for 9/21/19.

4. A review of the policy titled Restraints and Seclusion, updated 3/01/2019, revealed in part: "Any order for restraint or seclusion must be given by the attending physician or LIP [Licensed Independent Practitioner] or designated physician or LIP credentialed at this facility."

5. An interview was conducted with the Nurse Manager on 9/24/19 at approximately 1:00 p.m. She concurred there were no orders for the four (4) point restraint episodes for patient #2 and seclusion episode for patient #3.

6. An interview was conducted with the Chief Nursing Assistant on 9/25/19 at 1:30 p.m. She concurred there were no orders for the seclusion episodes for patient #21.

Based on a review of documents and staff interviews it was revealed the facility failed to ensure all verbal orders were signed promptly and in accordance with State law. This failure was identified in one (1) of three (3) restraint records reviewed (patient #2). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the Hospital Licensure 64-12-7.2.r stated "Physicians shall countersign and date all verbal and telephone orders at the next hospital visit in which a patient visit occurs and an entry is written in the chart."

2. A review of the medical record for patient #2 revealed a verbal order for restraints was received on 9/19/19 at 5:40 p.m. The verbal order was signed by the physician on 9/21/19 at 7:13 a.m. A verbal order for restraints was received on 9/19/19 at 7:55 p.m. and the verbal order was signed by the physician on 9/21/19 at 7:13 a.m. A verbal order for restraints was received on 9/20/19 at 4:45 p.m. and this order was not signed by the physician. Further review revealed the physician completed a history and physical on 7/20/19 at 7:21 a.m. but did not sign the verbal orders for restraints.

3. An interview was conducted with the Nurse Manager on 9/24/19 at approximately 1:00 p.m. She stated verbal orders for restraints are to be cosigned by the physician within twenty four (24) hours.

Based on observation and interviews it was revealed the facility failed to ensure a safe environment related to infection control on the facility's psychiatric unit A where an unknown orange, rust colored substance was observed in the patient shower stalls about one third (1/3) of the way up from the bottom of the shower. This failure to adequately provide infection control for patient showers has the potential to negatively impact all patients if the facility does not provide adequate disinfection of patient shower facilities.

Findings include:

1. A physical tour was conducted on the psychiatric unit A on 9/23/19 at about 10:30 a.m. along with the clinical nurse manager and the head of the psychiatric units. Patient rooms 142, 145, and 155 were inspected due to patients were not occupying them. The shower area was about six (6) feet by three (3) feet with a light bluish green tile. The grout was a grayish color. Tiny areas of grout were missing in some spots. About one third (1/3) of the way up from the shower floor an orange, rust colored substance was on the tiles and the grout.

2. An interview was conducted on 9/23/19 at about 1:25 p.m. with the housekeeper for the days/routine cleaning of the unit. The above finding was discussed. She stated she followed the facility policy for daily and terminal cleaning. She uses the approved neutral cleanser and/ or hydrogen peroxide in the showers. She sprays the walls then wipes them down with a long handled mop with a microfiber head. She does not clean the bathrooms daily, only if a patient is discharged.

3. An interview was conducted on 9/23/19 at about 2:48 p.m. with the housekeeping supervisor. The above findings were discussed. He stated the facility does not do any deep cleaning due to it was combined with the terminal cleaning procedure. He said he did not know what the orange substance was on the showers on the unit.

4. An interview and tour were conducted on 9/24/19 at about 1:00 p.m. with the head of maintenance and the head of the psychiatric unit A. Patient room 142 was revisited and the shower was observed. The orange, rust color was still present. The head of maintenance stated it was difficult to repair items on the locked unit, rooms had to be closed. He reached over and wet a piece of toilet paper with water and rubbed the grout with it. The orange, rust colored substance came off. He stated 'this is a housekeeping issue'.

5. An interview was conducted on 9/24/19 at about 2:00 p.m. with the infection control person of the facility. The above findings were discussed. She stated she does do environment rounds and produced the last dated infection control rounds for the unit on 6/24/19. She stated she did not go into the patient rooms and do any observations there.