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Based on review of the grievance log, policy and procedure and staff interview it was determined the facility failed to ensure a patient grievance was resolved in a timely manner for one (#9) of ten patients sampled.

Findings include:

Review of the grievance log revealed patient #9 submitted a letter concerning the facility's physical environment, the quality of care and treatment, patient rights and infection control.

Documentation revealed on 8/7/2014 the patient was called to confirm the facility received the letter and it would be forwarded to the Vice President of Inpatient and Residential Services for investigation. Documentation of the investigation was requested on 9/11/2014 from the risk manager but no documentation was provided.

Review of the facility policy, "Patient/Client Grievance Resolution", #II.A13.3 stated a compliant is any verbal or written expression of dissatisfaction with any aspect of the facility's service which is not immediately resolved to their satisfaction. The complaint will be reviewed with input from the appropriate manager and the complainant will receive a response within thirty (30) working days. If the complaint cannot be resolved within thirty (30) working days, a mutually agreeable extension is decided upon and a letter is sent to the complainant.

Interview with the Vice President of Inpatient and Residential Services on 9/11/2014 at approximately 4:30 p.m. confirmed receipt of the complaint on 8/6/14 and stated the concerns were being investigated. A letter would be sent to the patient as early as today. She confirmed the complaint was received more than 30 days ago and a letter stating the resolution of the complaint had not been sent.

Based on record review, observation, review of policies and procedures and staff interview it was determined the Registered Nurse failed to supervise and evaluate care related to the initiation of a plan of care for a patient determined to be a fall risk, failed to assess a patient after a fall and after sustaining insect bites, failed to follow the policy and procedure for fall precautions, failed to implement physician orders for patient placement and failed to meet the needs for three (#8, #9, #10) of ten patients reviewed.

Findings include:

1. Patient #9 was admitted to the hospital on 6/30/14. Review of the Registered Nurse (RN) progress note dated 6/30/14 at 4:59 p.m. indicated "...Client placed on fall and CO (Close Observation) precautions". Review of inpatient shift notes from 7/1/14 to 7/8/14 indicated "Is client at risk for fall? Yes." "Was client placed on fall precautions? Yes. Review of physician orders dated 6/30/14 revealed "Fall Precautions".

Review of the hospital policy "Patient Fall Precautions" last reviewed 9/9/14 and last revised 1/13 indicated: C. Guidelines for clients on fall precaution: 4. Encourage the client to use bedside bell to request assistance, ensure the bell is within easy reach. 6. Encourage clients to use grab bars mounted in toilet and bathing areas and railings along corridors".

Review of shift note dated 7/6/14 7:00 p.m. to 7:00 a.m. stated "At 2 a.m. woke up...Fell down in shower...". There was no further documentation in the patient's record regarding the fall. There was no documentation of an assessment by the nurse. There was no documentation the patient had been given a call bell. Review of the Master Treatment Plan, signed and dated by the nurse supervisor on 6/30/14 revealed the treatment plan did not include the patient being at risk for falls and was not updated after the fall on 7/6/14 to include falls.

An interview was conducted with the Risk Manager on 9/9/14 at 2:11 p.m. regarding policies and procedures for patient falls. She stated there were two policies, the Fall Precautions Policy and a Policy entitled "Neuro Checks" for evaluation of the patient who had a possible head trauma from a fall or possible overdose.

An interview was conducted with the Assistant Director of Nursing (ADON) on 9/11/14 at 1:10 p.m. She stated patient #9 should have had a treatment plan for falls and there should have been a nursing assessment after the fall. She confirmed there was no treatment plan for falls and no nursing assessment after the fall. She indicated the patient was in a room on the "addiction side" of the hospital. Those rooms do not have grab bars. She stated there are only a few rooms in the hospital that have grab bars in the shower and toilet areas. There are none in the rooms that are designated for substance abuse patients. She stated there are no call bells available for each patient. If a patient was given a call bell, it would have been indicated in the patient's record.

An interview with a behavioral health technician on 9/11/14 at 1:15 p.m. revealed the hospital had only five call bells for a capacity of 30 patients.

During an interview with the Vice President of Inpatient and Residential Services on 9/11/14 at 4:00 p.m. revealed the patient should have been given a call bell and should have been placed in a room that had grab bars.

Review of inpatient shift note dated 7/6/14 at 5:53 p.m. indicated "Client was complaining about ant bites from ants being in her bed". Review of a Therapist note dated 7/6/14 at 12:16 p.m. stated "Client ...has visible ant bites...Client states she has ants in her bed.

Review of Case Manager/Counselor note dated 7/7/14 at 6:36 p.m. revealed "Client stated that she was bitten by ants two nights ago and has visible ant bites on her arm. She stated that she had already told the nurse and was treated".

Review of the record revealed no documentation of a nursing assessment being completed after the patient sustained insect bites. This was confirmed with the Director of Nursing on 9/10/14 at 4:25 p.m.

2. Patient #8 was admitted to the hospital on 9/1/14. Review of the Level of Care Assessment completed on 9/1/14 revealed "What level of care is recommended at this time ? Inpatient MH (Mental Health).
To which program is the client being referred? Hospital Psych". Physician order dated 9/1/14 at 4:23 a.m. revealed "Inpatient Psychiatric". Review of the Face Sheet revealed Program: Hospital -Psychiatric Admitted 9/1/2014.

Review of an electronic record entry entitled "New Admission" dated 9/1/14 revealed "Client is being admitted to the Hospital unit..."

Review of the Unit Census- Hospital for 9/ 9/14, 9/10/14 and 9/11/14 documented patient #8 was noted to be "Housed on CSU A. (Crisis Stabilization Unit)".

An observation was conducted of patient #8 on 9/10/14. The patient was observed in the CSU licensed facility in the day room.

On 9/9/14 at 2:10 p.m. an interview was conducted with the Director of Nursing regarding the placement of patient #8. She stated the patient was moved from the Hospital to the Crisis Stabilization Unit because "it has a day room that can contain her better". She stated the patient was pulling the fire alarm and trying to get into male's rooms in the Hospital.

On 9/11/14 at approximately 4:00 p.m. an interview was held with the Vice President of Inpatient and Residential Services regarding patient #8's placement. She stated patient #8 was moved from the Hospital to the CSU when she pulled the fire alarm in the Hospital. She stated the fire alarm pull stations in the Hospital are not covered and the ones in the CSU are covered. She stated the patient would be in a more contained environment in the CSU for safety.

3. Patient #10 was admitted to the Hospital on 8/27/14. Review of the Level of Care Assessment completed on 8/27/14 revealed: "What level of care is recommended at this time? Inpatient Mental Health. To which program is the client being referred? Hospital Psych. Explain level of care assessment/screening recommendations: Client is admitted to Hospital unit..." Review of the Face Sheet revealed "Program: Hospital-Substance Abuse. Physician orders dated 8/27/14 stated to admit to inpatient substance abuse.

Interview with the Risk Manager on 911/14 at 11:00 a.m. confirmed that this meant the hospital.

An interview was conducted with the Director of Nursing on 9/9/14 at 3:11 p.m. regarding patient #10. She stated she could not find any specific documentation in the record as to why she was housed on the CSU. She stated she on the CSU from admission on 8/27/14 to 9/9/14 when she was moved to the hospital. She stated "...it was easier to contain her on the CSU".

An interview was conducted with the Director of Nursing on 9/9/14 at approximately 1:00 p.m. She stated patients come in through the Access Center then are are admitted to either the hospital or the CSU. She stated the programming are the same. Usually Medicare, private pay and insurance patients are placed in the hospital. She stated if there is a patient who is aggressive, "we can manage the patient better on the CSU, we have a day room where we can contain them better, we can contain them better in a central area". She stated "it is a safety issue for the patients. If they were in the hospital they could walk up and down the hallway, in the CSU they are contained in a central area".