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Based on record review and interview, the facility failed to ensure grievances were identified and managed as a grievance for one discharged patient (#36) of one patient grievance reviewed not identified by the facility. This had the potential to affect all patients, when patient care issues could remain unidentified and uncorrected. The facility census was 301. The Behavioral Health census was 60.

Findings included:

1. Record review of the facility's policy titled, "Patient Grievance Policy," dated 10/10/17, showed that:
- When a patient or a patient's representative telephoned the hospital with a complaint regarding the patient's care post-discharge, it was considered a grievance.
- Grievances could be reported to any facility employee and would be referred to the Patient Relations Manager or designee.
- All grievances would be addressed as quickly as possible.
- The administrator or manager who received a grievance would enter the information into the complaint management system while the investigation was underway.
- Upon completion of the investigation, Patient Relations would send a written response within seven days of receipt of the complaint/grievance.

2. During an interview on 10/12/17 at 9:00 AM, Staff O, Behavioral Health Nursing Supervisor, stated that he received a phone call from a discharged patient's (believed to be Patient #36) family member, who complained that the patient was discharged prematurely. Staff O stated that he recommended the family member speak with the patient's psychiatrist, which he believed satisfied the complaint. Staff O stated that if he believed a complaint was not resolved, he would email his superior with the details for follow-up, and added that he may or may not have emailed Staff S, Behavioral Health Interim Manager or Staff X, Behavioral Health Executive Director, with details of the complaint related to Patient #36.

3. Record review of the facility's "Grievance Log" dated 04/2017 through 10/2017, showed no grievance was received by the facility related to Patient #36.

4. During an interview on 10/12/17 at 11:27 AM, Staff S and Staff X, stated that they were not informed verbally or by email, of the grievance related to Patient #36's premature discharge. Staff X added that if a complaint was filed after a patient was discharged, and the complaint was resolved, it would not be handled as a grievance.

5. During an interview on 10/12/17 at 9:38 AM, Staff P, Registered Nurse, stated that if she received a complaint or grievance related to a patient's care, she would document it in the patient's medical record.

6. During an interview on 10/11/17 at 1:47 PM, Staff U, Director of Quality, stated that the facility had identified issues with staffs' failure to report complaints and grievances as well as issues with the electronic management of grievances, when the facility moved from one electronic system to another.

Based on interview, review of facility grievance files and policy review, the facility failed to provide a written notice of resolution of a patient's grievance for two patient's (#18 and #21) of four grievance files reviewed. This had the potential to affect all patients and or patient's representatives who filed a grievance when needed response to their grievance was not supplied. The facility census was 301.

Findings included:

1. Record review of the facility policy titled, "Patient Grievance Policy," updated 10/10/17, showed that:
- A verbal patient care complaint that cannot be resolved at the at the time of the complaint by the staff present, was postponed for later resolution, was referred to other staff for later resolution, required investigation, and/or required further actions for resolution, is considered a grievance.
- Upon completion of the investigation, Patient Relations will send a written response.
- The response will contain the decision of the hospital regarding the complaint, steps taken by the hospital to investigate the complaint, and the name of the hospital's contact person.

2. Record review of the two grievances showed:
-Patient #18 filed a grievance on 08/10/17 and the grievance file contained no documentation showing a resolution letter had been sent to the patient.
-Patient #21 filed a grievance on 08/11/17 and the grievance file contained no documentation showing a resolution letter had been sent to the patient

During an interview on 10/12/17 at 10:15 AM, Staff V, Chief Nursing Officer, stated there was no record of the resolution letters being sent to the patients who had filed these two grievances.

1.Based on observation, interview and record review, the facility failed to ensure a safe environment was maintained for one current patient (#37) and one discharged patient (#36), as well as two units ("walking well" and adolescent) of two units observed for environmental and contraband (prohibited items that can be used to harm self or others) checks. The facility also failed to ensure 15 minute patient safety observations (staff visually observe each patient to ensure they are safe) were completed in a safe and accurate manner for all 13 patients on the adolescent behavioral health unit, including one current patient (#38) who was not observed by staff but documented as safe. This had the potential to affect all patients, and placed all patients at risk for the potential for self-harm and/or injury. The facility census was 301. The Behavioral Health census was 60.

Findings included:

1. Record review of the facility's policy titled, "Precautions/Safety Checks/Environmental Checks," dated 12/09/16, showed that all patients in the behavioral health units would undergo safety observation during each 15 minute safety check and contraband checks were performed twice daily in all behavioral health unit rooms and units.

2. Record review of the facility's policy titled, "Psychiatric Search Procedure," dated 11/18/16, showed the search procedure was to ensure that patients did not have items or contraband in their possession that may cause harm to self or others.

3. Record review of the facility's policy titled, "Suicide Risk Assessment," Dated 03/25/14, showed that food products, pencils, and small items that could be swallowed were identified to be potentially unsafe items.

4. Record review of the facility's form titled, "What to Observe When Conducting the Every 15 Minutes Safety Checks," dated 11/2016, showed:
- All patients' location would be confirmed by direct visual observation and identification by checking the identification (ID) bracelet.
- The environment should be observed for contraband and obstacles that could cause the patient to fall (included loose carpet or tile).

5. During an interview on 10/10/17 at approximately 3:30 PM, Staff E, Behavioral Health Technician (BHT), stated that environmental/contraband room checks were already completed for the day.

6. Observation on 10/10/17 at approximately 3:30 PM, showed Staff E, completed an environmental/contraband room check, on the "walking well" unit, upon request. When Staff E checked the room, he failed to observe:
- The underside of pillows/pillowcases;
- The inside of a patient information folder;
- The gap between the wall and desk;
- The tops of doorframes;
- Underneath bed linens;
- Pockets of spare clothing stored within the room; and
- Underneath the trash can.
After Staff E had completed the room check, markers and a mayonnaise packet were found by the survey team, wedged between the wall and back of the desk.

7. Record review of the behavioral health precautions sheet showed that Patient #37 was a fall risk, and on suicide precaution level two (increased safety precaution and monitoring for patients who demonstrate/verbalize suicidal intent/plan with availability of means and lethality).

Observation on 10/10/17 at approximately 3:45 PM, of Patient #37's room, showed a commode (portable toilet chair) inside the patient's shower stall. The back of the chair contained two wingnuts (metal device used to secure a screw or bolt in place, which has a pair of projections for the fingers to screw it on/off), which measured less than one inch by one inch. The room also contained a plastic transition strip (used to separate rooms when transitioning between one flooring type to another), between 30-36 inches long. Approximately five inches of the carpet strip was attached to the flooring, and the remainder of the strip was loose and laid across the carpet.
The wingnuts and screws could be easily removed and ingested or used for self-injury or to injure others. The loose carpet strip created a fall risk and could be used to self-harm or to injure others, by creating a ligature (to bind or tie tightly, and use for choking or suffocation) or weapon.

Observation on 10/11/17 at 10:45 AM, showed Staff Q, Secretary Technician, completed an environmental/contraband room check on the adolescent unit, upon request. During the room check, Staff Q failed to observe:
- The tops of doorframes;
- Between the wall and bed frames;
- Behind loose base cove (baseboard made of vinyl) where approximately six inches of vinyl had separated from the wall (created a pocket); and
- A gap above cubby storage (fingerbreadth tall and approximately 30 inches long).
After Staff Q had completed the room check, two band-aids and paper were found by the survey team, wedged between the wall and the bed frame.

Observation on 10/11/17 at 11:00 AM, showed Staff Q completed an environmental/contraband room check on the adolescent unit, upon request. During the room check, Staff Q failed to observe between the wall and desk, and between the wall and bed frames.
After Staff Q had completed the room check, a marker was found by the survey team, wedged between the wall and the desk.

Record review of a Risk Manager Report dated 08/14/17, and documented by Staff P, Registered Nurse (RN), showed that at 3:00 PM, discharged Patient #36 cut her arm, and provided a crushed or chewed piece of plastic that may have been part of a toiletry bottle or marker.

8. Record review of Patient #36's medical record showed:
- A progress note dated 08/14/17 at 1:18 PM, which documented that Patient #36 self-harmed and had "approximately" five superficial scratches to her left forearm, and an abrasion near her wrist.
- A progress note dated 08/14/17 at 8:12 PM, which documented Patient #36's family member was notified that the patient had self-harmed and that it was recommended that the patient sleep in the "time-out room" (room next to nurses station, used to closely observe a patient and to remove a patient from the environment without restricting them to a room) with every four hour room checks to be conducted for safety,
- Nursing flowsheets showed that the patient's room was not checked for contraband between 08/07/17 at 5:11 PM and 08/08/17 at 4:45 PM (approximately 23.5 hours) or between 08/09/17 at 9:00 PM and 08/10/17 at 8:00 PM (23 hours).
- An order report showed a nursing order dated 08/14/17 at 6:23 PM, for room checks (also known as contraband checks) every four hours.
- Nursing flowsheets showed that the patient's room was not checked for contraband between 08/15/17 at 9:20 PM and 08/16/17 at 11:00 AM (13.5 hours).

Observation, interview and concurrent record review on 10/11/17 at 10:30 AM, showed Staff Q, Secretary Technician, completed and documented 15-minute patient safety observations. During the observations, Staff Q documented that she observed Patient #38 to be safe, on the patient safety observations sheet. The patient was not present nor observed by Staff Q, and when questioned, Staff Q stated that she knew Patient #38 was in a consult room down the hall with a physician. Staff Q added that she did not typically work on the adolescent behavioral health unit and was not familiar with the patients. Staff Q provided a report sheet, which she stated she used to verify who patients were when she completed the patient safety observations. Record review of the report sheet showed hand written notes next to each patient's name, such as "blonde", "purple", "glasses" and "orange shirt" (for example). Further review of the report sheet showed that Patient #38 was admitted after he attempted suicide by drinking antifreeze.

During an interview on 10/11/17 at 2:27 PM, Staff T, Patient Care Technician, stated that she was responsible for safety observations on half of the patients on the adolescent behavioral health unit. Staff T stated that she did not typically work the adolescent unit and therefore did not know the patients. Staff T stated that she learned patient name after "introducing self" during the morning shift to shift report, and accurately completed patient safety observations based on her identification of patients at that time.
This indicated that Staff T did not verify patient's during safety observations through ID bracelet identification, as per policy.

During an interview on 10/12/17 at 11:27 AM, Staff S, Behavioral Health Interim Manager and Staff X, Behavioral Health Executive Director, stated that arm bands (bracelets) should be verified when completing patient safety rounds and that all patients must be visualized to ensure the patient was safe before documenting on the patient safety rounding log.

Based on interview, record review, and policy review the facility failed to provide evidence a one-hour face-to-face assessment was completed after behavioral restraint (use of wrist/ankle strap-like devices that restrict the freedom of movement) application for two patients (#4 and #26) of two patients reviewed with behavioral restraints. This had the potential to affect any patient admitted with behaviors, and could result in unidentified injuries related to the restraint, prolonged use of the restraint, or the failed attempt to use a lesser restrictive method of restraint. The facility census was 301.

Findings included:

1. Record review of the facility's policy titled, "Restraint/Seclusion," reviewed 11/21/16, showed the following:
- Restraints used for the management of aggressive or self-destructive behaviors require a one-hour face-to-face assessment by the responsible physician or trained registered nurse within one hour of of the initiation of the restraint.
- Assessments shall occur as often as indicated by the patient's condition, behavior, and environmental considerations.
- Documentation shall include any in-person medical and behavioral evaluation for the intervention used to manage aggressive behavior.

2. Record review of Patient #4's Emergency Department (ED) notes, dated 10/01/17, showed the patient presented on that date and was aggressive with staff. ED staff placed four-point restraints (bilateral wrists and ankles) on the patient at 7:39 AM. Facility staff failed to document a one-hour face-to-face assessment was completed by 8:39 AM, or at any time after initiation of the restraints.

3. Record review of Patient #26's Emergency Department (ED) notes, dated 07/31/2017, showed that the patient presented on that date and was combative with staff. ED staff placed four-point restraints (bilateral wrists and ankles) on the patient at 3:05 AM. Facility failed to document that a one-hour face-to-face assessment was completed by 4:05 AM, or any time after initiation of the restraints.

During an interview on 10/12/17 at 10:54 AM, Staff W, Regulatory Coordinator, stated that the physician responsible for this patient should have documented a face-to-face assessment, but failed to do so.






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