HospitalInspections.org

Based on facility policies, documents, observations and interviews conducted, the facility failed to protect and promote the rights of 8 (10,11, 12, 13, 26, 27, 28, 29) of 8 patients reviewed and 2(A, B) of 2 units observed.

The facility failed to follow the established process for investigating and resolving complaints and grievances in a timely, reasonable and consistent manner. Refer to A0118.

The Governing Body failed to ensure that patient grievances were reviewed, investigated, resolved and documented. Refer to A0119.

The facility failed to form an individual treatment plan in cooperation with the patient. Refer to A0130.

The faciltiy failed to ensure the patients basic right to respect, dignity and comfort. Refer to A0143

Based on facility policy, documentation and interviews conducted, the facility failed to follow the established process for investigating and resolving complaints and grievances in a timely, reasonable and consistent manner for 4 (patients 26, 27, 28, 29) of 4 grievances reviewed.

Findings included:

Facility policy Complaints and Grievances, last reviewed 07/2024, states "When grievances are received, the Patient Advocate and/or Risk Manager will review, investigate and resolve grievances and determine the appropriate response to the complainant. Documentation should include ... .... resolution of grievance and follow up."

Review of facility's complaints and grievances revealed:
On 09/28/2024 Patient #26 filled out the complaint and grievance form. There is no documentation of resolutions or follow ups noted.
On 09/30/2024 Patient #27 filled out the complaint and grievance form. There is no documentation of resolutions or follow ups noted.
On 10/20/2024 Patient #28 filled out the complaint and grievance form. There is no documentation of resolutions or follow ups noted.
On 10/22/2024 Patient #29 filled out the complaint and grievance form. There is no documentation of resolutions or follow ups noted.

Review of document labeled "Grievances" given by Staff S/Patient Advocate, reveals "no grievances recorded for this time period".

During an interview on 11/06/2024 at 09:02 AM, Staff S/Patient Advocate stated I did follow ups to the complaint and grievances, but I did not document it. I did not know I was supposed to. Yes, I see it does not look good and looks as if it was not fully investigated.

During an interview on 11/06/2024 at 12:15 PM, the CEO stated I am involved with all the complaints and grievances to make sure they are resolved properly and closed accordingly; I work very closely with the patient advocate.

Based on facility policy, documentation and interviews conducted, the Governing Body failed to ensure that patient grievances were reviewed, investigated, resolved and documented in 4 (#) of 4 grievances reviewed. Failure to review and resolve patient grievances places patients at risk of not receiving appropriate care and services.

Findings included:

Facility policy "Complaints and Grievances" last reviewed 07/2024 states "When grievances are received, the Patient Advocate and/or Risk Manager will review, investigate and resolve grievances and determine the appropriate response to the complaint. Documentation should include ... .... resolution of grievance and follow up."

Review of facility's complaints and grievances revealed on 09/28/2024 Patient 26 filled out the complaint and grievance form and there is no documentation of resolution's or follow ups noted. On 09/30/2024 Patient 27 filled out the complaint and grievance form and there is no documentation of resolution's or follow ups noted. On 10/20/2024 Patient 28 filled out the complaint and grievance form and there is no documentation of resolution's or follow ups noted. On 10/22/2024 Patient 29 filled out the complaint and grievance form and there is no documentation of resolution's or follow ups noted.

During an interview on 11/06/2024 at 09:02 AM, Staff S/Patient Advocate stated I did do follow ups to the complaint and grievances, but I did not document it. I did not know I was supposed to. Yes, I see it does not look good and looks as if it was not fully
investigated.

During an interview on 11/06/2024 at 12:15 PM, the CEO stated I am involved with all the complaints and grievances to make sure they are resolved properly and closed accordingly; I work very closely with the patient advocate.

Based on facility policy, facility documents, medical record review, and interviews, the facility failed to form an individual treatment plan in cooperation with the patient in 4 (#10, #11, #12, and #13) out of 4 medical records reviewed on Unit M.

Findings included:

Review of the Policy and Procedure title, "Treatment Planning and Review", #0651.COMP.1018.004, review 12/2023, Policy- Every patient shall actively participate in treatment planning needs ...and have an individual comprehensive treatment plan ...A comprehensive interdisciplinary treatment plan is initiated upon the patient admission through the first 24 hours and is fully develop/ reviewed/ revised by the multidisciplinary treatment team within 72 hours ...Patient will be expected to participate in all, or a portion, of their team conference, including the planning and evaluation of their individual treatment plan. Treatment team takes place at least 3 times weekly on all units ...Care, Treatment or services for each patient is based on the treatment plan ...

Review of the Policy and procedure title, "Treatment planning", # 651.OP-029.001, reviewed 07/2024 ... Patient and families ...are involved in the treatment planning ...B. problems entered on the master problem list form the basis of the master treatment plan. Each discipline performing an assessment adds their findings to the problems in the master problem list ... Patients should sign the master treatment plan indicating their review and understanding.

Review of facility document titled Interdisciplinary Treatment Plan master sheets showed this treatment plan has been presented to/ reviewed with the patient and/or legal representative. The patient / legal representative have been given the opportunity to ask questions and make suggestions (By signing this, patient/ legal rep agrees that he/she has actively participated in treatment planning and agrees to the plan) area. The area for patient comments and patient signature with date and time.

Review of Patient #10's medical record revealed that patient was admitted on 10/29/2024 with diagnosis major depressive disorder. The initial treatment plan was started 10/29/2024 at 8:05 PM. Interdisciplinary Treatment Plan was not completed. The area for patient comments and patient signature with date and time was blank. There was no evidence that the patient participated in their treatment plan. The patient was discharged 11/04/2024 at 4:05 PM.

Review of Patient # 11's medical record revealed that patient was admitted on 10/31/2024 with diagnosis of major depressive disorder. The initial treatment plan started on 10/31/2024 at 22:35 PM. Interdisciplinary treatment plan master sheets not completed. The area for patient comments and patient signature with date and time was blank. There is no evidence that patient participated in their treatment plan. The patient discharged 11/05/2024 at 5:00 PM.

Review of Patient #12's medical record review revealed that the patient was admitted on 11/01/2024 with diagnosis major depressive disorder. The Interdisciplinary Treatment Plan revealed the patient signed on 11/04/2024 at 4:06 PM, which was one hour and 7 minutes before discharge from the facility.

Review of Patient #13 Medical record review revealed that the patient was admitted on 10/31/2024 with diagnosis major depressive disorder. The Interdisciplinary Treatment Plan revealed the patient signed on 11/05.2024 at 12:39 PM, which was one hour and forty-seven minutes before discharge from the facility.

During an interview on 11/05/2024 at 9:37 AM, Staff R/Therapist stated the treatment team meets every morning, and they will meet with the patient one to two days after admission. The patient signs the plan. If the patient refuses to sign, then the therapist would document that.

During an interview on 11/05/2024 at 3:02 PM, Staff M/ Nurse Manager reviewed Patient #12's care plan signed by the patient 1 hour and 7 minutes prior to discharge. He stated it should have been done earlier. The patient's signature means he/she is agreeing to actively participate in the treatment plan. Staff M reviewed Treatment Plan for Patient's #10, 11, and 13 and stated, "I can't tell you what happened, other than it was not done."

Based on observations, interviews, documents, and policy review, the hospital failed to ensure the patients basic right to respect, dignity and comfort while in the hospital on 2 (Unit A and B) of 5 nursing units for patients that do not require 1:1 observation. Failure to allow capacitated patients the right to use the restroom in private, access to their bedrooms and denying personnel hygiene items results in violating the patients dignity and worth.

Findings included:

On 11/04/2024 at 09:44 AM, a tour was conducted on Unit A; census 21 patients. The supply closet with all the following bins empty: toothpaste, soap, lotion, deodorant, brush/comb, maxi pads and socks. 3 tampons and adult diapers were present.

During an interview on 11/04/2024 at 09:50 AM, Staff Y/ BHT stated the patients sit around a lot and just watch TV because there is nothing for them to do. The supply closet is never stocked so the patient's basic hygiene needs are not being met. If we call the person who is supposed to stock the closet, she will say supplies are in the patient's room but they are not in there. For example, the employee hired for stocking was supposed to stock the supply closet prior to leaving on Friday but she did not so we had to call family members and ask them to bring in feminine hygiene products since we didn't have any. We had many female patients that needed feminine hygiene products. The families were not happy we did not have the supplies to meet their basic needs.

During an interview on 11/04/2024 at 9:55 AM, Patient #4 stated "I don't like that the room doors are locked all day. You can't go in the room. It's locked from 7:00 [AM] to curfew [bedtime]. You're not allowed in your room except for hygiene. That's their policy. They are very short staffed. Water, tea and the phone are only accessible from a tech [a tech is a behavioral health assistant-BHT], so it's very difficult to get anything. It's very hard on her and us. You have to wait for a beverage. It may be a while, because there is only one tech. There is a locked bathroom in the TV room. The tech has to let you in. You can't close the door. You have to leave it cracked."

During an interview on 11/04/2024 at 10:16 AM, Staff T/BHT confirmed the patient rooms are locked during the day. There has to be an order for them to be in their room. If they are not feeling well and want to lie down, there are exceptions. "But from 8 AM to 5 or 6 PM the rooms are locked. We open them for hygiene care. They don't want to go to groups. They will stay in their room and sleep and then won't go to group. Then they will say we didn't wake them up for group.

During an interview on 11/04/024 at 10:22AM, Staff Z/RN stated the patient's basic hygiene needs are not being met because the supply closet is never stocked like it is supposed to. The patients do spend a lot of time sitting around watching TV because there not enough room for them to do activities like play cards, write, etc. They are not allowed to have markers or crayons due to the acuity.

During an interview on 11/04/2024 at 03:05 PM, Staff E/ Medical Director said "the room lockout is during groups. They told me I can override them and write an order for them to be allowed to go to their room. I do not expect them to be locked out all day and I do not expect to write an order to allow them to go in their room. They are detoxing. They have detox symptoms and medications for withdrawals that make them tired. They need rest."

During an interview on 11/05/2024 at 09:22 AM, Staff L, Nurse Manager confirmed the rooms on the detox unit (Unit B) are locked during the day. "The new schedule we are implementing in a couple of days will include nap times in the morning and afternoon. The rooms are locked for the patients' safety. We do allow for room access if the patient doesn't feel well. They are available in the morning and evening. We do not leave hygiene supplies in the patients' rooms for safety reasons. It is a detox unit, but we do have some suicide/homicide risk patients on that unit sometimes. We do allow for room access if the patient doesn't feel well. We had pitchers and cups out and the infection preventionist said that is an infection control issue. We moved it to the nurses' station and infection control said it can't be at the nurses' station either. She also stated anticholinergic (a group of medications used in psychiatric disorders that stop involuntary muscle movements and various bodily functions) side effects includes dry mouth. Beverages are in the kitchen and provided by the BHT upon request. I gave the last package of sanitary napkins to another unit yesterday. The product was not provided in the last order. She stated sanitary napkins should be available and they bought some this morning on the corporate credit card. Towels are stocked two times a day by environmental services. They are provided during hygiene times. They are available in the morning and evening.

During an interview on 11/06/2024 at 11:37 AM, the CEO (Chief Executive Officer) stated we do not differentiate in the population (mental health vs detox patients). The safety of the unit and the patient is the same for every unit. We can't determine fully the risks of detox patients. Many are here on a Marchman [detoxification order], which is the equivalent of a Baker Act. There are exceptions. If a patient is not feeling well and needs to lie down and rest they can. These are basic safety measures we are mandated to abide by. They need a doctor's order to be able to have access to their rooms. When they are not sleeping or performing hygiene, the rooms are locked. If they don't feel well the nurse needs to call the doctor and get some orders to care for them. Patients hide in bathrooms or isolate to their rooms. When they are not present or visible they may be difficult to locate for fifteen-minute checks. It also prevents acting out of sexual behaviors. The tech has to be able to see and hear the patient. They can't use the bathroom in the TV room and lock the door. "These are best practices and safety measures in psychiatry. The tech needs to have access to the bathroom. The patient has to keep the door cracked for their safety. The tech must have unrestricted access to the patient. The tech has to remain in the vicinity of the patient. There are two nurses and one tech on B unit for thirteen patients. That's a ratio of five to one. The nurses are responsible for the supervision of the patients. In fifteen minutes, anything can happen. The liability is great."

During an interview on 11/06/2024 at 12:15, the CEO stated 6-8 weeks ago, we changed the ways supplies are distributed. We found the quantity of supply items (shampoo, soap, toothpaste, etc) in the patient's room were becoming unsafe. So, we reorganized the system of stocking. We hired an employee to manage the supplies on the floor. The floors, maybe CNA's, did not like the re-organization. Every Friday there is a meeting held with all employees so they can ask questions and clarifying any confusion they may have. I cannot answer if the employees all comprehended what we told them, but I can say that we did tell them. We did communicate with the staff but they clearly are not understanding. I will have to re-evaluate the plan with the employee hired for stocking the units or come up with another plan for distribution. After the hurricane, our supplier was not able to restock properly, so we bought our own supplies to make sure the facility is fully stocked for the patients.

A review of the policy, Patient Rights and Responsibilities, last reviewed 7/23, revealed the following:
Policy: Patient Rights: These rights will adhere to Florida Statute 394 as established by the Baker Act. These rights shall include, but not be limited to, the patient's right to:
e. Considerate, dignified, and respectful care, provided in a safe environment, free from all forms of abuse, neglect, harassment and/or exploitation... ff. Reasonable continuity of care to include freedom of movement and fresh air (scheduled daily at least ½ hour daily unless clinically contraindicated.)... pp. The right to personal privacy and confidentiality includes at a minimum that patients have privacy during personal hygiene activities and when requested by the patient as appropriate.

A policy for room lock-outs was requested three times throughout the survey and was not provided.

A review of the Patient Handbook reflected "we discourage you isolating in your room while not in active programing."

Based on facility policy, facility documents, medical record review, and interviews, the facility failed to form an individual treatment plan in 4 (#10, #11, #12, and #13) out of 4 medical records reviewed on Unit M.

Findings included:

Review of the Policy and Procedure title, "Treatment Planning and Review", #0651.COMP.1018.004, review 12/2023, Policy- Every patient shall actively participate in treatment planning needs ...and have an individual comprehensive treatment plan ...A comprehensive interdisciplinary treatment plan is initiated upon the patient admission through the first 24 hours and is fully develop/ reviewed/ revised by the multidisciplinary treatment team within 72 hours ...Patient will be expected to participate in all, or a portion, of their team conference, including the planning and evaluation of their individual treatment plan. Treatment team takes place at least 3 times weekly on all units ...Care, Treatment or services for each patient is based on the treatment plan ...

Review of the Policy and procedure title, "Treatment planning", # 651.OP-029.001, reviewed 07/2024 ... Patient and families ...are involved in the treatment planning ...B. problems entered on the master problem list form the basis of the master treatment plan. Each discipline performing an assessment adds their findings to the problems in the master problem list ... Patients should sign the master treatment plan indicating their review and understanding.

Review of facility document titled Interdisciplinary Treatment Plan master sheets showed this treatment plan has been presented to/ reviewed with the patient and/or legal representative. The patient / legal representative have been given the opportunity to ask questions and make suggestions (By signing this, patient/ legal rep agrees that he/she has actively participated in treatment planning and agrees to the plan) area. The area for patient comments and patient signature with date and time.

Review of Patient #10's medical record revealed that patient was admitted on 10/29/2024 with diagnosis major depressive disorder. The initial treatment plan was started 10/29/2024 at 8:05 PM. Interdisciplinary Treatment Plan was not completed. The area for patient comments and patient signature with date and time was blank. There was no evidence that the patient participated in their treatment plan. The patient was discharged 11/04/2024 at 4:05 PM.

Review of Patient # 11's medical record revealed that patient was admitted on 10/31/2024 with diagnosis of major depressive disorder. The initial treatment plan started on 10/31/2024 at 22:35 PM. Interdisciplinary treatment plan master sheets not completed. The area for patient comments and patient signature with date and time was blank. There is no evidence that patient participated in their treatment plan. The patient discharged 11/05/2024 at 5:00 PM.

Review of Patient #12's medical record review revealed that the patient was admitted on 11/01/2024 with diagnosis major depressive disorder. The Interdisciplinary Treatment Plan revealed the patient signed on 11/04/2024 at 4:06 PM, which was one hour and 7 minutes before discharge from the facility.

Review of Patient #13 Medical record review revealed that the patient was admitted on 10/31/2024 with diagnosis major depressive disorder. The Interdisciplinary Treatment Plan revealed the patient signed on 11/05.2024 at 12:39 PM, which was one hour and forty-seven minutes before discharge from the facility.

During an interview on 11/05/2024 at 9:37 AM, Staff R/Therapist stated the treatment team meets every morning, and they will meet with the patient one to two days after admission. The patient signs the plan. If the patient refuses to sign, then the therapist would document that.

During an interview on 11/05/2024 at 3:02 PM, Staff M/ Nurse Manager reviewed Patient #12's care plan signed by the patient 1 hour and 7 minutes prior to discharge. He stated it should have been done earlier. The patient's signature means he/she is agreeing to actively participate in the treatment plan. Staff M reviewed Treatment Plan for Patient's #10, 11, and 13 and stated, "I can't tell you what happened, other than it was not done."