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Based on interview and document review the facility failed to log all complaints and grievances of patients receiving psychiatric care at the facility resulting in denying the right of all psychiatric patients to file a complaint or grievance. Please see A-0118.

Based on interview and document review the facility failed to log all complaints and grievances of patients receiving psychiatric care at the facility resulting in denying the right of all psychiatric patients to file a complaint or grievance. Findings include:

On 6/15/2021 at 0930 an interview with Staff K, the Director of the Psychiatric units and Staff L, the Manager of the Psychiatric units took place. Staff K and Staff L were queried about complaints received regarding food services. Staff K and Staff L stated that patients had complained about the quality and choices of food served on the psychiatric units. Staff K and Staff L were asked if they could provide a log of patient complaints received pertaining to food. Staff L stated that complaints were logged by the Recipient Rights Officer. The Recipient Rights Officer was on vacation at the time of survey and the Recipient Rights log contained only one complaint logged in regard to food services. Staff L stated that they had received more than one complaint, but complaints were only handled through Recipient Rights.

On 6/16/2021 at 0930 an interview was conducted with Staff MM, the Patient Experience Administrator. Staff MM was queried about the logging of complaints and grievances for patients in the APU and GPU units. Staff MM stated that all complaints and grievances were handled by the Recipient Rights Officer and were not logged by the Patient Experience Department. Document review of the posting in both psychiatric units failed to include the Department of Patient Experience contact information. Staff MM was asked what the timeline was for response to a complaint or grievance received from a patient on the psychiatric units. Staff MM stated that because all complaints and grievances were allowed a 90-day response limit as outlined in the Mental Health Code. When asked about the Centers for Medicare and Medicaid Services (CMS) regulation regarding a process for prompt resolution and timely response to patients Staff MM stated that was not the procedure for the psychiatric department.

On 6/16/2021 at 1045 a document review occurred of the policy titled, "Grievance and Complaint Management," dated 3/5/2021. According to the policy under the subsection titled, "Concerns with Behavioral Health," it states, "In the event that a grievance or complaint is received from patients treated for psychiatric services on the Behavioral Health Unit, the Patient Experience Department will notify the hospital's appointed Recipient Rights Officer to initiate and manage the investigation process and complete the appropriate documentation."

Based upon observation, record review, and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:

A-0701 - Failed to maintain adequate physical facilities

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based on observation and interview the facility failed to maintain a physical environment resulting in the potential for unsafe conditions for all psychiatric patients. Findings include:

On 6/14/2021 at 1000 a tour of the adult psychiatric unit (APU) occurred.

On 6/14/2021 at 1020 the clean utility/linen room was observed to have a floor with no finish and exposed concrete with an uncleanable surface.

On 6/14/2021 at 1025 the pantry area was observed to have multiple areas of unpainted torn drywall located around the countertops and liquid dispensers.

Further tour of the APU unit reveal torn lifted drywall around the patient phones on 6/14/2021 at 1040. Observation of the exam room on the APU unit on 6/14/2021 at 1042 revealed a rust underneath the sink area with an uncleanable surface.

On 6/14/2021 at 1055 a tour of the Gero Psychiatric Unit (GPU) unit was conducted. On 6/14/2021 at 1110 during the tour of the GPU pantry area the refrigerator seal on the refrigerated section door contained a black substance that lined the top of the seal. On the bottom of the door the seal was broken and hanging down.

On 6/14/2021 at 1113 during the tour of the GPU pantry area torn drywall along the backsplash with one area having foam tape holding the torn drywall was observed.

The above findings were confirmed at the time of observation by Staff L.

Based upon observation, interview and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated June 15, 2021.
Building 1
K-0222
K-0321
K-0341
K-0351
K-0353
K-0362
K-0711
K-0920

Building 2
K-0351
K-0372

Based on observation and interview the facility failed to maintain a clean and sanitary environment resulting in the potential for less than optimal patient outcomes for all psychiatric patients. Findings Include:

On 6/14/2021 at 1000 a tour of the adult psychiatric unit (APU) occurred with accompanying Staff L. A tour of patient rooms occurred. Patient room #1 was found to have debris located under the mattress. Staff L was asked when a patient leaves a room if the bed was removed from the base and surface areas were wiped down and disinfected. Staff L stated, " Yes. Environmental Services removes the mattress and disinfect the mattress and the bed base. " Further observation of the room revealed two sets of socks located on the open top shelf of the patient shelving. Staff L was asked if the socks were clean or dirty. Staff L stated, " I ' m not sure. We will place these in the laundry. " The floor in patient room #1 was found to have dirty areas. Staff L was queried if she thought the floor was clean. Staff L agreed the floor was dirty in some areas and needed to be cleaned.

On 6/14/2021 at 1010 while on tour of the adult psychiatric unit a bundle of dirty bed linen was located in the common hallway. Staff L was queried if dirty bed linen was to be put in the common hallway. Staff L responded, " the patient was being discharged and probably was stripping the bed trying to help, but no dirty linen should not be in the hallway. "

On 6/14/2021 at 1020 the clean utility/linen room was observed to have a dirty floor.

On 6/14/2021 at 1025 the top of the refrigerator in the pantry was observed to have dust and debris.

On 6/14/2021 at 1030 the common room area / dining room area was found to have dust located along the chair railing. Staff L was queried if Environment Services (EVS) dusted these areas. Staff L stated, " Yes, they should be dusting. "

Observation of the exam room on the APU unit on 6/14/2021 at 1042 revealed a dirty used glove located underneath the enclosed sink area, torn wrinkled patient exam paper located on the exam table, and a breast pump with visible soil on the top of the breast pump machine. On 6/14/2021 at 1055 a tour of the Gero Psychiatric Unit (GPU) unit was conducted. During the tour of the GPU unit, it was revealed a weighted blanket partially covered by a trash bag was located in a dirty storage area. Staff L was queried if the blanket should be in the storage area. Staff L responded, " No. I do not know who would have placed it in this area. "