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Based on review of policy and procedure, interview, and written grievances, it was could not be determined the patient was informed of the resolution of a grievance in writing to include the hospital contact person, the steps taken on behalf of the patient and the results and the date of completion of the grievance. Failure to provide the resolution of a grievance in writing does not allow for recognition, closure, tracking or trending of issues related to real or perceived poor patient care. Findings follow:

A. Review of 12 of 12 written grievances revealed no evidence of who conducted the investigation, no report of the investigation to include how it was investigated, who was involved in the investigation and the results of the investigation.

B. There was no evidence the patient was informed in writing about the results of the investigation of a grievance.

C. Review of the policy and procedure titled Complaint/Grievance Policy revealed the following:

Definitions:
Staff Present-will include any hospital staff member who is immediately available to take care of the patient's complaint.

Complaint-an issue brought up verbally to a member of hospital staff by a patient that can be resolved by that staff during their shift. a. If staff is available to take care of the issue the complaint will not be considered a grievance.

Grievance -the issue becomes a grievance:
a. If the concern cannot be resolved by the staff person receiving the complaint.
b. Is postponed for later resolution
c. Is referred to another staff member for later resolution
d. Requires investigation, and /or further actions to resolve the concern
e. ...h.
i. All verbal and written complaints regarding a violation of patient rights such as: abuse, neglect patient harm or hospital compliance with CMS or other licensing Agency requirement are to be considered a grievance ...

Requirements for Responding to Patient Grievances-Once the investigation has been completed the Patient Advocate will prepare a letter to the person making the complaint outlining: a. Letters shall at a minimum: Be typed on hospital letterhead stationary. Contain the name of the Patient Advocate as the contact person. The steps taken to address the patient's concerns. The result of the investigation and subsequent actions.

D. Interview with the Director of Nursing and the Patient Advocate on 03-04-16 at 1330 revealed no documentation of the investigation of the grievances.

Based on clinical record review, review of facility policies and procedures, and interview with Facility staff, it was determined the Facility failed to ensure clients were made aware of their health status in 1 (#5 ) of 2 (#1 and #5) clinical records reviewed where patient's were placed on a 72 hour hold.. This failed practice prevented the patient from understanding his status or being involved in his treatment.

Findings follow:

1. Review of clinical record #5, revealed a patient that was admitted on 02/08/16 with a problem of depression. Review of the record revealed the following:

A. A document titled "Physician Order Form" and dated 02/11/16 revealed a Physician's order that stated "Place patient on 72 hour hold". There was no evidence in the clinical record to indicate the Patient had been aware that he was placed on a hold.

B. Review of a document titled, "Nursing Daily Flow Sheet and Assessment" revealed the Nurse documented ..."Pt [Patient] depressed and irritable. Pt frequently requesting pain medications, states "I need my Percocet". Pt intrusive, demanding and inconsiderate of others at times. Pt has poor impulse control and poor coping skills. Encouraged participation in tx [treatment] plan. Pt remains depressed, irritable, intrusive and impulsive. Continue to monitor for safety."

1) There was no mention in the nursing note of the client being placed on a 72 hour hold.

2) There was no mention of the 72 hour hold in any of the additional nursing notes.


2. Review of the Facility's Policy and Procedure titled, "72 Hour Hold" under sub-title "Voluntary Admissions" stated: ..."The attending physician will write an order for 72-hour fold and the Involuntary Commitment Procedures set forth herein will be initiated. The patient must be provided with a written statement advising him/her of their rights within one hour of detention. If the patient refuses to sign a written acknowledgement of his/her rights, that refusal must be noted in the patient's chart and the refusal must be attested by two eyewitnesses on a separate document."

A. There was no evidence in the clinical record the Involuntary Commitment Procedures were . initiated.

B. There was no evidence a written acknowledgement was presented to the Patient or that hospital staff signed an acknowledgement if the Patient refused.


3. On 03/03/16 the assistant to the CNO [Chief Nursing Officer] and on 03/04/16 the CNO reviewed the patient's record and found the same findings as above. Neither employee could explain why the patient was placed on a 72 hour hold or why there was no documentation in the clinical record regarding that situation.

Based on clinical record review and interview it was determined the Facility failed to provide care in a safe setting. Patient #6 was transferred to another Facility. Although the patient was not in the Facility staff continued to document every 15 minute checks that Patient #6 was in her room sleeping. This failed practice was likely to affect all patients on the Adult Unit in that staff did not know where patients were located.

Findings:
A. Review of the clinical record for Patient #6 revealed Patient #6 was admitted 02-13-16. Admission Orders dated 02-13-16-Monitoring Level II (Q [every] 15 minutes).

Adult Aftercare Plan & Instructions dated 02-16-16 at 1615-Transfer to (Named) Memorial due to medical issues. Nursing Daily Flow Sheet & Assessment page 2-02-16-16 at 1955- Patient left Unit on (Named Ambulance) to transfer to (Named) Memorial Hospital ER (Emergency Room) for medical clearance and treatment ...Discharge Summary-Date Discharged 02-16-16-Course of Hospitalization- ...Patient discharged from Rivendell due to admission to (Named) Memorial Hospital for treatment ...

B. Review of the Patient Observation Record revealed although Patient #6 was not in the Facility Q 15 minute checks for Behavior and Location continued to be done from 2215 till 2345 (1 hour and 15 minutes) which reflected Patient #6 was Sleeping (S) in Patient Room (R).

Based on documentation, observation and interview, it was determined the Facility failed to ensure that patient's were free from harassment, in that, patient's were refused the opportunity to smoke without first attending patient groups. This failed practice prevented the consistency of on-going care without torment or worry to the patient.

Findings:
A. On 03/03/16, at 1400, a tour of the Adult Unit was conducted with the CNO (Chief Nuring Officer) and the Clinical Director. During the tour, a staff member was overheard telling a patient to come out of their room and attend group, "If you don't go to group, you will not be allowed to smoke at the next smoke break and maybe not the one after that either."

B. The CNO was questioned in regards to the staff patient encounter and stated, "I didn't really hear the conversation." The Surveyor further clarified and stated, "So if the patient's do not attend groups they are not allowed to smoke?" The CNO responded with "Sometimes."

C. A document titled, "Medical Admission Orders/Initial Plan of Care for Adult Unit" sub-title "Activity Level" (page 1 of 3) revealed a Physician order that stated, ..."Patient allowed to smoke unless otherwise specified"...
There was no additional follow-up order stating the patient had to attend groups prior to following the Physician's order to smoke.