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Based on medical record review, policy review, observation, review of the facility's admission packet, and staff interview, the facility failed to ensure patients were informed whom to contact to file a grievance (A118). The facility failed to ensure patients had the right to participate in the development and implementation of their plan of care (A130). The facility failed to ensure patients were free from all forms of abuse or harassment (A145).

Based on observation, review of the facility's admission packet, and staff interview, the facility failed to ensure patients were informed whom to contact to file a grievance. The facility census was 48.

Findings include:

Tours were conducted on two of two inpatient psychiatric units on 05/24/22 at 2:57 PM. The facility posted patient rights and information on how to file a complaint and/or grievance in an enclosed bulletin board on each unit. The information posted lacked evidence of contact information on how to file a complaint with the State Agency.

Review of the patient admission packet included a resource list of various agencies contact information on how to file a complaint and/or grievance. The information provided lacked evidence of contact information on how to file a complaint with the State Agency.

Interviews were conducted with four patients at various times throughout the tour who reported being unaware of how to file a complaint with the State Agency.

Staff C confirmed the above findings on 05/24/22 at 4:12 PM.

Based on medical record review, staff interview, and policy review, the facility failed to ensure patients had the right to participate in the development and implementation of their plan of care for one of ten medical records reviewed (Patient #1). The facility census was 48.

Findings include:

Review of the policy and procedure titled, Interpreter, Language, and Communication Services, approved 09/2021, revealed in order to fulfill "Title VI of the Civil Rights Act of 1964" 45 CFR Part 80 and Section 504 of the Rehabilitation Act of 1973, the patient with a language, vision, or hearing barrier has a right to special arrangements designed to enhance communication and comfort. The procedure states patients with a language, vision, or hearing barriers who present for treatment shall be asked during the admission process what special arrangements will meet their communication and comfort needs.

Review of the medical record for Patient #1 revealed an involuntarily admission to the psychiatric facility on 05/13/22 at 4:45 AM with diagnoses to include bipolar disorder and legally blind. The vulnerability risk assessment noted the patient to be visually impaired with no peripheral vision. The admission assessment noted interventions to include assisting with ambulation and educating to call for assistance. Review of the master interdisciplinary treatment plan noted the legal blindness was deferred with no interventions in place. The medical record also lacked evidence the patient was asked during the admission process what special arrangements would meet her communication and comfort needs.

Staff C stated in an interview on 06/01/22 at 3:23 PM the facility is not required to include interventions since it had been deferred on the treatment plan.

Based on medical record review, staff interview, and policy review, the facility failed to ensure patients were free from all forms of abuse or harassment for three of ten medical records reviewed (Patient #3, #4, and #5). The facility census was 48.

Findings include:

1) Review of the policy and procedure titled, Patient Rights and Responsibilities, approved 08/21, revealed patients have a right to reasonable protection from physical, sexual, emotional abuse or harassment. Suspicions must be reported to the Chief Executive Office or designee immediately.

Review of the policy and procedure titled, Incident Reporting, last revised 08/21, revealed the supervisor or person in charge of the patient area is immediately notified. Any employee or medical staff member may complete an Incident Report (IR). A shortcut to the Online Tool is located on the desktop of all Haven Computers. The online form should be fully completed no later than the end of the shift that the event occurred.

Review the incident report log revealed on 05/16/22 an incident of staff to patient physical abuse. Review of an incident report dated 05/16/22 at 1:30 PM revealed a behavioral health technician witnessed another behavioral health technician hitting Patient #3 in the arm and trying to tie a mask on his face.

An interview was conducted with Staff B on 05/23/22 at 12:53 PM who reported that on 05/17/22 Staff I reported witnessing Staff M strike Patient #3 while providing care on 05/16/22. The facility immediately began investigating the alleged staff to patient abuse and found that Behavioral Health Technician #3 had witnessed the incident as well. The facility interviewed Staff M on 05/17/22 at 3:40 PM who reported the patient struck her in the head and she attempted to grab his wrists but never hit him. A timeline of events and witness statements was provided on 05/23/22 regarding the alleged incident and internal investigation findings. Furthermore, Staff M was immediately placed on administrative leave pending the investigation and was terminated at the conclusion of the investigation with local law enforcement notified.

Review of the undated written statement by Staff I revealed while doing rounds on 05/16/22 she observed Staff J and M needing assistance with Patient #3. Both techs were noted to be holding the patient's hands so that he could not hit the techs. Staff I observed Staff M swing the patient to the floor with the patient falling to the ground. Staff M then left the room and returned with a face mask and attempted to tie the mask to the patient's face due to the patient spitting. The face mask broke and a face shield was applied. The patient began hitting Staff M on the leg and Staff M then began hitting the patient really hard in the arm. She was advised she could not do that to patients. Staff I and J got the patient up off the floor and walked him to the bed and Staff M then pushed the patient on to the bed and left the room.

Review of the witness statement documented by Staff J revealed Staff M requested assistance while providing personal care to Patient #3 as he was soaked in urine. While changing the patient he became combative and punched Staff M in the head from a standing position. Staff M and J were noted to be holding the patient's arms to avoid him striking staff, he continued to hit/spit and tumbled to the floor. Staff J reported the other two techs proceeded to change the patient and she had her back turned while cleaning the bed with sanitizer wipes. The patient continued to be combative and spitting and Staff M asked the techs to remove their face masks being worn and when told no, she left the room and returned with a face mask and attempted to cover the patient's face. She reported the techs got a depend on the patient and when attempting to stand him from the floor he struck Staff M in the leg and Staff M then began hitting him several times in the body. The techs yelled at Staff M telling her to stop, which she did, and she exited the room after the patient was placed in bed.

An interview was conducted with Staff E on 05/24/22 at 11:06 AM who reported not witnessing the incident involving Patient #3 however was asked to assess the patient the following day when the incident was reported. Staff E was advised a behavioral health technician had physically abused the patient the prior day. Upon assessment he did not see any visual injuries and the patient reported being fine. This patient did have a history of being aggressive and assaultive however it was never acceptable for a staff member to strike a patient.

An interview was conducted with Staff D on 05/24/22 at 12:53 PM who reported Staff M was immediately placed on administrative leave on 05/17/22 pending the investigation of abuse. Following the investigation the facility terminated the employee effective 05/20/22. Review of the employee file revealed a termination date of 05/20/22 due to misconduct/performance. Staff M was not eligible for rehire due to the incident that occurred on 05/17/22.

An interview was conducted with Staff I on 05/25/22 at 10:47 AM who reported doing rounds and observed Staff J and M providing personal care to Patient #3 who was being combative. Staff I saw one tech leave the room to get supplies so she went in to assist the other tech provide personal care. Staff I witnessed Staff M grab Patient #3 making him fall to the floor and attempted to tie a face mask to the patient's face due to spitting. While the patient was on the floor he began hitting Staff M in the legs and she started slapping the patient in the arm with a closed fist. When they got the patient up off the floor to put him in the bed Staff M pushed the patient on to the bed and left the room. Staff I stated she had never witnessed staff abuse a patient and felt this was terrible and could not sleep that night and decided to report it the next day. The facility conducted an investigation and the tech was terminated.

An interview was conducted with Staff J on 05/25/22 at 11:48 AM who reported Staff M requested assistance providing personal care for Patient #3 as the patient was kicking, hitting, and spitting. Staff J witnessed the patient hit Staff M and she did not see her hit him at that time. Staff J had her back turned and was cleaning the patient's bed and she heard Staff M striking the patient. She turned around quickly and witnessed her hitting him in the upper body while he was on the floor. She was unsure if Staff M was striking the patient with an open or closed fist. Staff J and Staff I told Staff M to stop and she did and exited the room. Staff J provided a written statement of the incident the following day when requested by management.

The staff failed to notify appropriate staff immediately and complete the incident report by the end of shift as required by policy.

2) Review of the policy titled, Levels of Observation and Special Precautions, last revised 04/20, revealed the hospital is to maintain safety and provide quality care to patients while maintaining their dignity and respect. All patients automatically receive fifteen minute observations for the duration of their hospital stay. The nurse may increase the patient's observation level if the patient's condition changes. The physician may order one of four levels of observation at time of assessment, and change the level of observation based on the patient's condition at any time during the course of treatment. The special precaution levels include every five minutes, line of sight, and one to one observation.

Review of complaint filed by Patient #4 on 03/18/22 revealed on 03/17/22 she woke up and found Patient #6 lying in her bed. The patient reported telling him to get out and the patient verbalized he would be back when the coast was clear. The patient reported she did not feel threatened by the patient but found it concerning and felt the facility should be aware. Further review of the complaint log revealed on 03/18/22 Patient #5 reported Patient #6 came into her room on 03/13/22 and fondled her breast.

Review of the medical record revealed Patient #6 was involuntarily admitted to the psychiatric facility on 03/12/22 at 4:45 PM. On 03/12/22 at 5:15 PM it was documented the patient was being sexually inappropriate with himself. On 03/13/22 at 11:18 AM the patient was observed to be sexually inappropriate and reported to the charge nurse he was going into female patient rooms. On 03/15/22 at 2:25 PM staff noted the patient was observed masturbating. On 03/16/22 at 11:30 AM the physican noted the patient as sexually preoccupied with select female patients' rooms. On 03/17/22 at 9:33 AM the physican noted several female patients accused the patient of sexual harassment and attempting to fondle their breasts.

Review of the nursing documentation and observation sheets revealed Patient #6 remained on the standard fifteen minute safety checks with no increased level of observation. On 03/18/22 the facility notified local law enforcement after Patient #5 reported wanting to file charges for being sexually assaulted. Review of a police report dated 03/18/22 at 1:00 PM revealed the patient was taken into police custody and transferred to the county jail for a misdemeanor charge of sexual assault imposition.

Staff C confirmed in an interview on 05/25/22 at 3:23 PM the patient's level of observation should have been increased for more frequent monitoring as per policy.

This deficiency substantiates Substantial Allegation OH00132868 and OH00132794.

Based on review of QSO Memo 22-09-ALL Revised Attachment D, review of facility COVID-19 vaccination records, staff interview, and policy review, the facility failed to ensure a contingency plan and/or procedures were in place for unvaccinated staff for 14 of 101 staff members. The facility census was 48.

Findings include:

Review of QSO Memo 22-09-ALL Revised Attachment D, dated 01/14/22 and revised 04/05/22, revealed the facility's policies and procedures must include, at a minimum, a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19.

Review of the policy titled, Influenza And Covid-19 Vaccine Policy, approved 03/22, revealed no contingency plan for unvaccinated staff while working and/or providing direct care at the facility.

Review of the vaccine tracking log identified 14 unvaccinated staff members with either a religious or medical exemption. The staff members identified included six Behavioral Health Technicians, one Activity and Recreation Specialist, three Registered Nurses, one Licensed Practical Nurse, one Intake Specialist, one Nurse Manager, and one Activities Therapist Assistant.

These findings were confirmed with Staff C in an interview on 05/23/22 at 11:09 AM.