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Based on review of grievances, staff interview, and policy review the facility failed to ensure all grievances were provided a prompt resolution. The facility census was 10.

Findings include:

Review of the facility policy titled,"Client Complaint and Grievance Procedures," effective 01/15/18, revealed the Client Advocate/designee will conduct an internal investigation and render an initial determination, including the client, physician, nursing staff, or the therapist in the resolution. The Client Advocate/designee provides the grievant a formal, written response within twenty days of the date the formal grievance is initiated. The Client Advocate will file this grievance in the client grievance log. The data from this log will be collected monthly by the performance improvement designee. Complaints and grievances are reported in the performance improvement committee on a monthly basis.

A request was made for all complaints and/or grievances. The surveyor was provided manila folders separated by month. There was a written grievance filed on 03/19/21 with regard to services provided by a Treatment Assistant (TA). A second grievance was identified that was dated 07/08/21 in which a patient provided written notification to the facility a patient was making inappropriate comments to four woman on the unit and she wanted him removed from the facility as soon as possible because he was "gross" and this behavior was unacceptable.

Review of both grievances revealed no documented resolution to the patients as per policy.

An interview was conducted with Staff B on 05/09/23 at 12:50 PM who confirmed the facility had not been maintaining a complaint/grievance log. Staff B stated this was partially her fault. She had been busy with other tasks/assignments and did not train the responsible staff member on how to correctly document and track complaints/grievances in the system.

This deficiency represents non-compliance investigated under Substantial Allegation OH00141850.

Based on staff interview, policy review, and review of incident reports, the facility failed to measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital service and operations. The active census was 10.

Findings include:

Review of the facility policy titled, "Incident Reporting," effective 2018, revealed an incident is defined as any occurrence that is not consistent with the normal or usual operation of the hospital or department. When an incident occurs, and incident report shall be completed immediately by the person observing or involved with the incident or by one who is directly aware of the incident. All incident reports will be entered into the risk management data for trending, analysis, and generating monthly reports for review by the performance improvement team. The Risk Manager/designee shall enter the incident report into the data base at least weekly.

On 05/09/23 a request was made for all hospital wide incident reports. The surveyor was provided with manila folders for each month an incident report was documented. Further, a request was made for the incident report log to ensure all incidents were being entered into a data base at least weekly for monthly trending and analysis by the performance improvement team. The facility was unable to provide the incident report log upon request.

An interview was conducted with Staff B on 05/09/23 at 12:50 PM who confirmed the facility had not been maintaining an incident report log or generating a monthly report.