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Based on record review and interview the hospital failed to ensure effective implementation of the grievance process as evidenced by failing to initiate the grievance process once a family member brought forward their concerns about their family member being overly sedated and lethargic for 1 out 6 sample patients (Patient #3) reviewed for the effectiveness of the grievance process. Findings:

Review of the Grievance Log for the last three months revealed no grievances reported or investigated for Patient #3.

An interview was conducted with S1Corporate Administrator on 3/20/12 at 2:30 p.m. She reported she had spoken to the daughter of Patient #3 for a long time one day about the daughter's concerns about her mother being over sedated and lethargic the day before. But when S1 went to look at Patient #3 she was very alert. She then brought the daughter to see her mother, to show her how alert she was at the time. The daughter seemed relieved and S1 stated she didn't consider it a grievance and she did not investigate the grievance, and she didn't write the incident up as a grievance. She also stated she never sent written notification to the family since she didn't consider it a grievance.

Review of a hospital policy titled "Rights - Grievance Procedure", policy number RTS-04, with a date of August 2011 without indication of whether this was an adopted or revised date, presented as current policy, reads in part: "Policy...To differentiate: A grievance is defined as an allegation of a violation of a patient's rights, discrimination, abuse/neglect, sexual misconduct, or unethical practices. A complaint is: An expression of dissatisfaction, however made, about the standard of service, actions or lack of action by staff or regarding the facility. The policy and procedure for resolving complaints is outlined in RTS-04a. Purpose: To provide an internal process for addressing allegations from patients (and/or family members) regarding grievances, patient rights violations, and/or ethical issues. To provide an internal process by which allegations of discrimination against handicapped persons can be investigated for validity by facility personnel. Procedure:..Patient: Depending on the nature and severity of the complaint, a decision will be made at this point by the therapist/nurse to classify the complaint as a complaint or grievance as outline by the following definition: A grievance alleges a violation of a patient's rights, discrimination, abuse/neglect, sexual misconduct, or unethical practices. A complaint is: An expression of dissatisfaction, however made, about the standard of service, actions or lack of actions by staff or regarding facility. If the complaint is classified as a complaint as identified by the definition above, the procedure for resolving complaints is outlined in RTS-04a. If the issue is considered a grievance as defined by the definition above and the therapist/nurse is unable to resolve issue, will forward to the appropriate department supervisor as soon as feasible.

Based on record review and interview the hospital failed to complete written documentation of a grievance and failed to follow their policy related to written response time to a patient's grievance as evidenced by no grievance form being filled out and no response to the grievance for 1 out of 6 sample patients (Patient #3) reviewed for the effectiveness of the grievance process. Findings:

Review of the Grievance Log for the last three months revealed no grievances reported or investigated for Patient #3.

An interview was conducted with S1Corporate Administrator on 3/20/12 at 2:30 p.m. She reported she had spoken to the daughter of Patient #3 for a long time one day about the daughter's concerns about her mother being over sedated and lethargic the day before. But when S1 went to look at Patient #3 she was very alert. She then brought the daughter to see her mother, to show her how alert her mother was at the time. The daughter seemed relieved and S1 stated she didn't consider it a grievance and she did not investigate the grievance, and she didn't write the incident up as a grievance. She also stated she never sent written notification to the family since she didn't consider it a grievance.

Review of a hospital policy titled "Rights - Grievance Procedure", policy number RTS-04, with a date of August 2011 without indication of whether this was an adopted or revised date, presented as current policy, reads in part: "Policy...To differentiate: A grievance is defined as an allegation of a violation of a patient's rights, discrimination, abuse/neglect, sexual misconduct, or unethical practices. A complaint is: An expression of dissatisfaction, however made, about the standard of service, actions or lack of action by staff or regarding the facility. The policy and procedure for resolving complaints is outlined in RTS-04a. Purpose: To provide an internal process for addressing allegations from patients (and/or family members) regarding grievances, patient rights violations, and/or ethical issues. To provide an internal process by which allegations of discrimination against handicapped persons can be investigated for validity by facility personnel. Procedure:..Patient: Depending on the nature and severity of the complaint, a decision will be made at this point by the therapist/nurse to classify the complaint as a complaint or grievance as outline by the following definition: A grievance alleges a violation of a patient's rights, discrimination, abuse/neglect, sexual misconduct, or unethical practices. A complaint is: An expression of dissatisfaction, however made, about the standard of service, actions or lack of actions by staff or regarding facility. If the complaint is classified as a complaint as identified by the definition above, the procedure for resolving complaints is outlined in RTS-04a. If the issue is considered a grievance as defined by the definition above and the therapist/nurse is unable to resolve issue, will forward to the appropriate department supervisor as soon as feasible...Department Supervisor:..Resolves or investigates validity of the grievance within 48 hours of receipt of the grievance. Issues a written decision within 72 hours of the hearing regarding the validity of the grievance and any corrective actions taken, if necessary. If no resolution occurs at this level, the grievance may be filed with the Administrator who in turn may opt to charge resolution of the grievance to the 504 coordinator, PI (performance Improvement) Committee, or surface same at governing board meeting ...Patient/Family Grievance Procedure. A Patient or family may bring a complaint to the morning nursing group for discussion and resolution. To differentiate: A grievance is defined as an allegation of a violation of a patient's rights, discrimination, abuse/neglect, sexual misconduct, or unethical practices. A complaint is: An expression of dissatisfaction, however made, about the standard of service, actions or lack of action by staff or regarding the facility...Depending on the nature and severity of the complaint, a decision will be made at this point by the therapist/nurse to classify the complaint as a complaint or grievance as outline by the following definition: A grievance alleges a violation of a patient's rights, discrimination, abuse/neglect, sexual misconduct, or unethical practices. A complaint is: An expression of dissatisfaction, however made, about the standard of service, actions or lack of actions by staff or regarding facility."

Based on record review and interview the hospital failed to notify a physician of a patient's change in medical condition as evidenced by failing to notify the physician of a patient's change in mental and ambulatory status once the change was assessed for 1 out 6 sample patients (Patient #3). Findings:

Patient #3 was a 92 year old white female with a history of dementia who was admitted from a nursing home to Oceans Behavioral Hospital on 1/25/12 and was discharged to the family on 02/08/12. The nursing home stated she was wandering in and out of other patients' rooms. She was delusional and disorientated and kept looking for small children. She required constant redirection. The nursing home reported she scratched another patient during an argument, when she thought that another patient was her husband and another female patient was trying to take her "husband" from her. Patient #3 had been widowed for a number of years. Patient #3's daughter wanted her admitted to the hospital to have her medications reevaluated.

Review of the Nursing Psychiatric Assessment dated 2/6/12 at 2000 (8 p.m.) revealed Patient #3 was orientated to person with guarded affect and neurologically she was alert.

Review of the Nursing Psychiatric Assessment dated 2/7/12 at 11:20 a .m. revealed she was orientated to person and place, neurologically she was unimpaired with unsteady gait and nutrition and fluids were adequate. The narrative part of the assessment stated the following, "Pt AA (awake and alert) sitting in grp rm (group room) with other residents, calm, cooperative follows verbal command appropriately, can be demanding at xs (times) denies thoughts of harm to self or others. Denies being fearful, Pt in no acute distress. Continue POC (Plan of Care) and provide safe therapeutic environment. Ate 100% breakfast." The assessment was signed by S5RN.

An interview was conducted with S5RN on 3/20/12 at 12:30 p.m. She stated she took care of the patient on the 7a.m. to 7 p.m. shift on 2/7/12. She reported that the patient could not stand up or use her rolling walker like she had the last time she saw her. She went on to report the patient kept saying she was tired. She didn't go to breakfast and didn't eat breakfast, lunch or dinner that day. Patient #3 had to be pushed in a wheelchair. At this point, she was unable to ambulate in her rolling walker. When the daughter came to visit that evening during the 4 to 5 p.m. visiting hours, the daughter was upset and teary eyed with the change in her mother's mental and ambulatory status. The patient was in the dining room probably sitting in a wheelchair, stated S5RN. The daughter and S5RN discussed the change in Patient #3's mental status and S5RN felt it was the medication. She spoke to the doctor and he held the afternoon Haldol dose. When the daughter came into the hospital "b" on 02/08/12 she wanted her mother transferred immediately to hospital "a".

Another interview was conducted with S5RN on 03/21/12 at 10:50 a.m. Review of her written assessment of Patient #3 on 2/7/12 revealed no documentation of Patient #3's change in condition. There wasn't any documentation of the patient being lethargic and not wanting to get out of bed. S5RN said she should have reported this to the doctor at breakfast when Patient #3 was unable to walk with her walker. S5RN stated that she didn't discuss the change in her condition until the daughter came to visit and the daughter recognized the change in Patient #3's condition also. With review of the medical chart for Patient #3, S5RN stated there was no other documentation in the medical record where she documented the change in the patient's condition.

Review of the Close Observation Check Sheet dated 2/7/12 revealed the patient was in her room sleeping from 7:30 a.m. until 1 p.m. At 11 a.m. and 1:45 p.m. she was incontinent. At 2 p.m. she was documented as being in the dayroom until 3:45 p.m. From 4 p.m. to 6 p.m. she was documented as being in the dining room. The MHT (Mental Health Tech) assigned to Patient #3 at this time was S10MHT..

An interview was conducted on 3/21/12 at 1 p.m. with S10MHT. She stated she was the MHT that was assigned to Patient #3 on 2/7/12 on the 7a.m to 7 p.m. shift. S10 reported Patient #3 was in bed that morning and refused to get up. S10 stated she reported it to the nurse, but didn't remember which nurse she reported the information to. The patient didn't go to breakfast and she refused to eat. When she took her to the bathroom she was very unsteady on her feet and this was new for her because she was walking with her walker on admission to the hospital. S10 stated she put Patient #3 back in bed at her request. S10MHT said she held her lunch and warmed it up later and she ate some of it. She then sat in the dayroom after group and nodded off to sleep on the couch. She further stated she pushed Patient #3 in her rolling walker because she couldn't walk with her walker at this time. S10MHT went on to state the walker had a seat on it and she pushed the patient around while she sat on the walker. She stated she reported the change in the Patient #3 to S5RN.

Review of the Graphics/Vital Sign Flow Sheet revealed on 02/06/12 revealed she consumed 100% of breakfast, lunch, and dinner. On 2/7/12 she did not consumed any breakfast, lunch, or dinner (0%).Further review of the Graphic/Vital Sign Flow Sheet revealed she consumed 75% to 100% of most of her meals since admission.

Review of a hospital policy titled "Nursing Documentation", policy number NSG-02, adopted March 2006, last revised June 2011, presented as current hospital policy, revealed in part: "Policy: Nursing service personnel document on the daily nurse's notes and in the integrated progress notes...Purpose: To maintain a comprehensive and chronologically continuous account of treatment delivered to a patient by nursing staff. To provide specific information regarding medications, treatments, and observations which reflect the care and progress of the patient. To increase communication among the various disciplines providing care to the patient. To provide concise and comprehensive information as part of a legal document...Procedure:..Documentation: Inpatient: RN (Registered Nurse/LPN (Licensed Practical Nurse) documents on the daily nurse's note a minimum of once per shift or at the time any pertinent event occurs (may utilize integrated progress notes if additional space is needed)...Documents pertinent, factual information, including assessment, education and outcome...BIRP (Behavior/Observed; Intervention; Response; Plan)...Behavior/Observed - Document the behavior seen related to the patient's condition and symptoms identified on the treatment plan. Intervention: What the staff member actually did for the patient in relation to the treatment plan. Response: The charting should relate to steps being completed to improve patient's condition or situation. Capabilities and limitations are addressed..."

Review of a hospital policy titled "Early Response Intervention to Deteriorating Patient Condition", policy number TX-SPEC-11, dated August 2011 without indication of whether this is adopted or revised date, reads in part: "Policy: It is the policy of the facility to improve recognition and response to changes in a patient condition. This facility identifies unexpected acute illnesses which pose life threatening situations for our patients which could benefit. This facility identifies (1) for situations in which an individual's psychological health is degrading and they are becoming a threat to themselves or others. (2) respiratory/cardiopulmonary arrest and (3), response, to abnormal changes/fluctuation in a patients status: I (intake) & O (output), CBG (capillary blood glucose) levels and Vital Signs. As required by CFR (Code of Federal Regulations) 482.23b, an RN is immediately available as needed to provide bed side care to any patient and that RN is also qualified, through a combination of education, licensure and training to conduct an assessment that enables the RN to recognize the fact that the patient may need emergency care. It is the policy that an MD (Medical Doctor)/ DO (doctor of Osteopathy) (on site or on call) may directly provide appraisals of emergency, provide medical direction/oversight of onsite staff conducting appraisals or provide initial treatment directly...III. Early Intervention plan/criteria calling additional response/assistance/assessment early recognition and response to early recognition of abnormal changes/fluctuates in a patients status which could be high risk indicators:..B. Early warning signs: Input/Output status (I&O sheet): A patient food/water intake is reduced 50% in a 24 hour period, A patient has a weight loss of 2 lb. (pounds) or greater, A patient has had no bowel movement in 3 days, A patient has diarrhea for more than a 24 hour period ...Early Intervention Plan (B&C): Should a patient be experiencing any of the aforementioned status changes: MHT's (mental health technicians) will notify nurse who will in turn notify the medical physician on site or on call. Nurse call attending psychiatrist. Enact immediate falls precautions due to possible unstable gait/focus/confusion. Consult ICF (Infection Control) nurse as to need for contact/respiratory precautions. Initiate same as directed. Nurse should ask for second nursing assessment and opinion, call DON (Director of Nursing) if second nurse not available. Educate patient/and or family as to medical interventions being employed ...Implement physicians orders. Keep physician abreast of significant changes. Document in medical record all processes, implements use the word, "Early Response Intervention" in margin of nursing note to delineate early response instruction process was implemented."

Based on record review and interview the hospital failed to have complete and accurate medical records as evidenced by not having accurately dated medication administration records in the medical record for 1 out 6 sample patients (Patient #3). Findings:

Patient #3 was a 92 year old white female with a history of dementia who was admitted from a nursing home to Oceans Behavioral Hospital on 1/25/12 and was discharged to the family on 02/08/12. The nursing home stated she was wandering in and out of other patients' rooms. She was delusional and disorientated and kept looking for small children. She required constant redirection. The nursing home reported she scratched another patient during an argument, when she thought that another patient was her husband and another female patient was trying to take her "husband" from her. Patient #3 had been widowed for a number of years. Patient #3's daughter wanted her admitted to the hospital to have her medications reevaluated.

Review of the MARs (Medication Administration Record) in Patient #3's chart revealed two MARs dated 2/05/12 with different information on the MARs and one MAR with no date on the MAR at all. With further investigation of comparing the staff schedule with signatures on the MARS and with comparing the patient's blood glucose's on specific days, the surveyors and S2Corporate Administrator were able to concur on the dates the MARS actually represented. Also a phone interview was conducted with S3Pharmacist on 3/20/12 at 2:20 p.m. S3Pharmacist was able to print out the date, time and name of the nurses who pulled out medications out of the medication drawer system, Pyxis. This assisted the surveyors with matching the staff who worked on specific days to the signatures on the MARs. The undated MAR was for 2/8/12. One of the MARs dated 2/5/12 was dated incorrectly and was really the MAR for 2/7/12.

An interview was conducted with S2Owner and S1 Corporate Administrator on 3/20/12 at 2:30 p.m. and they reported that they recognized that the undated MAR and inaccurately dated MAR were a problem.

Based on record review and interview the hospital failed to ensure discharge recommendations for appropriate follow up care was provided as evidenced by no follow up care appointments for 1 out of 3 discharged patients (Patient #3) reviewed for appropriate discharge procedure out of a sample of 6. Findings:

Patient #3 was a 92 year old white female with a history of dementia who was admitted from a nursing home to Oceans Behavioral Hospital on 1/25/12 and was discharged to the family on 02/08/12. The nursing home stated she was wandering in and out of other patients' rooms. She was delusional and disorientated and kept looking for small children. She required constant redirection. The nursing home reported she scratched another patient during an argument, when she thought that another patient was her husband and another female patient was trying to take her "husband" from her. Patient #3 had been widowed for a number of years. Patient #3's daughter wanted her admitted to the hospital to have her medications reevaluated.

Review of the Medical Progress Note dated 2/08/12 at 1500 (3 p.m.) revealed, " Staff report daughter requested patient leave hospital {NC admission (noncontested) to AMA(Against Medical Advise)} Psychiatrist gave d/c (discharge) order. Sedating meds (Haldol) held, pt now alert responsive. "

Review of the Discharge Physician's Orders dated 2/8/12 at 1235 (12:35 p.m.) revealed in part, " D/C (discharge) to family ...Condition on D/C: Stable, Prognosis: Guarded, Follow up with PCP (Primary Care Physician)."

Review of the Continuing Care Plan dated 2/08/12 revealed under the heading labeled Follow- up Continuing Care Outpatient Appointments revealed, "Pt discharged to family against medical advice (AMA) and report that pt will be taken to Hospital "a" ." On the form it was checked she was discharge to home. The discharge papers were signed by S8Social Worker.

Review of the Discharge Checklist revealed by the section labeled, "Schedule follow up appointment, psychiatric outpatient appointment, and other appointments", N/A was written by S8Social Worker indicating it was not applicable to the patient. There was no evidence follow up appointments and any resources were provided to the patient or the family.

An interview was conducted with S1Corportate Administrator on 03/20/12 at 1 p.m. She reported that S8Social Worker was not longer employed by the hospital.

An interview was conducted with S4Social Worker on 3/21/12 at 9:15 a.m. She stated even if the patient was discharge AMA (against medical advice) the social worker should had set up follow up appointments for the patient. The patient should have had mental health and Primary Care Doctor appointments set up for her. Even if the family didn't want to go to the appointments, the social worker should had documented that information.

An interview was conducted with S9MD on 03/21/12 at 1:25 p.m. He was the psychiatrist for Patient #3 and medical director of the hospital. He reported on 2/8/12 he released the patient to the care of her family, at the family's request. He further stated he didn't think Patient #3 was so unstable the family could not take care of her. She was not a danger to self or others. She was not discharged AMA (against medical advice). S9MD stated the patient should have been discharged with a full set of follow up appointments.

An interview was conducted with S1Corporate Administrator on 3/20/12 at 2 p.m. She reported Patient #3 was not discharged AMA (against medical advice) and follow up appointments should had been set up for the patient even if the patient left AMA and even if the patient's family brought her to another facility. She also should have been given specific instructions about her disease process and given a list of resources in the area.

An interview was conducted with S2Owner on 3/21/12 at 1:30 p.m. He reported Patient #3 should have been discharged from the facility with follow up appointments even if the family said they were taking her to Hospital "a" .

Based on record review and interview the hospital failed to have social services arrange follow-up care and provide information on resources outside the hospital on discharge from the hospital as evidenced by no follow up appointments being set up and resource information being given on discharge for 1 out 3 sample patients (Patient #3) reviewed for appropriate discharge procedures out of a sample of 6. Findings:

Patient #3 was a 92 year old white female with a history of dementia who was admitted from a nursing home to Oceans Behavioral Hospital on 1/25/12 and was discharged to the family on 02/08/12. The nursing home stated she was wandering in and out of other patients' rooms. She was delusional and disorientated and kept looking for small children. She required constant redirection. The nursing home reported she scratched another patient during an argument, when she thought that another patient was her husband and another female patient was trying to take her "husband" from her. Patient #3 had been widowed for a number of years. Patient #3's daughter wanted her admitted to the hospital to have her medications reevaluated.

Review of the Medical Progress Note dated 2/08/12 at 1500 (3 p.m.) revealed, "Staff report daughter requested patient leave hospital {NC admission (noncontested) to AMA(Against Medical Advise)} Psychiatrist gave d/c (discharge) order. Sedating meds (Haldol) held, pt now alert responsive."

Review of the Discharge Physician's Orders dated 2/8/12 at 1235 (12:35 p.m.) revealed in part, " D/C (discharge) to family ...Condition on D/C: Stable, Prognosis: Guarded, Follow up with PCP (Primary Care Physician).

Review of the Continuing Care Plan dated 2/08/12 revealed under the heading labeled Follow- up Continuing Care Outpatient Appointments revealed, " Pt discharged to family against medical advice (AMA) and report that pt will be taken to Hospital "a"." On the form it was checked she was discharge to home. The discharge paper was signed by S8Social Worker.

Review of the Discharge Checklist revealed by the section labeled, "Schedule follow up appointment, psychiatric outpatient appointment, and other appointments," N/A was written by S8Social Worker, indicating it was not applicable to the patient. There was no evidence follow up appointments and any resources were provided to the patient or the family on discharge from the hospital.

An interview was conducted with S1Corportate Administrator on 03/20/12 at 1 p.m. She reported that S8Social Worker was not longer employed by the hospital.

An interview was conducted with S4Social Worker on 3/21/12 at 9:15 a.m. She stated even if the patient was discharge AMA (against medical advice) the social worker should had set up follow up appointments for the patient. The patient should have had mental health and Primary Care Doctor appointments set up for her. Even if the family didn't want to go to the appointments, the social worker should had documented that information.

An interview was conducted with S9MD on 03/21/12 at 1:25 p.m. He was the psychiatrist for Patient #3 and medical director of the hospital. He reported on 2/8/12 he released the patient to the care of her family, at the family's request. He further stated he didn't think Patient #3 was so unstable the family could not take care of her. She was not a danger to self or others. She was not discharged AMA (against medical advice). S9MD stated the patient should have been discharged with a full set of follow up appointments.

An interview was conducted with S1Corporate Administrator on 3/20/12 at 2 p.m. She reported Patient #3 was not discharged AMA (against medical advice) and follow up appointments should had been set up for the patient even if the patient left AMA and even if the patient's family brought her to another facility. She also should have been given specific instructions about her disease process and given a list of resources in the area.

An interview was conducted with S2Owner on 3/21/12 at 1:30 p.m. He reported Patient #3 should have been discharged from the facility with follow up appointments even if the family said they were taking her to Hospital "a" .