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Based on interviews, record review, and review of facility policy it was determined the facility failed to ensure the facility's grievance process was implemented. A review of patient records revealed one of ten patients (Patient #1) and/or their guardians made a grievance regarding the care provided by the facility and the facility's discharge planning process. However, there was no evidence the facility had resolved the patient's/guardian's grievance promptly.

The findings include:

Review of the facility policy titled "Customer Satisfaction Program: Receiving and Responding to Compliments/Complaints/Grievances" (dated 8/10/10) revealed the purpose of the policy was to trend and actively improve customer satisfaction and care. The policy further revealed that if a complaint or concern was not within the responsibility of the individual team member that received the complaint or was not satisfactorily resolved, the complaint/concern would immediately be reported to the immediate supervisor, the House Supervisor, and Department Supervisor or the Patient Service Representative in an effort to accomplish immediate resolution of the complaint/concern. The policy further stated grievances could be written or verbal and it was the facility staff's responsibility to resolve and document a patient/guardian complaint/grievance. The grievance resolution process should be initiated immediately upon receipt of the grievance/complaint. The policy further stated if an investigation of a grievance would take longer than seven business days the patient or their representative would be notified by phone call or mail.

Review of Patient #1's record on 11/03/11, at 10:30 AM, revealed the facility admitted Patient #1 on 10/01/11, with diagnoses of unspecified episodic mood disorder, impulse control disorder, and unspecified urinary incontinence. The patient's record contained a legal document entitled Disability Judgment, dated 02/04/11, that revealed Patient #1 was "wholly disabled" in the management of his/her personal affairs and financial resources and had been appointed a guardian. The facility discharged Patient #1 home on 10/05/11, to the care of his/her guardian. Continued review of the record revealed Patient #1's guardian spoke with the facility's social worker by telephone on 10/05/11, to verbalize complaints related to the patient's care and the facility's discharge planning process.

Interview with Patient #1's guardian on 11/03/11, at 2:35 PM, confirmed the facility had admitted Patient #1 on 10/01/11, and discharged the patient home on 10/05/11. Patient #1's guardian stated he/she telephoned the facility on 10/05/11, after Patient #1 was discharged home, and informed a facility social worker of numerous complaints related to the patient's care during the hospitalization and the manner in which Patient #1 was discharged home. The interview further revealed the unit social worker did not inform the patient's guardian of the facility's process on how to file a grievance and offered no resolution to the complaints made during the telephone call.

Interview with the social worker on 11/03/11, at 11:15 AM, revealed she has been employed as a unit social worker for six years and has been trained annually on all policy and procedures for the facility. The interview confirmed she had received a telephone call from Patient #1's guardian after the patient had been discharged from the facility. The social worker stated the guardian voiced numerous complaints related to the patient's care and discharge. The social worker confirmed she had documented the guardian's concerns in patient #1's medical record. However, the social worker stated that she did not tell Patient #1's guardian how to file a grievance with the facility nor did she inform her immediate supervisor, the Unit Manager, or Risk Management of the complaints. The social worker further stated at that time (after discharge) she could not resolve the complaints verbalized by Patient #1's guardian.

Interview with the Unit Manager on 11/03/11, at 11:42 AM, revealed she was not aware of Patient #1's guardian's complaints related to the patient's care and his/her discharge plan. The interview further revealed when/if a patient, guardian, or family member called the facility to complain about care provided to the patient, the complaint should be written/documented and given to Risk Management for a complete internal investigation.

Interview with the Risk Manager on 11/03/11, at 3:00 PM, revealed that Patient #1's guardian's complaints had never been logged in as a grievance and had not been investigated by the facility. The interview further revealed the facility social worker did not follow facility policy related to Patient #1's guardian's complaints. Furthermore she stated the complaints documented in Patient #1's medical record by the social worker most definitely should have been logged and reported immediately to Risk Management for an internal investigation.

Interview with the Chief Nursing Officer (CNO) on 11/03/11, at 1:40 PM, revealed all complaints were to be written and routed to the immediate supervisor so that Risk Management could investigate each complaint promptly. The interview further revealed all facility staff was educated annually on facility policy and procedures which included the facility's grievance process. Furthermore, the CNO confirmed the unit social worker failed to follow the facility policy on grievances.

Based on interview, record review, and review of facility policies it was determined the facility failed to ensure a patient's representative (legal guardian) had the right to make informed decisions related to the care of one of ten patients (Patient #1). The facility failed to include or offer the guardian of Patient #1 the opportunity to be involved in the patient's care planning/treatment.

The findings include:

Review of the facility's policy "Patient Rights" (dated 06/22/11) revealed the purpose of the policy was to assure the rights and responsibilities of all patients were preserved and contributed to more effective patient care. The policy also revealed a team concept with the patient, his/her physician, care givers, and the hospital organization would be developed. According to the policy, patients and/or their significant other had the responsibility to make decisions regarding the patient's health care, to participate in the development and implementation of the patient's care, and to actively participate in decisions regarding the patient's medical care.

Review of Patient #1's record on 11/03/11, at 10:30 AM, revealed the facility admitted Patient #1 on 10/01/11, with diagnoses of unspecified episodic mood disorder, impulse control disorder, and unspecified urinary incontinence. A legal document in the record entitled Disability Judgment, dated 02/04/11, revealed Patient #1 was "wholly disabled" in the management of his/her personal affairs and financial resources, and had been appointed a guardian. The facility discharged Patient #1 home on 10/05/11, to the care of his/her guardian. Continued review of Patient #1's record on 11/03/11, at 10:45 AM, revealed an unsigned treatment plan consent form dated 10/03/11, at 2:42 PM, with the statement "patient unable to sign-has guardian." Based on documentation, the facility social worker had completed the form. The record review revealed no documentation the guardian of Patient #1 had been invited to participate in the treatment planning session.

Patient #1's guardian on 11/03/11, at 2:35 PM, revealed the facility had contacted the guardian to obtain a copy of the patient's guardianship documents on 10/02/11. The guardian also confirmed the facility had not included the guardian in the patient's treatment planning, discharge planning, or decisions related to the provision of care for Patient #1. In addition, the guardian stated the patient's physician had contacted the guardian on 10/05/11, by telephone to inform him/her of Patient #1's discharge from the hospital on that date.

Interview with the facility's social worker on 11/03/11, at 11:15 AM, revealed that Patient #1 was admitted on an involuntary basis on 10/01/11, and the guardian had consented to the patient's admission. The interview further revealed when a patient was admitted to the unit facility staff immediately initiate the development of a care plan and discharge plan related to the patient's care needs. In addition, the social worker stated facility staff was to include the guardian in the development of the care plan for the patient. The social worker also stated she recalled a discussion with Patient #1's guardian related to the patient's discharge options; however, the patient's guardian had not been included in the development of the patient's treatment plan.

Interview with the Unit Manager on 11/03/11, at 11:42 AM, revealed facility social workers, nursing staff, and physicians were in charge of each patient's treatment and discharge plan. In addition, the Unit Manager stated in accordance with facility policy patient guardians were also to be included in the development of the patient care/treatment plan.

Based on interview, record review, and review of facility policies it was determined the facility failed to ensure a family member was counseled prior to the discharge of one of ten patients (Patient #1). The facility failed to counsel and/or prepare the family member (guardian) of Patient #1, prior to the patient's discharge, of the patient's post-hospital care.

The findings include:

A review of facility policy titled "Discharge Planning" (dated 01/10/10) revealed the purpose of the policy was to provide a multi-disciplinary approach to discharge planning and would include the patient, the family, and/or primary care giver. The policy stated the staff would assess every patient at the time of admission and throughout hospitalization for discharge planning and instructional needs. The policy further revealed at the time of the patient's discharge, discharge instructions would be provided verbally and in writing to the patient/significant other, and would be in layman's terms. According to the policy, the nurse assigned to the patient was responsible to complete the discharge instructions, have the patient/significant other/guardian sign the discharge instructions, and would send a copy of the discharge instructions home with the patient.

A review of Patient #1's record on 11/03/11, at 10:30 AM, revealed the facility admitted Patient #1 on 10/01/11, with diagnoses of unspecified episodic mood disorder, impulse control disorder, and unspecified urinary incontinence. A Disability Judgment, dated 02/04/11, revealed Patient #1 was "wholly disabled" in managing his/her personal affairs and financial resources and had been appointed a guardian (his/her spouse) to manage his/her personal affairs and financial resources. Based on documentation, RN #1 discharged Patient #1 on 10/05/11, to his/her home to the care of his/her spouse. The record also included discharge instructions signed by the patient and dated 10/05/11. The record review revealed no documentation of discharge planning with Patient #1's guardian.

Interview with the guardian of Patient #1 on 11/03/11, at 2:35 PM, confirmed the facility admitted Patient #1 on 10/01/11, and discharged the patient to home on 10/05/11. The interview revealed the facility had not included Patient #1's guardian in the treatment and/or discharge planning or decisions related to the patient's care. The interview also revealed the facility had contacted the guardian to obtain a copy of the patient's guardianship papers and the physician had contacted him/her on 10/05/11, to inform the guardian the patient would be discharged on that date. Patient #1's guardian stated the facility had not educated him/her on the patient's discharge instructions and had brought the patient to the door of the unit on the day of discharge (10/05/11) and was given the discharge instruction sheet that Patient #1 had signed.

Interview with the social worker on 11/03/11, at 11:15 AM, revealed the facility had admitted Patient #1 on an involuntary basis on 10/01/11, and his/her guardian had consented for the patient's admission. The interview further revealed discharge planning was to begin immediately upon admission to the facility and the guardian would be included in the planning. The interview also revealed the social worker had documented a telephone conversation with the guardian of Patient #1 about post hospital care options available in the community.

Interview with RN #1 on 11/03/11, at 11:51 AM, revealed that he vaguely recalled Patient #1. The RN also stated in accordance with facility policy staff was to discuss the patient's discharge instructions with the patient and/or guardian/family member. RN #1 acknowledged his signature was on the patient's discharge instructions and stated he could not recall if he had discussed the patient's discharge instructions with the patient's guardian at the time of discharge.