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Based on observation, record review and interview the hospital fail to ensure compliance with the hospital requirements specified in Subparts A,B, C, and D of Part 482 of the common requirement of 412.25 for Critical Access Hospitals that provide inpatient psychiatric services related to 482.13 Patient Rights (A-0115) as evidence by:

1. The hospital failing to ensure that patients in the Behavioral Medicine Unit (BMU) received care in a safe setting by having door knobs, bathroom fixtures, safety railing, beds, shower rods, soap dishes, electrical outlets, ceiling tiles in the patients' bathroom, a chair, and a light fixture that could provide a risk for the psychiatric patient.(A-0144)

2. The hospital failing to ensure that patients in the Behavioral Medicine Unit had a safe outdoor environment free from potential elopement risks.(A-0144)

3. The hospital failing to identify a patient's representative complaint as a grievance, conduct a through investigation and provide the complainant with a written response.(A-0119)

4. The hospital's grievance policy and procedure for grievances failing to specify time frames for review of a grievance and provision of a response. (A-0122)

Findings:

1. Care in a Safe setting in the Behavioral Medicine Unit (A-0144)

An observation was made on 9/25/13 at 10 a.m. in Rooms a, b, c, and d in the BMU of 2 beds in each of the rooms with metal rods and spring frames for the base of the bed with metal mechanical hardware and metal rod siderails. Rooms e and f had one bed in each room with the metal rod and spring frames for the base of the bed and with metal mechanical hardware and metal rod siderails. There was one window in each room with a wooden box at the top of the window that was once used to house curtains. A sink was in each room with cabinets and drawers located under and around the sink. When the cabinet door under the sink was opened, the metal plumbing was exposed. The handle hardware on the cabinet, 4 drawers and 1 closet cabinet were not anti-ligature. All the doors to the patients' room (6 rooms) had 2 door levers on each door that were not anti-ligature. The window in Group room j and Patient rooms a, b, c, d, e, and f all have eagle winged lever locks on the windows.
An observation was made on 9/25/13 at 10:10 a.m. of the patients' bathrooms in Rooms a, b, c,d, e, and f had exposed metal plumbing to the toilets and safety railing with a 4 inch gap between the wall and the railing. The ceiling in the patients' bathrooms consistent of square tiles that were easily raised. The door knobs to all the patients' bathrooms were round and not anti-ligature.

An observation was made on 9/25/13 at 10:15 a.m. in shower room g of 2 safety railings. One railing was about 2 feet long in the shower and the other railing in the bathtub was about 3 feet long. There was a 4 inch gap between the railing and the wall. The shower curtain was not on a breakaway rod. There were two soap dishes grouted into the tile of the shower and the bathtub with about a 2 inch slot for hand placement. The knobs for the hot and cold water were circular with extended edges. Shower room h housed a shower and a metal electrical box with metal cord wiring coming from the ceiling to the metal electrical box. The light fixture in the ceiling had a metal cage around the light bulb and the shower curtain rod was not breakaway.

An interview was conducted with S4RN Director of the BMU on 9/25/13 at 10:15 a.m. She stated not all patients on suicide precautions are on 1:1 observation. She further reported most patients with suicidal ideations are on every 15 minutes observation and are allowed into the shower room without constant observation.

An observation was made on 9/25/13 at 10:20 a.m. of a pay phone being located on the wall in hallway i of the BMU. The pay phone had the phone receiver attached to the phone by an accordion metal cord.
An observation was made on 9/25/13 at 10:25 a.m. in Room b of a chair in the room that when the back cushion was removed from the chair, 3 thin metal rods were visible that could be easily removed from the chair frame.
All observations on the BMU were confirmed by S4RN Unit Manager, S5Facility Manager and S9RN Regional Manager for the Contract agency for the BMU. They all verified these all were safety hazards for the psychiatric patients on the BMU.
An interview was conducted with S5Facility Manager on 9/25/13 at 10:30 a.m. He reported that all the electrical outlets on the BMU, except the outlets by the sinks in the patients' rooms, were not protected by ground fault interrupters (GFIs). He estimated he would have to replace 40 to 50 electrical outlets in the BMU.
An observation was made on 9/25/13 at 10:25 a.m. of Room f's door being able to be locked on the inside of the room.
An interview was conducted with S5Facility Manager on 9/25/13 at 10:30 a.m. He stated when he performed maintenance in Room f, he placed a lock on the inside of the door to protect the patients from the maintenance that was occurring in the room. He further reported he forgot to remove the lock on the inside of the door once the maintenance was completed.
2. Care in a Safe outdoor area free of elopement risks (A-0144)
An observation was made on 9/25/13 at 9:50 a.m. of the outside fenced in area of the BMU. The outside area had a 7 foot wooden fence surrounding the area. The 2 wooden 4 X 4 crossbars for the fence were in the inside of the fence giving easy access to the patients to use the cross bars as ladder rungs. An elevated wooden patio with wooden railing was next to the fence giving the patient the ability to reach the top of the 7 foot fence. A 2 ? foot high rectangular cable box was next to the fence along with a wooden hand railing for the gate entrance. These items were easily climbed on top of to reach the top of the 7 foot fence.
An interview was conducted with S4RN Unit Manager on 9/25/13 at 9:50 a.m. She confirmed the patients are allowed outside in the fenced in area with 1 Mental Health Techs to 5 patients. She confirmed the fence, the handrail, railing around the elevated wooden deck patio and the cable box were all elopement risks.
3. Grievance (Tag A0119)
Review of the Patient Handbook for the Behavioral Medicine Unit (BMU), which is given to all patients on admission to the unit, revealed in part, "...Grievance Procedure:...Patients are entitled to information about the hospital's mechanism for the initiation, review, and resolution of patient complaints. If a Patient believes that these or other rights (or the right of another Patient) are being violated in a way that the staff cannot resolve or has not resolved, the Patient should bring the matter to the attention of the Charge Nurse or Administration. The Hospital hopes that the Patient will make known any complaints about the services they receive, or grievance that may have with respect to another Patient and that all complaints can be immediately resolved. The Patient should submit the complaint to the Charge Nurse or Administration in writing or verbally, stating specifically the facts upon which the complaint is based and the decision or action the patient seeks. Upon receiving a verbal complaint, a complaint report form will be completed by the employee receiving the complaint. Administration or administrative on-call personnel will be notified immediately upon receipt of a complaint. The patient has a right to complain regarding the quality of care and will receive response form the organization that substantially addresses the complaint..."
Review of the medical record for Patient #4 revealed she was admitted to the facility from the Emergency room of Hospital B for suicidal ideation with a suicide plan. She was admitted on 7/21/13 at 3:00 a.m. to the BMU with a PEC (Physician Emergency Certificate) dated 7/20/13 at 10:24 p.m.
Review of the Social Service Progress Note dated 7/23/13 at 8:20 a.m. revealed , "Spoke to Patient #4's mother, she called and displayed verbally an agitated mood. Through further questioning discovered her agitation was because she felt her daughter was not being cared for properly. This social worker stated we follow policy and procedure and her daughter was in a safe environment. Patient #4's mother stated she will contact Channel 3 and Channel 10 and her daughter's lawyer to complain about her treatment. Will contact as needed." The progress note was signed by S7LCSW (Licensed Clinical Social Worker).
An interview was conducted with S7LCSW on 9/24/13 at 2:45 p.m. S7LCSW stated when she spoke to Patient #4's mother on the telephone she was upset about the care her daughter was receiving in the BMU. She went on to state the mother wasn't specific about what part of her daughter's care she was concerned about. When questioned if she reported the incident to S4RN Unit Manager of the BMU or S2 Quality Assurance Manager she stated she did not and she did not fill out a grievance form.
An interview was conducted with S4RN Unit Manager of the BMU on 9/25/13 at 9:35 a.m. She stated she was not aware of Patient #4's mother's concern about her daughter's care in the unit. She confirmed it should have been a grievance.
An interview was conducted with S2 Quality Assurance Manager on 9/25/13 at 9:40 a.m. She reported all grievance were handled by her and she was not aware of Patient #4's mother's grievance. The grievance was not investigated and a response was not provided to the complainant.
4. Grievance Timeline (Tag A0122)
Review of the Policy and Procedure for the hospital for Grievances revealed in part the following, "... 4. Patient grievances, received by hospital personnel, will be addressed if possible, at the time of the report. A written report will not be necessary for grievances resolved in this fashion.
The time frame for responding to grievances varies with the nature of the complaint.
A. Neglect, abuse, and fraud ...investigation of the complaint shall begin within 24 hours from notification to the hospital and shall be concluded with 30 days from said notification. A written summary of the findings or resolution of the complaint shall be provide to the complainant or authorized representative thereof upon conclusion of the investigation. .. "
Review of the Patient Handbook for the Behavioral Medicine Unit (BMU), which is given to all patients on admission to the unit, revealed in part, "...Grievance Procedure:...Complaints will be referred to the Administrator, Director of Nursing, or Program Director and a "Lead Investigator" will be assigned within 24 hours of receipt of grievance. Within 72 hours of receipt of grievance, Lead Investigator will respond in writing to complainant indicating the name of the contact person(s) who will assist the patient and family in the resolution of problems. The Lead Investigator shall ensure a complete investigation is conducted and prepare a report for the PI (Performance Improvement) Committee. (The lead investigator may designate other staff members to participate in the investigation.) The lead Investigator will develop a corrective plan of action to resolve the current grievance and to prevent future grievances. The Corrective Plan of Action will be submitted to the PI committee for approval. The Lead Investigator will provide the following written communication to the complainant within 7 days. Description of complaint, Steps taken to resolve complainant, Date of completion/resolution..."
An interview was conducted with S2 Quality Assurance Manager on 9/25/13 at 1:45 p.m. She stated she was the person that handled formal grievances in the hospital. She went on to report she typically sends a written response to the complainant in 30 days after the investigation is complete. Typically she stated it takes about 30 days to investigate a grievance. She confirmed there was no timeline in the hospital's policy about acknowledgement of the grievance within 7 days.
Review of the hospital's grievance policy and the grievance policy and procedure in the Patient's Handbook for patients admitted to the Behavioral Medicine Unit revealed they are different. S2 Quality Assurance Manager handles the grievances and is following the hospital's grievance policy.