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Based on interview and record review it was determined the facility failed to ensure that the established process for the prompt resolution of patient grievances was effective for one (1) of ten (10) sampled patients (Patient #1). A review of the nursing progress notes revealed Patient #1's family member(s) called the facility on more than one occasion to voice grievances related to the patient's care. Interviews and a review of documentation revealed the facility met with Patient #1's family member(s) regarding their concerns on 07/11/14; however, the facility failed to conduct an investigation or enter the complaint into the facility's computerized program for event reporting as described in the facility's policy. As a result of the facility's failure to follow policy, there was no written documentation that the facility had determined an outcome of the family members' complaint.

The findings include:

Review of the facility policy titled "Patient Grievance," adopted 07/30/10, revealed the facility had developed a process for the resolution of patient grievances. According to the policy, any staff member could accept a patient complaint, whether expressed verbally or in writing. The complaint or grievance was to be documented on the "ARH form A-1-3 Patient/Customer Grievance/Concern" or entered directly into the facility's "CS Stars" event reporting system. The policy further stated that complaints, concerns, or expressions of dissatisfaction communicated to facility staff that could be resolved promptly by the staff present in the facility should be resolved at that level. The policy further stated staff should address the complaint with the patient and collect pertinent information concerning the complaint. Measures taken to resolve the complaint would be documented on the facility's "ARH form A-1-3 Patient/Customer Grievance/Concern" or documented in "CS stars" on the patient concern/complaint review screen. According to the policy, a timeframe of seven days to issue a response to the patient was appropriate for grievances that required investigation.

A review of Patient #1's medical record revealed the facility admitted the patient on a voluntary basis on 06/30/14 for psychiatric evaluation and treatment. The patient's diagnoses included Recurrent Major Depression, Anxiety, and Benzodiazepine Withdrawal. Review of the History and Physical (H&P) dictated on 6/30/14 revealed Patient #1 had been agitated and had been having problems with regard to losing his/her job and one of his/her friends. According to the physician's History and Physical report, Patient #1 was evaluated and found to have "garbled" speech. Patient #1 was admitted for psychiatric evaluation and treatment. Review of the Advanced Registered Nurse Practitioner (ARNP) progress notes dated 07/11/14 revealed staff met with Patient #1's family members on 07/11/14 and they voiced a grievance that Patient #1's medical condition was not improving and family wanted to take Patient #1 home against medical advice. However, further review revealed the patient voluntarily agreed to stay another day. On 07/12/14, the psychiatrist deemed Patient #1 to be a danger or threat of danger to him/herself or others as a result of his/her illness and initiated an emergency 72-hour involuntary hospitalization for the patient. Continued review of documentation revealed on 07/15/14, Patient #1 was transferred to a "Crisis Unit" and according to the Social Worker's progress note dated 07/15/14, the patient had improved but further stabilization was recommended prior to returning home.

Review of the facility's investigation log revealed the facility failed to provide documentation that verified the facility conducted a family meeting on 07/11/14 regarding Patient #1's care in an effort to resolve the family's grievance. In addition, the facility failed to document that they had provided the patient's family member(s) information and/or a report of the actions the facility had taken in an effort to resolve the family member's grievance.

Interview with Patient #1's family member on 07/15/14 at 2:15 PM confirmed he/she had voiced a complaint to the facility on more than one occasion regarding the family's concerns that Patient #1 had been overmedicated, not properly assessed, and that family visitation had been cut short. The family member stated he/she spoke with Registered Nurse (RN) #1, who was responsible for Patient #1's care, on 07/07/14 and asked for updates on the patient's condition but did not get any information. The family member also voiced concerns that Patient #1 was overmedicated during family visitation. The family member stated Patient #1 had not attended group sessions and had not benefited from treatment received at the facility. The family member stated he/she called a second time and spoke with RN #1 on 07/07/14 at 3:55 PM and according to the family member, he/she did not receive any answers to his/her concerns. The family member stated a family meeting was scheduled with facility staff on 07/11/14 regarding family concerns. The family member stated a request was made to take Patient #1 home against medical advice on 07/11/14 but the patient was placed on a hold and discharge was denied. The family member stated the facility did nothing to resolve any of the family's concerns/complaints. The family member stated the facility failed to contact him/her, verbally or in writing, to inform him/her of the results of a facility investigation regarding the family's complaints.

Patient #1 stated in interview on 07/15/14 at 11:15 AM that he did not know if the facility staff had overmedicated him/her. Patient #1 stated staff tried to get him to go to groups but "I'm just not a social person and rather stay in my room." Patient #1 was being discharged to a Crisis Unit at the time of the interview and the patient's transportation was waiting. Patient #1 did not have any complaints regarding care and services received.

A telephone interview was conducted with RN #1 on 07/15/14 at 1:40 PM. RN #1 stated a telephone call was received from Patient #1's family member on 07/07/14 and the family member voiced concerns/complaints that Patient #1 was overmedicated. RN #1 informed the family member the patient had a psychotic disorder, was withdrawn to his/her room, and that the patient had not been overmedicated. In addition, RN #1 stated the patient's family member contacted the facility numerous times a day by telephone and RN #1 thought the family member's concerns were resolved before the telephone calls ended. RN #1 also stated the information regarding the family's concerns was "passed on" to the next shift during shift report and that the concerns had not been entered into the facility's system as a complaint because the family member had not alleged abuse or neglect.

Interview with the facility's Patient Advocate on 07/15/14 at 3:10 PM revealed the facility had a system in place to log patient complaints/grievances. According to the Patient Advocate, the log was sent to Utilization Review monthly to track all complaints/grievances. The Patient Advocate stated he was not aware of Patient #1's family member's concerns and the concerns had not been documented on the complaints/grievance log.

Interview with the Interim Executive Director on 07/15/14 at 11:08 AM revealed Patient #1's family member came to the facility on 07/11/14 and met with the treatment team in an attempt to resolve the family's concerns. The Interim Executive Director stated the team explained to the family that Patient #1 was not overmedicated and a formal complaint was not entered into the facility's system because it was the team's understanding that the family member's concerns were resolved. According to the Interim Executive Director, Patient #1 did not have any complaints and did not want to the leave the hospital against medical advice. The Interim Executive Director stated the patient's family was also informed they could contact the facility's Patient Advocate if they had any further complaints. The Interim Executive Director stated he had not been made aware of any additional concerns voiced by the patient's family members.

Based on interview and record review it was determined the facility failed to ensure a written notice of the facility's decision related to a verbal complaint had been provided to one (1) of ten (10) sampled patients (Patient #1) and/or the patient's representative. Interviews and a review of documentation revealed a family member of Patient #1 had contacted the facility on numerous occasions to voice concerns related to the care the patient received at the facility. In addition, Patient #1's family member met with facility staff to discuss concerns they had related to Patient #1's care at the facility. However, the facility failed to provide Patient #1's family member written notice of its decision including the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date the grievance was resolved.

The findings include:

Review of the facility's policy titled "Patient Grievance," adopted 7/30/10, revealed the facility had developed a process for the resolution of patient grievances. According to the policy, any staff member could accept a patient complaint whether expressed verbally or in writing, and the complaint was to be documented on the facility's "A-1-3 Patient/Customer Grievance/Concern" form or entered directly into the facility's "CS Stars" event reporting system on the facility's website. The policy also revealed measures taken to resolve the complaint were to be documented on page two of the facility's "A-1-3 Patient/Customer Grievance/Concern" form or documented in the facility's "CS Stars" event reporting system on the facility's website. The policy revealed the facility had a timeframe of seven days to issue a written response to the patient or patient representative for grievances that required investigation.

A review of Patient #1's medical record revealed the facility admitted the patient on 06/30/14 with diagnoses that included Recurrent Major Depression, Anxiety, and Benzodiazepine Withdrawal. Review of the Advanced Registered Nurse (ARNP) progress note dated 07/11/14 revealed staff met with family members who voiced a complaint/concern regarding Patient #1's care and services. According to the progress note, the family was upset that Patient #1 had been placed in an environment where other patients argued, had physical altercations, and were not permitted to have razors. The family was also upset that Patient #1's medications had been changed and demanded to have a family meeting. On 07/11/14, family requested to take Patient #1 out of the hospital against medical advice. Further review revealed the patient voluntarily agreed to stay another day. However, on 07/12/14, the psychiatrist deemed Patient #1 to be a danger or threat of danger to him/herself or others as a result of his/her illness and initiated an emergency 72-hour involuntary hospitalization for the patient. Continued review of documentation revealed on 07/15/14, Patient #1 was transferred to a Crisis Unit in London, Kentucky and according to the Social Worker's progress note dated 07/15/14 the patient had improved but further stabilization was recommended prior to returning home.

Interview with Patient #1's family member on 07/15/14 at 2:15 PM confirmed he/she had voiced a complaint to the facility on more than one occasion regarding the family's concerns that Patient #1 had been overmedicated, not properly assessed, and that family visitation had been cut short. The family member called the facility on 07/07/14 and asked to speak with the Nurse (RN #1) assigned to provide care for Patient #1. The family member asked for updates on the patient's condition but, according to the family member, did not get any information. The family member also stated during the phone call that family voiced concerns to RN #1 that Patient #1 was overmedicated during family visitation. The family member stated he/she called the facility a second time on 07/07/14 at 3:55 PM and spoke with RN #1 and according to the family member, he/she did not receive any answers to his/her concerns. The family member stated several more calls were made to the facility and a family meeting was scheduled with facility staff on 07/11/14 regarding the family member's concerns. The family member stated at the meeting with facility staff, he/she requested to take Patient #1 home against medical advice on 07/11/14; however, the psychiatrist at the facility obtained a 72-hour hold for Patient #1 and the patient remained at the facility. The family member stated the facility did nothing to resolve any of the family's concerns/complaints. The family member stated the facility failed to contact him/her, verbally or in writing, to inform him/her of the results of a facility investigation regarding the family's complaints.

Review of the facility's investigation log revealed the facility had not documented the meeting conducted with Patient #1's family member and the complaints/concerns that had been verbalized in the meeting. In addition, the facility failed to provide documentation that a written notice had been provided to the patient's family regarding actions taken to resolve the family member's complaint.

Interview with the Interim Executive Director on 07/15/14 at 11:08 AM revealed Patient #1's family member came to the facility on 07/11/14 and met with the treatment team in an attempt to resolve the family's concerns. The Interim Executive Director stated no formal complaint was entered because the team explained to the family member that Patient #1 was not overmedicated, and stated it was the team's understanding that the complaint was resolved at the time of the meeting. According to the Interim Executive Director, Patient #1's family member was informed to call the facility's Patient Advocate if the family had any further complaints and stated, to his knowledge, the family member had not voiced any other concerns. The Interim Executive Director stated since the compliant was not logged into the system, the facility had not provided Patient #1's family member a written response sent regarding their complaint.

Patient #1 stated in interview on 07/15/14 at 11:15 AM that he did not know if the facility staff had overmedicated him/her. Patient #1 stated staff tried to get him to go to groups but "I'm just not a social person and rather stay in my room." Patient #1 was being discharged to a Crisis Unit at the time of the interview and the patient's transportation was waiting. Patient #1 did not have any complaints regarding care and services received.