The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

EASTERN IDAHO REGIONAL MEDICAL CENTER 3100 CHANNING WAY IDAHO FALLS, ID 83404 Jan. 9, 2013
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policies and grievance documentation and staff interview, it was determined the hospital failed to ensure the Behavioral Health Center established and adhered to a process for prompt resolution of grievances for 16 of 17 BHC patients (#3 - #18) who submitted grievances between 5/01/13 and 1/08/13. This failure resulted in a lack of documentation of grievances including the issue to be addressed, the investigation, and resolution letter provided to the complainant. Findings include:

1. The grievance policy for the BHC was requested. The "BHC - PATIENT GRIEVANCE" policy, dated 6/14/11, was provided and reviewed. The policy did not contain guidance for the prompt resolution of grievances as follows:

a. The "BHC - PATIENT GRIEVANCE" policy did not define a complaint or a grievance.

The hospital's grievance policy was requested and compared to the BHC grievance policy. The hospital policy, "Patient Complaint & Grievance Management," dated 7/19/12, provided a definition of a complaint and a grievance. According to the policy a complaint, "is a concern represented by a patient or patient's representative that can be addressed or resolved promptly by staff members who are present at the time of the complaint. 'Staff present' includes those individuals close to the complaint situation or who can quickly be at the patient's location (i.e. nursing, clinical ancillary staff, risk management, administration, nursing director/manager, etc.) to resolve the patient's complaint. Generally and it should be the objective, that complaints should be resolved timely while the patient is still receiving care at the facility."

The hospital's policy defined a grievance as "a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient representative, regarding the patient's care...A written complaint is always considered a grievance, whether from an inpatient, outpatient, released or discharged patient or their representative...A verbal complaint is a grievance if it cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it requires investigation, and/or if it requires further actions for resolution." The policy stated, "This policy and procedure is applicable to all hospital departments, services, and contract employees."

b. The "BHC - PATIENT GRIEVANCE" policy stated, "After attempts to resolve the complaint with the involved staff have been exhausted, the patient may file a grievance by completing the Patient Grievance Form." However, according to the hospital policy, "Patient Complaint & Grievance Management," if a complaint is not resolved it is, by definition, a grievance.

c. The "BHC - PATIENT GRIEVANCE" policy stated that each patient would be informed of the process to resolve a complaint and the review process for grievances. The policy did not outline the procedure staff were to use to resolve a complaint or review a grievance.

The hospital policy, "Patient Complaint & Grievance Management," provided guidance to be followed by staff members upon the receipt of a complaint. The policy also stated that grievances would be investigated.

d. The "BHC - PATIENT GRIEVANCE" policy did not define time frames for acknowledgement of, or response to, a grievance.

The hospital policy, "Patient Complaint & Grievance Management," stated "a written initial letter must be provided to complainant within 7 days after receipt of the Grievance. This letter will provide the name of the hospital, contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion. If the grievance is not resolved with in the 7 days a letter of notification will be sent to the complainant. The letter will indicate the time period for resolution, with the goal of completion within two weeks after the 7 day letter."

The Executive Director of the BHC was interviewed on 1/09/12 at 2:50 PM. She stated the "BHC - PATIENT GRIEVANCE" policy was the policy referred to at the BHC. She confirmed that prior to 1/09/13 she was not aware of the hospital's grievance policy or procedure. She acknowledged the current process to manage complaints and grievances was not adequate and lacked the necessary guidance of the hospital policy.

The policy did not contain guidance for the prompt resolution of grievances.

2. Staff involved in the grievance process at the BHC were interviewed. Understanding of the process to promptly resolved grievances was not consistent as follows:

The Executive Director of the BHC was interviewed on 1/08/13 at 11:15 AM. She stated that the Grievance Officer was responsible for initially handling complaints and grievances at BHC. She stated that any written concern was considered a grievance. She explained that patients had access to a "Patient/Resident Grievance Form." She explained that once a patient documented the concern on the grievance form, the form was reviewed by the Grievance Officer. She stated that the Grievance Officer spoke with the patient and other parties involved to resolve the issue. The Executive Director of the BHC stated that if the concern was resolved the Grievance Officer documented this on the form, otherwise the Grievance Officer would document that it was unresolved and sent to the appropriate manager. She stated if the concern was not resolved with the manager's involvement, she would become involved. She stated if the concern was not resolved at her level it would be sent to her supervisor and risk management. She confirmed that each step of the process was to be documented. She stated that the BHC did receive complaints from discharged patients and family members. She stated she did not document these concerns or handle them according to the hospital's grievance policy. She confirmed the complaints and grievances were not tracked.

The Grievance Officer was interviewed on 1/08/13 at 10:50 AM. She stated she was not aware there was a difference between a complaint and a grievance. She was asked to explain when a concern would be considered a grievance. She stated if "I feel like it's a grievance" or if she was not able to resolve the issue then it was a grievance. She stated she collected the "Patient/Resident Grievance Form(s)" "a couple of times a week." She explained she would then "triage" the concerns or comments and that she handled the "minor" issues. She stated that sometimes patients used the form for other things besides communicating a concern. The Grievance Officer stated her first step was to speak directly with the patient to better understand the exact nature of the concern. She stated if possible she would resolve the concern at that point and if she was not able to resolve the concern she would forward it on to the appropriate manager. She stated that occasionally a patient was not able to communicate clearly due to mental or emotional issues. She explained that in these cases she would speak with staff members and/or try to speak with the patient at a later time. She stated that when the grievance was handled by the manager the form was to be returned to her and filed. The Grievance Officer explained that she did not receive training when she was assigned this position. She stated that she was unaware of a policy related to complaints or grievances.

Understanding of the process to promptly resolved grievances was not consistent.

3. Information related to grievances submitted at the BHC was reviewed. A process for the prompt resolution of grievances was not used in the following examples:





a. Patient #3's medical record documented a [AGE] year old male who was admitted to the hospital's BHC from 6/15/12 to 6/28/12. His "PSYCH EVALUATION," dated 6/16/12, stated his diagnoses included mood disorder and polysubstance abuse. The evaluation stated Patient #3 had been abusing over the counter cough medication.

A form labeled "NURSING PLAN OF CARE FOR USE OF RESTRAINT/SECLUSION," dated 6/17/12 at 11:26 PM, indicated Patient #3 threw a chair and threatened staff with pieces of the broken chair. He was subsequently restrained for 20 minutes. As a result of the incident, he was banned from admission and treatment to the BHC.

Patient #3's psychiatrist was interviewed on 1/09/13 beginning at 10:35 AM. He stated Patient #3 was discharged home on 6/28/12. He stated around the middle of July 2012, Patient #3 again became suicidal. He stated he directed Patient #3's guardian to bring the patient to the BHC for treatment. He stated when Patient #3 arrived at the BHC, his guardian was told Patient #3 had been banned from admission to the BHC. The patient had to seek treatment at another hospital. The psychiatrist stated he encouraged Patient #3's guardian to talk with the hospital's CEO about his concerns.

The CEO was interviewed on 1/09/13 beginning at 1:50 PM. He stated Patient #3's guardian complained to him after the BHC refused to admit the patient. The CEO stated he did not refer this to the hospital's grievance team. Subsequently, the grievance was not investigated.

The grievance by Patient #3's guardian was not logged and was not investigated.





b. Patient #4 submitted a "Patient/Resident Grievance Form" on 5/10/12. The concern was about other patients singing religious songs during a group activity that she did not feel were appropriate in the hospital setting. Patient #4 also stated the policy was not to "promote religion." The Grievance Officer documented that she spoke to Patient #4 about the BHC policy, noted the issue was resolved and signed the form but did not date it. Patient #4 signed the form on 5/18/12, eight days after the form was submitted.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #4's grievance form. She confirmed there was no documentation to indicate a letter had been sent in response to this grievance.

c. Patient #7 submitted three "Patient/Resident Grievance Form(s)" related to an incident that took place on 5/19/2012. One form was submitted on 5/23/12 and two were submitted on 5/24/12. The forms documented that Patient #7 thought she had been discharged and called family to pick her up, but was told she could not be discharged because the physician was on vacation. Patient #7 was very upset about this and called for the physician to be fired. On the form dated 5/23/12 Patient #7 wrote that she did not turn in the form on the day of the incident "Because I was concerned about staff retaliation..." The Grievance Officer documented on the grievance form from 5/23/12, "patient too psychotic to interview...verbally assaultive." The Grievance Officer signed the form but did not date it. There was no documentation of whether the issue was investigated or resolved. The forms from 5/24/12 had no documentation from the Grievance Officer.

The Executive Director of the BHC was interviewed at 11:15 AM on 1/8/13. She reviewed the grievance forms for Patient #7. She stated that the forms were not "adequately" completed. She confirmed the forms did not contain documentation of an investigation of the concern or a written response to the patient and that there was no documentation at all to the grievance forms dated 5/24/12. She stated that if Patient #7 was psychotic at the time the Grievance Officer attempted to discuss the issue with Patient #7, there should be more documentation stating why Patient #7 was unable to discuss these concerns. She stated she expected there to be documentation that the Grievance Officer attempted to follow up with Patient #7 at another time.

d. Patient #8 submitted the following concerns "Patient/Resident Grievance Form(s)" on 5/29/12, 6/18/12, and 12/28/12:

i. The concern on 5/29/12 was related to a staff member telling Patient #8 that her opinion did not matter. The Grievance Officer documented that she referred the complaint to a manager and signed the form but did not date it. Documentation from a manager indicated the staff member was spoken to about working with patients and avoiding conflict. The manager signed the form but did not date it. The issue was documented as resolved and Patient #8 signed the form but did not date it.

ii. The concern on 6/18/12 was related to confronting a staff member about a comment the staff member made. Patient #8 also documented that she was "sick of his attitude, infractions, and not listening (to) us." The Grievance Officer documented that she referred the concern to a manager on 6/20/12 (two days after it was submitted) because it was a staff issue, and signed the form. There was further documentation the staff member was being instructed on alternatives to control the class, but this documentation was not signed or dated. The issue was documented as resolved and Patient #8 signed the form but did not date it.

iii. The concern on 12/28/12 was related to Patient #8 feeling like a staff member "hates" her because she did not attend school. The Grievance Officer documented that when Patient #8 stated her emotions altered her perception of the staff member's attitude towards her. The concern was documented as resolved and the Grievance Officer signed the form on 12/31/12 (three days after it was submitted). Patient #8 also signed the form but did not date it.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #8's grievance forms. She confirmed there was no documentation to indicate when the grievance was resolved (for the 5/29/12 and 6/18/12 grievances) or that letters had been sent in response to any of the grievances. She stated she believed the manager provided the additional documentation to the 6/18/12 grievance but confirmed this documentation was not signed/dated.

e. Patient #18 submitted the following concerns on "Patient/Resident Grievance Form(s)" on 7/14/12 and 10/04/12:

i. The concern submitted on 7/14/12 was related to Patient #18's dislike of a staff member's actions and the way the staff member treated others. The Grievance Officer documented the issue was referred to a manager and signed the form on 7/18/12 (four days after it was submitted.) The concern was marked as unresolved and Patient #18 signed the form but did not date it. There was no documentation of a manger's involvement with this issue.

ii. The concern submitted on 10/05/12 was related to Patient #18 feeling like she couldn't "process with staff without getting yelled at." The Grievance Officer documented the concern was referred to a manager because it involved a staff member. The Grievance Officer signed the form on 10/12/12 (seven days after the grievance was submitted) . The grievance was documented as unresolved and Patient #18 signed the form on 10/12/12. There was no documentation to indicate a manager's involvement, that the grievance was resolved and a written notice of response provided to Patient #18.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance documentation for Patient #18. She stated it was her expectation that the manager speak with the patient and the staff member. She confirmed that there was no documentation of the manager's involvement in resolving either of these concerns. She stated it was possible the manager documented something in Patient #18's chart, but based on the documentation on the grievance forms it could not be determined the grievances were thoroughly reviewed and resolved. She also confirmed that there was no documentation to indicate a letter had been sent in response to the grievances.

f. Patient #13 submitted the following concerns on "Patient/Resident Grievance Form(s)" on 6/02/12, 6/05/12, and 7/15/12:

i. The concern submitted on 6/02/12 was related to a staff member and a peer using a word that Patient #13 found offensive. The Grievance Officer documented the issue was referred to manager because it involved staff. The Grievance Officer signed the form but did not date it. There was no documentation to indicate whether the issue was resolved or not. There was no documentation to indicate a manager was involved with this issue.

ii. The concern submitted on 6/05/12 was related to a staff member "always giving people infractions..." and the difficulty of this staff member's class. The Grievance officer documented the issue was referred to manager because it involved staff. The Grievance Officer signed the form but did not date it. There was no documentation to indicate whether the issue was resolved or not. There was no documentation to indicate a manager was involved with this issue.

iii. The concern submitted on 7/15/12 was related to a staff member "acting like a child..." Patient #13 also stated the staff member had fallen asleep on the job and was only doing the job to pay for school. The Grievance officer documented the issue was referred to manager because it involved staff. The Grievance Officer signed the form on 7/18/12 (three days after it was submitted) and marked the grievance as unresolved. There was no documentation to indicate whether the issue was ultimately resolved or not. There was no documentation to indicate a manager was involved with this issue.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance forms for Patient #13. She stated that she did not know if any of the grievances were reviewed by a manager as there was no documentation of this on any grievance form. She confirmed there was no date to indicate when the Grievance Officer reviewed the grievance forms from 6/02/12 and 6/05/12. She also confirmed that there was no documentation to indicate a letter had been sent in response to the grievances.

g. Patient #14 submitted a concern on the "Patient/Resident Grievance Form" on 10/05/12 related to a staff member being irritable towards others. The Grievance Officer documented the concern was referred to a manager because it involved a staff member. The Grievance Officer signed the form on 10/12/12 (seven days after the grievance was submitted) and marked the concern as unresolved. There was documentation that this concern was discussed with the staff member, but there was no signature or date indicating who spoke with the staff or when. Patient #14 signed the form on 10/12/12.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance form for Patient #14 and stated she believed the unidentified documentation was from the manager. She confirmed there was no documentation to indicate a letter had been sent in response to this grievance.

h. Patient #11 submitted two "Patient/Resident Grievance Form(s)" on 6/18/12 related to a staff member giving "infractions" unnecessarily. The Grievance Officer documented on each form that the concern was referred to a manager because it involved a staff member. The Grievance Officer signed the forms on 6/20/12 (two days after they were submitted.) There was no documentation on either form to indicate a manager was involved in this issue. There was no documentation on either form to indicate if the issue was resolved or unresolved. Patient #11 signed both forms on 7/29/12.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #11's grievance forms. She stated that she did not know if this complaint was reviewed by a manager as there was no documentation from the manager on the forms. She stated the form appeared to have been signed by Patient #11 when the grievance was resolved but confirmed this was difficult to determine. She also confirmed that there was no documentation to indicate a letter had been sent in response to this grievance.

i. Patient #15 submitted a "Patient/Resident Grievance Form" on 10/22/12. The concern was related to a comment a staff member made to Patient #15. Patient #15 requested a meeting with staff members to resolve this issue. The Grievance Officer documented the concern was referred to a manager per Patient #15's request. The Grievance Officer signed the form on 10/23/12. The concern was documented as unresolved. There was no documentation to indicate a manager had been involved in the issue or a meeting with staff had taken place.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #15's grievance form. She stated that she did not know if this complaint was reviewed by a manager as there was no documentation from the manager on the form. She stated she "assumed" the meeting was set up and stated that perhaps there was documentation of this in Patient #15's medical record. She agreed that it was preferable to have all of the documentation regarding any investigation and resolution to a grievance in one location. She confirmed there was no documentation to indicate a letter was sent in response to this grievance.

j. Patient #16 submitted a "Patient/Resident Grievance Form" on 6/17/12. The concern was that a staff member changed a planned activity to a different activity. The Grievance Officer documented the issue had been referred to a manager because it involved a staff member. The Grievance Officer signed the form on 6/18/12 (one day after the grievance was submitted.) There was no documentation to indicate a manager had been involved in the resolution of this concern. There was no documentation to indicate the issue was resolved or unresolved. Patient #16 signed the form but did not date it.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #16's grievance form. She stated that she did not know if this complaint was reviewed by a manager as there was no documentation from the manager on the form. She confirmed there was no documentation to indicate a letter was sent in response to this grievance.

k. Patient #17 submitted a "Patient/Resident Grievance Form" on 6/18/12. The concern was related to a staff member. The Grievance Officer documented the concern was referred to a manager and signed the form on 6/20/12 (two days after it was submitted). There was no documentation to indicate a manager had been involved in the resolution of this concern. There was no documentation to indicate the issue was resolved or unresolved. Patient #17 signed the form on 7/29/12.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #17's grievance form. She stated that she did not know if this complaint was reviewed by a manager as there was no documentation of this on the form. She stated the form appeared to have been signed by Patient #17 when the grievance was resolved but confirmed this was difficult to determine. She also confirmed that there was no documentation to indicate a letter had been sent in response to this grievance.

l. Patient #9 submitted 16 "Patient/Resident Grievance Form(s)" dated from 9/12/12 to 9/16/12. There were multiple nonspecific concerns on each page, some dealing with people watching him, conditions in his room, the food, and the number of patients the facility had at a given time. There were also references to his "grievances" not being addressed, no one listening to him, issues with staff and his rights being violated. Only one page contained documentation that the grievance(s) had been acknowledged. At the bottom of the page was a note dated 6/18/12 documenting Patient #9 was transferred to a state hospital and diagnosed with paranoid schizophrenia. There was no signature.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance forms for Patient #9. She confirmed there was no response from the Grievance Officer on any of the forms. She stated that it was the BHC's policy that if the patient was too agitated to be interviewed about the concerns on the form, then the interview was to be postponed until the patient was feeling better. She stated her expectation would have been for the Grievance Officer to speak to Patient #9 at some point during his stay or document on the forms why she could not. She confirmed there was no documentation to indicate the Grievance Officer had acknowledged the concerns.

m. Patient #12 submitted a "Patient/Resident Grievance Form" on 10/29/12 related to the temperature of her room. There was documentation on the form the issue was referred to a manager. There was no signature for this documentation and no date for when the issue was referred to the manager. There was documentation on the form from the manager that the temperature was in "normal ranges," the policy on bringing blankets from home was reviewed and the manager had spoken with other patients about the temperature. The manager signed the form on 11/05/12 (seven days after the grievance was submitted.) On the line for "Patient Signature" was written "discharged ."

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed Patient #12's grievance form. She stated the manager had probably interviewed Patient #12 before discharge but did not document the encounter until 11/05/12. She confirmed that there was no documentation to indicate the manager had spoken with Patient #12 or that a letter had been sent in response to the grievance.

n. Patient #6 submitted the following concerns on "Patient/Resident Grievance Form(s)" on 5/27/12, 5/29/12 and 10/28/12:

i. The concern submitted on 5/27/12 was related to Patient #6 wanting blue Powerade once a day.
There was no documentation from the Grievance Officer on this form.

ii. Three "Patient/Resident Grievance Form(s)" were submitted on 5/29/12. The concerns were related to being able to wear a watch, a glass ring being tampered with and ten dollars missing from her wallet. Only one form (from 5/27/12 and 5/29/12) contained documentation from the Grievance Officer. The Grievance Officer addressed the missing money and "suggested double check inventory on discharge (and) file complaint (at) that time if appropriate..." The Grievance Officer documented she would notify Patient #6's physician regarding the request for blue Powerade. The Grievance Officer documented the ring had been "inventoried" and was not accessible to Patient #6. In addition, the Grievance Officer documented she would follow up on the rules regarding watches. The issues were documented as resolved and signed by the Grievance Officer and Patient #6 on 5/29/12.

iii. The concern submitted on 10/28/12 was regarding ten dollars missing from Patient #6's wallet. There was no documentation on the form from the Grievance Officer.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance forms submitted by Patient #6. She stated the actions of the Grievance Officer were "not well documented." She stated that instead of waiting until discharge to see if money had been removed from Patient #6's wallet, something more immediate should have been done. She stated she expected a staff member to check the wallet contents against the list of inventoried items documented when Patient #6 was admitted to the facility. She stated there should have been documentation on each separate "Patient/Resident Grievance Form." She confirmed there was no documentation of a written response to the grievances.

o. Patient #10 submitted "Patient/Resident Grievance Form(s)" on 6/04/12 and 6/20/12 as follows:

i. The concern submitted on 6/20/12 was related to a female patient lying about a male patient. The Grievance Officer documented on the form that this was written as a warning to staff that a female patient was trying to frame a male patient to get him removed from the unit. The issue was documented as resolved, the Grievance Officer and Patient # 10 signed the form on 6/20/12.

ii. The concern submitted on 6/04/12 was a staff member giving patients "infractions" unnecessarily. The Grievance Officer documented the issue was sent to a manager because it involved a staff member and signed the form but did not date it. There was no documentation to indicate if the issue was resolved or unresolved.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance forms submitted by Patient #10. She confirmed there was no documentation to indicate the manager was involved in the resolution of the complaint submitted on 6/04/12. She confirmed there was no documentation that a letter of resolution was written in response to the grievances.

p. Patient #5 submitted the following concerns on "Patient/Resident Grievance Form(s)" on 12/21/12 and 12/30/12:

i. The concern submitted on 12/21/12 was related to a staff member speaking to her in a sarcastic tone when she was upset. The Grievance Officer documented that the she discussed with Patient #5 how her approach contributed to the staff member speaking the way he did. The Grievance Officer also discussed with Patient #5 alternate methods of having her needs met. The issue was documented as resolved and signed by the Grievance Officer on 12/31/12 (ten days after it was submitted.)

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She reviewed the grievance documentation for Patient #5. She confirmed that there was no documentation that the staff member in question was spoken to, only that Patient #5 needed to alter her reactions. She confirmed there was no documentation that a written response was provided to Patient #5.
ii. The concern submitted on 12/30/12 was about two staff members making Patient #5 "taste their breath." There was documentation on the form that Patient #5 acknowledged this was a joke. There was no signature or date for the documentation.

The Grievance Officer was interviewed on 1/08/13 at 10:50 AM. She confirmed that documentation submitted on the "Patient/Resident Grievance Form" was not always a grievance. She stated that occasionally patients wrote general comments on the grievance forms. She confirmed that grievances were handled by the appropriate managers to complete and returned to her to file. She confirmed that she was not aware whether or not patients received written responses to the grievances addressed by the managers.

The Executive Director of the BHC was interviewed on 1/08/13 at 11:15 AM. She stated if the concern was not resolved with the manager's involvement, she would become involved. She stated if the concern was not resolved at her level it would be sent to her supervisor and risk management. She stated written responses to grievances came from the Executive Director of Risk Management's office. She explained that she was often able to resolve issues over the phone, however this was not documented.

During an interview 1/09/13 at 2:50 PM, the Executive Director of the BHC explained that several of the grievances submitted were in regards to one staff member during one time frame. She stated the BHC met with the staff member, developed plans for additional education and training, and established a monitoring plan. She stated this plan was successful. After reviewing the above grievance forms, the Executive Director of the BHC stated she believed that all of the grievances regarding this staff member were handled at one time. She confirmed that each individual grievance form did not contain the appropriate documentation to support this.

A process for prompt resolution of grievances was not established at the BHC.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on interview and review of grievance documentation and policies, it was determined the governing body failed to ensure the effective operation of the grievance process at the BHC. This impacted 16 of 17 BHC patients (#3 - #18) who submitted grievances between 5/01/12 and 1/08/13 and had the potential to impact all patients who received care at the BHC. This resulted in the lack of the documentation of grievances, the investigation of grievances, and the resolution of the grievance process. Findings include:

1. The grievance policy for the BHC was requested. The "BHC - PATIENT GRIEVANCE" policy, dated 6/14/11, was provided and reviewed. The policy did not contain guidance for the prompt resolution of grievances as follows:

a. The "BHC - PATIENT GRIEVANCE" policy did not define a complaint or a grievance.

The hospital's grievance policy was requested and compared to the BHC grievance policy. The hospital policy, "Patient Complaint & Grievance Management," dated 7/19/12, provided a definition of a complaint and a grievance. According to the policy a complaint, "is a concern represented by a patient or patient's representative that can be addressed or resolved promptly by staff members who are present at the time of the complaint. 'Staff present' includes those individuals close to the complaint situation or who can quickly be at the patient's location (i.e. nursing, clinical ancillary staff, risk management, administration, nursing director/manager, etc.) to resolve the patient's complaint. Generally and it should be the objective, that complaints should be resolved timely while the patient is still receiving care at the facility."

The hospital's policy defined a grievance as "a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient representative, regarding the patient's care...A written complaint is always considered a grievance, whether from an inpatient, outpatient, released or discharged patient or their representative...A verbal complaint is a grievance if it cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it requires investigation, and/or if it requires further actions for resolution." The policy stated, "This policy and procedure is applicable to all hospital departments, services, and contract employees."

b. The "BHC - PATIENT GRIEVANCE" policy stated, "After attempts to resolve the complaint with the involved staff have been exhausted, the patient may file a grievance by completing the Patient Grievance Form." However, according to the hospital policy, "Patient Complaint & Grievance Management," if a complaint is not resolved it is, by definition, a grievance.

c. The "BHC - PATIENT GRIEVANCE" policy stated that each patient would be informed of the process to resolve a complaint and the review process for grievances. The policy did not outline the procedure staff were to use to resolve a complaint or review a grievance.

The hospital policy, "Patient Complaint & Grievance Management," provided guidance to be followed by staff members upon the receipt of a complaint. The policy also stated that grievances would be investigated.

d. The "BHC - PATIENT GRIEVANCE" policy did not define time frames for acknowledgement of, or response to, a grievance.

The hospital policy, "Patient Complaint & Grievance Management," stated "a written initial letter must be provided to complainant within 7 days after receipt of the Grievance. This letter will provide the name of the hospital, contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion. If the grievance is not resolved with in the 7 days a letter of notification will be sent to the complainant. The letter will indicate the time period for resolution, with the goal of completion within two weeks after the 7 day letter."

The Executive Director of the BHC was interviewed on 1/09/12 at 2:50 PM. She stated the "BHC - PATIENT GRIEVANCE" policy was the policy referred to at the BHC. She confirmed that prior to 1/09/13 she was not aware of the hospital's grievance policy or procedure. She acknowledged the current process to manage complaints and grievances was not adequate and lacked the necessary guidance of the hospital policy.

The policy did not contain guidance for the prompt resolution of grievances.

2. Staff involved in the grievance process at the BHC were interviewed. Understanding of the process to promptly resolved grievances was not consistent as follows:

The Executive Director of the BHC was interviewed on 1/08/13 at 11:15 AM. She stated that the Grievance Officer was responsible for initially handling complaints and grievances at BHC. She stated that any written concern was considered a grievance. She explained that patients had access to a "Patient/Resident Grievance Form." She explained that once a patient documented the concern on the grievance form, the form was reviewed by the Grievance Officer. She stated that the Grievance Officer spoke with the patient and other parties involved to resolve the issue. The Executive Director of the BHC stated that if the concern was resolved the Grievance Officer documented this on the form, otherwise the Grievance Officer would document that it was unresolved and sent to the appropriate manager. She stated if the concern was not resolved with the manager's involvement, she would become involved. She stated if the concern was not resolved at her level it would be sent to her supervisor and risk management. She confirmed that each step of the process was to be documented. She stated that the BHC did receive complaints from discharged patients and family members. She stated she did not document these concerns or handle them according to the hospital's grievance policy. She confirmed the complaints and grievances were not tracked.

The Grievance Officer was interviewed on 1/08/13 at 10:50 AM. She stated she was not aware there was a difference between a complaint and a grievance. She was asked to explain when a concern would be considered a grievance. She stated if "I feel like it's a grievance" or if she was not able to resolve the issue then it was a grievance. She stated she collected the "Patient/Resident Grievance Form(s)" "a couple of times a week." She explained she would then "triage" the concerns or comments and that she handled the "minor" issues. She stated that sometimes patients used the form for other things besides communicating a concern. The Grievance Officer stated her first step was to speak directly with the patient to better understand the exact nature of the concern. She stated if possible she would resolve the concern at that point and if she was not able to resolve the concern she would forward it on to the appropriate manager. She stated that occasionally a patient was not able to communicate clearly due to mental or emotional issues. She explained that in these cases she would speak with staff members and/or try to speak with the patient at a later time. She stated that when the grievance was handled by the manager the form was to be returned to her and filed. The Grievance Officer explained that she did not receive training when she was assigned this position. She stated that she was unaware of a policy related to complaints or grievances.

Understanding of the process to promptly resolved grievances was not consistent.

3. Patients #3 - #18 submitted a total of 41 grievances between 5/01/12 and 1/08/13 as follow:

* Patient #3 ' s parent complained to the CEO after being informed upon arrival at the BHC on approximately 7/20/12, that his son was banned from admission to the BHC.

* Patient #4 submitted a "Patient/Resident Grievance Form" on 5/10/12.

* Patient #5 submitted concerns on "Patient/Resident Grievance Form(s)" on 12/21/12 and 12/30/12.

* Patient #6 submitted concerns on three "Patient/Resident Grievance Form(s)" dated 5/27/12, 5/29/12 and 10/28/12:

* Patient #7 submitted three "Patient/Resident Grievance Form(s)" related to an incident that took place on 5/19/2012. One form was submitted on 5/23/12 and two were submitted on 5/24/12.

* Patient #8 submitted three "Patient/Resident Grievance Form(s)" dated 5/29/12, 6/18/12, and 12/28/12.

* Patient #9 submitted 16 "Patient/Resident Grievance Form(s)" dated from 9/12/12 to 9/16/12.

* Patient #10 submitted "Patient/Resident Grievance Form(s)" on 6/04/12 and 6/20/12.

* Patient #11 submitted two "Patient/Resident Grievance Form(s)" on 6/18/12.

* Patient #12 submitted a "Patient/Resident Grievance Form" on 10/29/12.

* Patient #13 submitted concerns on "Patient/Resident Grievance Form(s)" on 6/02/12, 6/05/12, and 7/15/12.

* Patient #14 submitted a concern on the "Patient/Resident Grievance Form" on 10/05/12.

* Patient #15 submitted a "Patient/Resident Grievance Form" on 10/22/12.

* Patient #16 submitted a "Patient/Resident Grievance Form" on 6/17/12.

* Patient #17 submitted a "Patient/Resident Grievance Form" on 6/18/12.

* Patient #18 submitted concerns on "Patient/Resident Grievance Form(s)" on 7/14/12 and 10/04/12.

Information related to these grievances was reviewed. There was no documentation that the BHC identified the concerns as grievances and responded to them as grievances.

4. The Executive Director of Risk Management was interviewed on 1/08/13 at 3:30 PM. He stated that he believed that the BHC was processing and tracking grievances in accordance with the hospital's policy. He stated he was not aware of the process used at the BHC and confirmed that the Executive Director of BHC was not involved in the hospital's grievance committee.

5. The Chief Operating Officer was interviewed on 1/09/13 at 11:40 AM. She confirmed that the Executive Director of BHC reported up to her. She stated the hospital considered the BHC a "free-standing facility." She confirmed that she met monthly with the Executive Director of BHC and BHC managers. She stated that grievance issues were handled by the Executive Director of Risk Management. She stated the BHC should be using the same process to manage grievances as the hospital.

The governing body did not ensure an effective grievance process was utilized at the BHC.
VIOLATION: PATIENT RIGHTS: GRIEVANCE PROCEDURES Tag No: A0121
Based on interview and review of patient rights information and facility policies, it was determined the facility failed to establish a clearly explained process for patients at the BHC to submit grievances. This failure had the potential to result in patients and/or their representatives not having concerns addressed. Findings include:

1. A pamphlet titled, "YOUR PATIENT RIGHTS & RESPONSIBILITIES," undated, was reviewed. One section of this pamphlet addressed complaint and grievance resolution. The pamphlet directed patients to "let your caregiver know of any concerns you have...Our goal is to respond to your concern in a timely manner and with an appropriate and clear resolution." The pamphlet listed staff members capable of responding to complaints/grievances, including physicians, department managers/directors, and charge nurses. In addition, patients were provided with the accrediting organization and state agency contact information.

On 1/08/13 at 1:55 PM the Executive Director of Risk Management presented an updated version of the patient rights pamphlet. The Executive Director of BHC was present during this interview and confirmed that the new pamphlet was not part of the admission paperwork given to patients or their representatives as of 1/09/13. The Executive Director of Risk Management stated the new pamphlet contained minor changes that were updated toward the end of the summer or the beginning of the fall of 2012.

The new pamphlet contained additional information regarding complaints and grievances. The pamphlet stated that "The patient and his or her family have the right to have complaints reviewed by the hospital." In addition to the staff members listed above, and outside entities to report concerns to, this pamphlet provided the contact information of the Executive Director of Risk Management.

The Executive Director of the BHC was interviewed on 11/08/13 at 11:15 AM. She stated BHC could "be a little more definitive about the grievance process. It's vague." She agreed that because the process is vague it could be difficult for a patient to understand.

Patient rights information did not clearly outline the process of submitting a grievance.

2. The grievance policy for the BHC was requested. The "BHC - PATIENT GRIEVANCE" policy, dated 6/14/11, was provided and reviewed. The policy stated, "A grievance procedure is available to all patients to systematically address unresolved patient complaints. All patients will be informed of their right to initiate a grievance and educated of the grievance procedure within 24 hours after their admission, unless impractical because of the patient's medical or emotional status." The policy explained that if attempts to resolve a complaint with involved staff were exhausted, the patient "may file a grievance by completing the Patient Grievance Form." The policy did not address the submission of a verbal grievance.

The Executive Director of the BHC was interviewed on 1/09/13 at 2:50 PM. She stated patients were given the pamphlet containing information about grievances and complaints on admission to the BHC. She stated sometimes patients are unable to process this information at the time of admission due to an altered mental or emotional state. She stated the staff was inconsistent in ensuring patients were informed of the grievance process.

The BHC policy does not address the procedure for the submission of a verbal grievance.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on review of policies and interview it was determined the facility failed to ensure time frames for investigation and response to grievances were established for the BHC. This directly impacted 16 of 17 BHC patients (#3 - #18) who submitted grievances between 5/01/12 and 1/08/13, and had the potential to impact all patients who received care at the BHC. This failure had the potential to result in delayed and unsatisfactory responses from the facility to the complainants. Findings include:

The patient grievance policy was requested. The "BHC - PATIENT GRIEVANCE" policy, dated 6/14/11, was provided and reviewed. The "BHC - PATIENT GRIEVANCE" policy did not define time frames for acknowledgement of or response to a grievance.

The hospital's grievance policy was requested and compared to the BHC grievance policy. The hospital policy, "Patient Complaint & Grievance Management," dated 7/19/12, stated "a written initial letter must be provided to complainant within 7 days after receipt of the Grievance. This letter will provide the name of the hospital, contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion. If the grievance is not resolved with in the 7 days a letter of notification will be sent to the complainant. The letter will indicate the time period for resolution, with the goal of completion within two weeks after the 7 day letter." The policy also stated, "This policy and procedure is applicable to all hospital departments, services, and contract employees."

Patients #3 - #18 submitted a total of 41 grievances between 5/01/12 and 1/08/13 as follow:

* Patient #3 ' s parent complained to the CEO after being informed upon arrival at the BHC on approximately 7/20/12, that his son was banned from admission to the BHC.

* Patient #4 submitted a "Patient/Resident Grievance Form" on 5/10/12.

* Patient #5 submitted concerns on "Patient/Resident Grievance Form(s)" on 12/21/12 and 12/30/12.

* Patient #6 submitted concerns on three "Patient/Resident Grievance Form(s)" dated 5/27/12, 5/29/12 and 10/28/12:

* Patient #7 submitted three "Patient/Resident Grievance Form(s)" related to an incident that took place on 5/19/2012. One form was submitted on 5/23/12 and two were submitted on 5/24/12.

* Patient #8 submitted three "Patient/Resident Grievance Form(s)" dated 5/29/12, 6/18/12, and 12/28/12.

* Patient #9 submitted 16 "Patient/Resident Grievance Form(s)" dated from 9/12/12 to 9/16/12.

* Patient #10 submitted "Patient/Resident Grievance Form(s)" on 6/04/12 and 6/20/12.

* Patient #11 submitted two "Patient/Resident Grievance Form(s)" on 6/18/12.

* Patient #12 submitted a "Patient/Resident Grievance Form" on 10/29/12.

* Patient #13 submitted concerns on "Patient/Resident Grievance Form(s)" on 6/02/12, 6/05/12, and 7/15/12.

* Patient #14 submitted a concern on the "Patient/Resident Grievance Form" on 10/05/12.

* Patient #15 submitted a "Patient/Resident Grievance Form" on 10/22/12.

* Patient #16 submitted a "Patient/Resident Grievance Form" on 6/17/12.

* Patient #17 submitted a "Patient/Resident Grievance Form" on 6/18/12.

* Patient #18 submitted concerns on "Patient/Resident Grievance Form(s)" on 7/14/12 and 10/04/12.

Information related to these grievances was reviewed. There was no documentation that the BHC identified the concerns as grievances or provided a response in any specific time frame.

The Executive Director of the BHC was interviewed on 1/09/12 at 2:50 PM. She confirmed the "BHC - PATIENT GRIEVANCE" policy was the policy referred to at the BHC. She stated that prior to 1/09/13 she was not aware of the hospital's grievance policy or procedure. She acknowledged that the current process to manage complaints and grievances was not adequate and the BHC policy lacked the time frame guidance found in the hospital policy.

The grievance process at the BHC did not include time frames for the investigation and response to grievances.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of grievance documentation and policies and staff interview, it was determined the facility failed to ensure the BHC responded to grievances with a written notice. This directly impacted 16 of 17 BHC patients (#3 - #18) who submitted grievances between 5/01/12 and 1/08/13, and had the potential to impact all patients who received care at the BHC. This resulted in lack of clarity related to the steps taken to investigate the grievance and resolution of the investigation process. Findings include:

The patient grievance policy was requested. The "BHC - PATIENT GRIEVANCE" policy, dated 6/14/11 was provided and reviewed. The "BHC - PATIENT GRIEVANCE" policy did not address providing a written notice to the patient with the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion.

The hospital's grievance policy was requested and compared to the BHC grievance policy. The hospital policy, "Patient Complaint & Grievance Management," dated 7/19/12, stated "a written initial letter must be provided to complainant within 7 days after receipt of the Grievance. This letter will provide the name of the hospital, contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion. If the grievance is not resolved with in the 7 days a letter of notification will be sent to the complainant. The letter will indicate the time period for resolution, with the goal of completion within two weeks after the 7 day letter." The policy also stated, "This policy and procedure is applicable to all hospital departments, services, and contract employees."

Patients #3 - #18 submitted a total of 41 grievances between 5/01/12 and 1/08/13 as follow:

* Patient #3 ' s parent complained to the CEO after being informed upon arrival at the BHC on approximately 7/20/12, that his son was banned from admission to the BHC.

* Patient #4 submitted a "Patient/Resident Grievance Form" on 5/10/12.

* Patient #5 submitted concerns on "Patient/Resident Grievance Form(s)" on 12/21/12 and 12/30/12.

* Patient #6 submitted concerns on three "Patient/Resident Grievance Form(s)" dated 5/27/12, 5/29/12 and 10/28/12:

* Patient #7 submitted three "Patient/Resident Grievance Form(s)" related to an incident that took place on 5/19/2012. One form was submitted on 5/23/12 and two were submitted on 5/24/12.

* Patient #8 submitted three "Patient/Resident Grievance Form(s)" dated 5/29/12, 6/18/12, and 12/28/12.

* Patient #9 submitted 16 "Patient/Resident Grievance Form(s)" dated from 9/12/12 to 9/16/12.

* Patient #10 submitted "Patient/Resident Grievance Form(s)" on 6/04/12 and 6/20/12.

* Patient #11 submitted two "Patient/Resident Grievance Form(s)" on 6/18/12.

* Patient #12 submitted a "Patient/Resident Grievance Form" on 10/29/12.

* Patient #13 submitted concerns on "Patient/Resident Grievance Form(s)" on 6/02/12, 6/05/12, and 7/15/12.

* Patient #14 submitted a concern on the "Patient/Resident Grievance Form" on 10/05/12.

* Patient #15 submitted a "Patient/Resident Grievance Form" on 10/22/12.

* Patient #16 submitted a "Patient/Resident Grievance Form" on 6/17/12.

* Patient #17 submitted a "Patient/Resident Grievance Form" on 6/18/12.

* Patient #18 submitted concerns on "Patient/Resident Grievance Form(s)" on 7/14/12 and 10/04/12.

Information related to these grievances was reviewed. There was no documentation that the BHC identified the concerns as grievances and provided a response with the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion.

The Executive Director of the BHC was interviewed on 1/08/13 at 11:15 AM. She stated if the concern was not resolved with the manager's involvement, she would become involved. She stated if the concern was not resolved at her level it would be sent to her supervisor and risk management. She stated written responses to grievances came from the Executive Director of Risk Management's office. She explained that she was often able to resolve issues over the phone, however this was not documented.

The Executive Director of the BHC was interviewed on 1/09/12 at 2:50 PM. She stated the "BHC - PATIENT GRIEVANCE" policy was the policy referred to at the BHC. She confirmed that prior to 1/09/13 she was not aware of the hospital's grievance policy or procedure. She acknowledged that the current process to manage complaints and grievances was not adequate.

Patients did not receive written responses to grievances.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure the right to be involved in care planning and treatment and the right to request treatment was afforded to 1 of 6 psychiatric patients (Patient #3) whose medical records were reviewed. This prevented patients from making informed decisions about their care. Findings include:

Patient #3's medical record documented a [AGE] year old male who was admitted to the hospital's BHC from 6/15/12 to 6/28/12. His "PSYCH EVALUATION," dated 6/16/12, stated his diagnoses included mood disorder and polysubstance abuse. The evaluation stated Patient #3 had been abusing over-the-counter cough medication. The section of the evaluation labeled "VIOLENCE" stated Patient #3's "...chart documents multiple previous suicide attempts including cutting, hanging, overdosing and huffing chlorine gas. The patient also has a history of self-cutting that is not motivated by suicidal intent." No mention of violence to others was documented.

Patient #3's medical record documented he was placed in 4 point restraints. A "CONTINUOUS MONITORING AND CARE OF PATIENT IN RESTRAINT/SECLUSION" form, dated 6/17/12 at 10:50 PM, indicated he was restrained from 10:15 PM until 10:35 PM. His behavior was listed as "calm" at 10:15 PM, 10:30 PM, and 10:35 PM. The form stated he was calm and apologized for his actions. It stated he denied a desire to assault staff. The "NURSING PLAN OF CARE FOR USE OF RESTRAINT/SECLUSION," dated 6/17/12 at 11:26 PM, stated Patient #3 "...was calm up to throwing chair and threatening staff with piece of broken chair." A form labeled "DEBRIEFING WITH STAFF," dated 6/17/12 at 11:31 PM, stated Patient #3 "...called girlfriend-told her he was going to throw chair through window and assault staff in order to get IM medication, [patient's] girlfriend called staff, [patient] carried out plan." The form stated this was Patient #3's first time for assaultive behavior and said he would not do it again. No documentation was present that staff asked Patient #3 what motivated his outburst.

No documentation was present that other incidents occurred during the other 13 days of Patient #3's hospitalization . No physician progress note mentioned the incident. The discharge summary did not mention the incident.

Patient #3's psychiatrist was interviewed on 1/09/13 beginning at 10:35 AM. He stated he had assumed Patient #3's care from the on-call psychiatrist on 6/18/12, the day following the incident. He stated he was still Patient #3's psychiatrist. He stated Patient #3 was discharged home on 6/28/12. He stated around the middle of July, 2012, Patient #3 again became suicidal. He stated he spoke with Patient #3's guardian and told the guardian to bring Patient #3 to the BHC where he would be admitted directly to the hospital. He stated he telephoned the BHC with orders to admit Patient #3. He stated he was then told Patient #3 had been banned from admission to the BHC and would not be admitted for treatment. The psychiatrist stated the guardian then called him and stated he was at BHC with Patient #3. The guardian told the psychiatrist BHC would not admit Patient #3. The psychiatrist stated he then arranged for Patient #3 to be admitted to a hospital approximately 52 miles away. The psychiatrist stated he had not been consulted prior to BHC's refusal to admit Patient #3. The psychiatrist stated Patient #3 was still banned from admission to BHC as of 1/09/13.

Patient #3 was admitted to the Emergency Department at Eastern Idaho Regional Medical Center 7 times from August through December 2012. He was stabilized in the Emergency Department and/or subsequently admitted to a medical floor for psychiatric complaints and medical stabilization. Patient #3's presenting complaints and disposition included:

A. 8/07/12 to 8/08/12-overdose on cold medication. Patient #3 was transferred to the other hospital for psychiatric treatment.
B. 8/16/12-depression and suicidal ideation. Patient #3 was transferred to the other hospital for psychiatric treatment.
C. 10/10/12-depression and suicidal ideation. Patient #3 was transferred to the other hospital for psychiatric treatment.
D. 10/20/12 to 10/21/12-drug overdose. Patient #3 was discharged to home.
E. 12/02/12-depression and suicidal ideation. Patient #3 was discharged to home.
F. 12/21/12 to 12/22/12-drug overdose. Patient #3 was admitted for medical stabilization and then transferred to the other hospital for psychiatric treatment.
G. 12/26/12 to 12/29/12-drug overdose. Patient #3 was admitted for medical stabilization and then transferred to the other hospital for psychiatric treatment.

The Executive Director of the BHC was interviewed on 1/08/13 beginning at 2:10 PM. She stated Eastern Idaho Regional Medical Center refused to consider Patient #3 appropriate for admission for psychiatric treatment. She stated she thought Patient #3's guardian had been verbally notified of that decision but had not been notified in writing. She did not know when he had been verbally informed. She stated there was no policy or procedure that outlined a process to ban patients from treatment at the BHC. She stated she there was no documentation which explained how the decision to ban Patient #3 from the BHC was made.

The decision to ban Patient #3 from admission to the BHC was not discussed with him and his guardian before a final decision was made. This prevented Patient #3 and his guardian from being involved in planning for his care and treatment and from being able to request treatment. The decision was not shared with Patient #3 and his guardian prior to them presenting to the BHC for admission of Patient #3 in a crisis situation.