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.

HOLLY HILL MENTAL HEALTH SERVICES 3019 FALSTAFF RD RALEIGH, NC Aug. 3, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on hospital policy review, grievance file review and staff interviews, the hospital failed to provide written notice of the resolution of a grievance for 1 of 3 grievances reviewed (#1).

The findings include:

Review of the hospital's "Patient and Family Grievances/The role of the Patient Advocate," with revision date of 12/15, revealed "......a grievance is defined as a 'patient grievance' is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by the staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489......If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complain is a grievance for the purposes of these requirements. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf......3. At each level of this process, the hospital staff shall listen to the patient's grievance, consider the circumstances and context of the grievance assure the patient that his/her concerns will be investigated and seek further information and input as needed. The hospital staff person shall express concern and empathy for the patient's condition and assure him/her that immediate attention will be given to the problem. 4. The staff member receiving a verbal or written grievance shall insure that a Patient Concern Notification is completed and notify the Patient Advocate or House Supervisor. 5. The Patient Advocate or in his/her absence, the House Supervisor, shall investigate and address the grievance within 24 hours of the time the grievance is received if possible....7. The Patient Advocate responding to the grievance shall inform the patient or family the timeframe within which he/she shall expect follow-up. This time frame shall not exceed 7 days unless there are extenuating circumstances, at which point the patient shall be notified of the need for an extended time frame and an agreement made as to when follow up will occur. 8. Once the issue has been resolved, the Patient Advocate shall provide a timely written response to the patient and/or family member. The response shall include: a. the name of the contact person. b. the steps taken to investigate the grievance. c. the results of the grievance process (i.e. how the grievance was resolved). d. date of investigation completion. Written responses to patients and/or family members shall be reviewed by the Risk Manager or CEO prior to being sent.....9. The grievance and problem resolution/follow up shall be documented. This documentation shall include: a. date and time grievance initiated. b. name of person voicing a grievance/how to contact. c. general description of grievance. d. pertinent investigation information e. resolution of grievance/follow up f. signature of person addressing grievance g. date and time of resolution h. date and time patient or family notified. 10. The Patient Advocate will present a grievance report to the Performance Improvement committee for review and further action as necessary. Trends shall be identified and addressed as indicated. Case may be referred by the Patient Advocate to the appropriate committee for Peer Review (i.e. Medical Executive, Performance Improvement or Utilization Review Committee) when concerns relate to quality of care or premature discharge issues....."

Patient relations worksheet review on 08/02/2016 for Patient #1 revealed the patient's mother phoned the facility on 06/20/2016 reporting care and patients' right concerns. Review revealed an investigation was conducted by a member of the administrative staff. Further review revealed case was closed on the opening date of 06/20/1016.

Interview with the administrative staff member #1 on 08/03/2016 at 1000 revealed that she conducted the investigation with (another member of the administrative staff #2). Further interview revealed there was no written response sent to the patient's representative.

Interview with the administrative staff member #2 on 08/03/2016 at 1310 revealed that she conducted the investigation by watching a video and interviewing staff. Further interview revealed there was no notes available from the investigation.

Interview with administrative staff member #3 on 08/02/2016 at 1230 revealed the investigation was completed without a written formal grievance to the patient representative. Further interview revealed grievance policy was not followed.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies, review of medical records and staff interviews, the hospital staff failed to supervise and evaluate nursing care by failing to reassess responses to emergency medications for 3 of 3 medical records reviewed (#1, #3, and #7).

The findings include:

Review of hospital policy titled "Medication Administration" with revision date of 6/16, revealed ".....Stat (immediately), Now (as soon as possible), PRN (as needed), Single Dose (one time)....Administration: 1. Enter the date, time and initial in the spaces indicated each time the medication is given, across the record. .....2. Decode your initials at the bottom of the MAR (Medication Administration Record) by placing your initials in the 'Initials' section and first and last name in 'Signature and Title' section......Documentation: 1. Document the reason for administering PRN medication on the PRN Medication form. Enter the date, time, name of PRN medication, reason given, and your initials in spaces indicated. 2. Reassess patient and document effect of PRN medication."

1. Review of a closed medical record for Patient #1 revealed a [AGE] year old female admitted on [DATE] for Suicidal thoughts for IVC (involuntary commitment). Review of telephone physician's orders dated 06/19/2016 (no time) revealed "10 mg Zyprexa IM (antipsychotic medication ordered intramuscular) x 1 dose now (one dose)" and "50 mg Benadryl (sedative) IM x 1 dose now." Review of nurses medication notes revealed no documentation of patient's response to medications.

Interview with the CNO on 08/03/2016 at 1630 revealed nurses are expected to assess patients after giving stat meds, PRN meds and one time meds on the MAR nurses notes documentation section on back of MAR. "I don't see any documentation of reassessment of the medications on the MAR."

2. Review of a closed medical record for Patient #3 revealed a [AGE] year old male admitted on [DATE] for threatening family with a sword and knife. Review of telephone physician's orders dated 07/09/2016 at 1025 revealed "Risperdal 1 mg (milligram) po (orally) tab now x 1 dose." Review of the MAR dated 07/09/2016 revealed documentation of administration of Risperdal 1 mg po at 1030. Further review revealed no documentation of reassessment of the patient after administration of the Risperdal. Review of a telephone physician's order dated 07/10/2016 (no time) revealed "Give Zyprexa 10 mg po x 1 now for agitation/aggression." Review of the MAR dated 07/10/2016 revealed documentation of administration of po Zyprexa on 07/10/2016 at 1635. Review of nurse's notes revealed no documentation of a nurses reassessment on MAR. Review of a telephone physician's order dated 07/15/2016 at 1800 revealed "Zyprexa 10 mg IM x 1 now. Benadryl 50 mg IM x 1 now." Review of the MAR dated 07/15/2016 revealed nurses documentation of administration of Zyprexa and Benadryl given at 1800. Review of nurse notes revealed no documentation of nurses reassessment on the MAR. Review of telephone physician's orders dated 07/25/2016 at 1440 revealed "Thorazine 50 mg one po x 1 for psychosis" and " Benadryl 50 mg one po x 1 for psychosis." Review of the MAR dated 07/25/2016 at 1445 revealed nurses documentation of Thorazine and Benadryl. Review of nurse's notes revealed no documentation of patient reassessment on MAR.

Interview with the CNO on 08/03/2016 at 1630 revealed nurses are expected to assess patients after giving stat meds, PRN meds and one time meds on the MAR nurses notes documentation section on back of MAR. "I don't see any documentation of reassessment of the medications on the MAR."

3. Review of a closed medical record for Patient #7 revealed a [AGE] year old female admitted on [DATE] for "cutting self" with diagnosis of PTSD (post traumatic stress disorder) and MDD (major depressive disorder). Review of the MAR dated 07/23/2016 at 1445 revealed documentation by RN of adminstration of Haldol 10 mg IM x 1, Ativan 2 mg IM x 1 and Benadryl 50 mg IM x 1. Review of the MAR revealed no documentation of the patient's response to the medication.

Interview with the CNO on 08/03/2016 at 1630 revealed nurses are expected to assess patients after giving stat meds, PRN meds and one time meds on the MAR nurses notes documentation section on back of MAR. "I don't see any documentation of reassessment of the medications on the MAR."

NC 794
NC 445