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.

Based on interview, review of patient complaints, and policy review, the facility failed to promote and protect the patients' right to complain by utilizing forms that did not exist in policy, failed to thoroughly investigate the complaints of two patients, (Patient #11 and #12), and failed to act on complaints for six patients (Patients #13, #14, #15, #16, #17 and #18) by indicating on the complaint log six patients (Patient #13, #14, #15, #16, #17, and #18) identified on the facility's complaint log (A118).
Based on interview and record review, the facility failed to follow a process for prompt resolution of patient grievances. This affected eight of 18 sampled patients, (Patients #11, #12, #13, #14, #15, #16, #17, and #18). The current census at the time of the survey was 113.

Findings include:

On 01/11/17 a review of the facility's complaint and grievance procedure was completed. The review revealed a recovery rights specialist is to interview appropriate staff and peers involved in the complaint and investigate complaint situations.

1. On 01/10/17 a review of the facility's complaint log was completed. The review revealed a complaint regarding Patient #11 dated 11/28/16. On 01/10/17 a review of Patient #11's Patient Complaint Form was completed. The review revealed the patient complained his physician, Staff G, acted unethically and was unable to provide an unbiased psychiatric evaluation. A review of the patient's Patient Complaint Form, Patient Request Form Meeting Notes, and Client Grievance forms did not reveal where Staff G was interviewed.

A review of the Client Grievance form revealed Patient #11's complaint was assigned to Staff D, the clinical services director. The form stated "writer (Staff D) followed up with chief clinical officer (Staff H) who will review patient concerns with unit physician (Staff G)."

On 01/10/17 at 3:15 PM in an interview, Staff G denied being interviewed by either Staff H or D regarding Patient #11's complaint.

On 01/10/17 at 4:15 PM Staff D in an interview confirmed she had not interviewed Staff G regarding the complaint.

On 01/10/17 at 4:30 PM Staff H, in an interview, confirmed he had not interviewed Staff G regarding the complaint.

Review of the client grievance form completed on 01/11/17 revealed three line items preceded by a box to tick:
" This grievance has been resolved to my satisfaction "
" This grievance has not been resolved to my satisfaction "
" I want to appeal this grievance "

Patient #11's grievance form did not have any of the boxes ticked. However, review of the complaint log revealed the box for satisfaction for grievance resolution was ticked.

On 01/11/17 at 1:30 PM in an interview, Staff A, the Chief Executive Officer, affirmed the complaint log was also the Chief Executive Officer's own grievance log and could not explain the discrepancy on whether or not Patient #11's grievance was satisfactorily resolved.

2. On 01/11/17 a review of the Patient #12's complaint was completed. A review of the Patient Complaint form revealed Patient #12 complained that due to her hospitalization she was fearful of being evicted and was told by Staff N that she would not have to worry about eviction because she would send a letter to the eviction court to have the eviction adjourned. Patient #12 complained Staff N never sent that letter. Patient #12's complaint continues that if she was going to be evicted she needed to get the keys to the property (which she was in possession of) to her mother. Patient #12 wrote that Staff N agreed to mail the keys to the mother if the patient gave them to her. She wrote after two weeks her mother had not received the keys, and that she did not have a receipt that they were ever being sent.

Review of the Patient Complaint Response Form included in Patient #12's complaint was completed on 01/11/17. That review revealed several attempts had been made to resolve the complaint with Staff N without success and the patient said she wanted to file a grievance. Review of the Client Grievance form revealed a different staff member would be working with the patient to assist with phone calls regarding housing and lost keys.

The review of the complaint did not reveal what the facility staff did to investigate the validity of Patient #12's allegations that she gave the keys to Staff N, whether or not the keys were mailed by Staff N or anyone else and whether or not a letter had ever been sent to the eviction court.

On 01/11/17 at 1:30 PM in an interview, Staff A confirmed the complaint investigation documentation lacked further information about where the keys were.

3. On 01/11/17 at 1:30 PM in an interview, Staff A was unable to explain why Patient #12's complaint involved a Patient Complaint Response Form while Patient #11's had not.

Review of the facility's complaint and grievance procedure did not reveal when to use the Patient Complaint Response Form and who is to fill it out.

The review of Patient #11 and #12's complaints revealed Patient #12 had Patient Request Form Meeting Notes Form whereas Patient #11 did not.

On 01/11/17 in an interview, Staff A was unable to show in policy when the Patient Request Form Meeting Notes Form is to be used and by whom and when.

4. A review of the facility's December complaint log was completed on 01/11/17. The review revealed complaints from six patients, Patient #13, #14, #15, #16, #17, and #18, all dated 12/07/16. The complaints were about medical/health care, other (online school), and freedom of movement. The log did not did not have documentation whether staff investigated the complaints and whether they were resolved.

On 01/11/17 at 1:30 PM in an interview Staff A stated there wasn't any further documentation regarding these patients' complaints. Staff A stated they are the subject of another outside matter, and she did not know why they were on the complaint log if no internal investigation was to be conducted.
Based on observation and staff interview the facility failed to develop policies to ensure effective, consistent housekeeping procedures (A701). The cumulative effect of these systemic practices precluded the facility from providing care to it's patients in a clean, maintained environment.
Based on observation and staff interview, the facility failed to develop and maintain a policy and procedure for consistent housekeeping throughout the facility. This affects all patients at the hospital. The current census at the time of the survey was 113.

Findings include:

A tour of the 500 unit was conducted on 01/09/17 at 6:10 PM. At 6:31 PM, Patient #3 lead the surveyor to the mens shower stall #B2229, complaining it was dirty. Patient #3 leaned over and ran a finger along the bottom of the shower stall. The patient's finger was soiled with a gray, sticky soap scum. Staff B who accompanied the surveyor on tour confirmed the shower stall was dirty. Staff B reported on 01/09/17 at 6:40 PM to the surveyor that showers on the 500 unit are cleaned daily.

On 01/10/17 at 12:45 PM, Staff B presented documentation of the daily cleaning logs for the 500 unit. According to the documentation, the most recent cleaning of shower stall #B2229 was 01/06/17. Staff B confirmed this finding on 01/10/17 at 12:50 PM.

1. Interview with the building supervisor, Staff E, was conducted on 01/10/17 at 1:15 PM. Staff E reports his employment began with the facility in February, 2016. In August, 2016 another employee, Staff J, was hired to supervise the housekeeping staff. Staff E and J developed a daily checklist for housekeeping staff to follow and record their completed duties. Staff E reported it was expected each housekeeper would turn in their completed checklist at the end of the 7:00 AM to 3:30 PM daily shift. Staff E reported inconsistency with the checklist being turned in. "Some staff turn it in but it's not filled out, some forget to use it or loose it and some only fill part of it out." Staff E confirmed on 01/10/17 at 1:20 PM that the use of the current checklist was not supported by facility policy, "It's just something (Staff J) and I put together so we'd have some idea of what's getting done by housekeeping staff."

2. Tour of the facility was conducted on 01/11/17 beginning at 9:40 AM on the 500 unit. The housekeeping staff (Staff H-1) was interviewed. Staff H-1 reported he doesn't scrub the shower stalls daily, "that's the regular housekeeper's job, I'm just filling in today." Staff H-1 had a checklist with him and was checking off tasks as he completed them.

3. At 10:24 AM the housekeeper (Staff H-2) on the 100 unit was interviewed. Staff H-2 reported she cleans the showers every other day. The checklist she was using was different from the one used by Staff H-1 on the 500 unit. Staff H-2 was checking off tasks as she completed them.

4. At 10:34 AM the housekeeper (Staff H-3) on the 300 unit was interviewed. Staff H-3 reported he fills the form out at the end of the shift and was unclear what tasks he was expected to complete daily.

5. At 10:50 AM the housekeeper (Staff H-4) on the 400 unit was interviewed. Staff H-4 reported he fills the form out at the end of the shift. Staff H-4 reported he can't possibly do everything on the list everyday but he does make sure to clean every toilet and sink everyday.

6. At 11:10 AM the housekeeper (Staff H-5) for the 200 unit was reportedly at lunch and unavailable for interview. Staff J, the housekeeping supervisor, retrieved the checklist that was supposed to be used by the housekeeper for the day. The checklist only had a few items checked off as having completed thus far. Staff J confirmed the amount of work checked as completed was unacceptable as this was now half way through the shift for Staff H-5.

The above findings were confirmed with Staff B on 01/11/17 at 11:30 AM who accompanied the surveyors on tour.

Staff B also confirmed during interview on 1/11/17 at 1:50 PM that he was unaware of the housekeeping inconsistencies as cleanliness is never discussed at the Quality committee meetings.