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 review and interview the facility failed to:

A.) Follow its own policy and procedures: to recognize and differentiate between a complaint and grievance, take grievances to the Grievance Committee to determine if the patient's issues were properly investigated and resolved, and failed to send quarterly reports regarding complaints and/or grievances to the Performance Improvement Committee and Governing Board.

B.) The facility staff failed to recognize the patients' rights to submit a written grievance, supply the materials, tools, and time needed to make a formal grievance, and failed to assist the patient through the process in 2 (#12 and #31) of 2 patient complaints reviewed and observed.

A.) Review of the facility's policy and procedure, "Patient Grievance/Complaint" stated,
A. A "patient grievance" is defined as a formal, written or verbal grievance that is filed by a patient, when a patient issue cannot be resolved promptly by staff present. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances. Any written complaint or concern will be classified as a grievance.

A "patient complaint" is an allegation or source of dissatisfaction expressed verbally or in writing. Complaints relevant to change in bedding, housekeeping of a room, and serving preferred food and beverages are expectations that require the implementation of a relatively minor change in a timelier manner than a written response.

B. Upon request, any Hospital employee may assist a patient or their representative in the completion of a grievance letter or a Compliment/Complaint/Grievance/Suggestion form.

C. Patient Advocate will make personal contact with the patient making the request within three working days of receipt of the grievance.

1. Jointly, the patient and the Patient Advocate will discuss the patient's verbal or written request in order to clarify the patient's concerns and formulate a statement of grievance.

2. The Patient Advocate will convene a meeting with the Grievance Committee to consider the patient's grievance that are received. Composition of the Grievance Committee may include any of the following:
CEO/C00 Director of Nursing Director of Compliance Director of Clinical Services

3. The Grievance Committee will review and further investigate the substance of the patient's grievance to assist in the provision of a response and resolve any deeper, systemic problems indicated by the Grievance.

4. A written response will be provided to the patient within (7) seven working days of the initial meeting of the Advocate and the patient. The response will include:

Name of the hospital contact person.
The steps taken on behalf of the patient to investigate the grievance.
The results of the grievance process.
The date of completion.
The response will be sent by US mail, postage prepaid, to the address included in the written grievance or the address on record for the most recent patient registration. The date of mailing will be logged as the date of response.

5. If patient is dissatisfied with written response, patient care advocate will forward grievance to chief executive officer or his designee in 10 working days.

D. Grievances about situations that endanger the patient, such as neglect or abuse, shall be reported immediately to the Director of Nursing and to the Director of Risk Management.

E. The Patient Advocate and Grievance Committee must ensure that what is learned from the grievance process is forwarded to the Performance Improvement/Quality Council Committee:

1. Compliment/Complaint/Grievance/Suggestion forms are forwarded as needed to the affected department manager, CEO/COO, Director of Nursing, Director of Compliance/Risk Management, and other leaders as necessary.

2. All grievances will be logged in a database maintained at facility. The log will include patient identifiers, date of the grievance, and the date of the written response.

3. Quarterly reports regarding complaints and/or grievances are presented to the Performance Improvement Committee and Governing Board. The Performance Improvement Committee activates Task Forces, PI Teams, and ad hoc committees to investigate and resolve issues and define trends."

Review of the facility complaint/grievance log revealed there was just complaints listed. An interview was conducted with Staff #11 on 1/29/19 at 10:10AM. Staff #11 reported she did not have any grievances just complaints. Staff #11 was unaware of what changed a complaint into a grievance. Staff #11 reported she was not familiar with the facility's policy and procedure for Complaints and Grievances. Staff #11 reported she did not have any grievances just complaints.

Review of the complaint log revealed a complaint written on a plain piece of paper and not on an occurrence form. The complaint stated,

" filing number ___ (Patient #12's name); M# 6-01 admitted [DATE] Today's date: 1/17/19 ___ (Staff #11's name) Patient advocate spoke with ___ (Patient #12's name) in regards to her commitment paperwork that she had just received and she was very emotional. She stated that she went to MHMR to get help and they tricked her by making her think they were going to help her and then they had officers detain her and bring her to RPBH. She stated she does not need to be here and asked that I speak to Dr. Torres. I spoke to Dr. Torres and he wants to hold her for 72 hours and observe her and see how she is doing. I explained this to ___ (Patient #12) and she was ok and knew she would be released soon if everything goes well."

Staff #11 informed the surveyor that she initially went to see Patient #12 because Patient #12 was upset that she was breast feeding and her baby was at home. Staff #11 reported that she did not write that down because she turned that over to Nursing and was trying to explain to patient #12 about her commitment process. Staff #11 did not have any follow up information concerning the breast feeding issue or what was done. Staff #11 failed to recognize this issue as a grievance. It was not followed through by The Patient Advocate and Grievance Committee nor Quality Assessment Performance Improvement (QAPI).

B.) A tour of the 300-400 unit was conducted on 1/30/19 in the afternoon. Patient #34 was found walking out of the unit with a group of patients. The patients were on their way to group therapy. Patient #34 was found loudly asking to fill out a complaint on one of the staff members. Patient #34 asked three times and the staff was not responding to her request or trying to address the situation. The Mental Health Technician (MHT) continued to keep walking and opening the doors to lead the group out. Staff #13 was asked by the surveyor why Patient #34 was not allowed to make a complaint nor was she even acknowledged. Staff #13 told the nurse to hand her a complaint form. The patient began to walk off and the surveyor asked her if she had a pen or pencil. Patient #34 stated, "no" and handed the complaint form back to the nurse and stated, "I can't do this or I will miss group and left the form on the desk. No staff member reached out to assist the patient in making her complaint or addressed with her after group session was over. The nurse at the desk stated, "she does this all the time." The surveyor asked the nurse, "does this mean she cannot lodge a complaint?" The nurse stated, "she can but it's always the same." The facility staff failed to recognize the patients' rights and failed to assist her in making a formal complaint or grievance.
Based on review of records, observation, and interviews, the facility failed to:

A.) prevent neglect by providing the patients with clean clothes. Provide needed clothes to promote patient dignity and avoid mental anguish in the milieu in 1(33) of 3 (#31,#32, and #33) patient observations on the 200 Geri/psych unit.

B.) provide a place for patients to sit down or lie down while being secluded. Patients were forced to sit or lie down on the floor in 3 (Unit 200, 300-400, and 500-600) out of 3 seclusion rooms.

Findings included:

A.) A tour was conducted of unit 200 (Geri/psych) on the afternoon of 1/28/19. Patient #31 was found sitting in the dining area eating his lunch. Patient #31 was wearing paper scrubs. He also had a pull over jacket on. On 1/29/19 Patient #31 was still in paper scrubs and was found outside in 40-degree weather smoking with no jacket or warm clothing. On 1/30/19 Patient #31 was in paper scrubs and socks.

An interview was conducted on 1/30/19 at 2:04PM with Staff #35. Staff #35 was asked why Patient #31 was in paper scrubs and has any effort been made to contact family or friends to help get his clothes. Staff #35 stated, "He's wearing paper scrubs because he was suicidal. We take all their clothes away if they are suicidal. It's to keep them from hanging themselves with their clothes." Patient #31 was standing in front of Staff #35 wearing his pull over shirt/jacket as she was explaining to the surveyor why he could have no personal clothes. Staff #35 reported it was the policy not to let suicidal patients have their own clothing. Staff #35 was asked about the patient's underwear and if he had clean underwear. Staff #35 stated, "We have that fish net underwear he can wear. You know, like we give to the ladies when they are on their periods and need to wear a Kotex." Staff #35 was unable to tell the surveyor what policy and procedure she was referring to, if the patient had on clean underwear or not, if family or friends had been notified to bring clothes, or if the facility had made arrangements to get the patient clothes appropriate for the facility and weather.

An interview with Staff #13 on the afternoon of 1/30/19 revealed he was unaware of a policy that stated a patient was not to have their clothing if suicidal, only unsafe clothing with strings or ties. Staff #13 confirmed that Patient #35 had jeans and underwear when he came in and will retrieve the cleaned items for the patient.

B.) Review of the Seclusion Rooms on Unit 200, 300-400, and 500-600 revealed they were empty. The three seclusion rooms had dirty and soiled tile floors. There was no place for a patient to sit or lie down while in seclusion. A video was reviewed of Patient #7 on unit 300-400. The video was dated and time stamped at 1/6/19 at 1:15:13PM. The video revealed Patient #7 was given an Emergency Behavioral Medication (EBM) on the unit hallway and was escorted to the designated "Seclusion" room. Patient #7 was taken to the ground in the seclusion room and staff were holding the patient down on the dirty and soiled floor.
An interview with staff #13 on afternoon of 1/30/19 stated that there was no furniture in the room but they could pull a mattress in the room if needed. Staff #13 reported that the patients are not given pillows or sheets for safety reasons. Staff #13 was asked what mattresses would be placed in the room and he stated, "we would find one somewhere." Staff #13 was asked if patients had ever been given a mattress in seclusion and staff #13 reported he was not aware of a time when they had.