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Based on interview and document review the facility failed to protect and promote each patient's right to a safe environment and failed to provide a comprehensive complaint and grievance process, resulting in the potential for harm to all patients served by the facility. Findings include:

1. Failure to log, investigate, and respond to complaints and grievances submitted to the facility. (See A-0118)

2. Failure to implement policy to protect a patient from an alleged abuser while an investigation was initiated. (See A-0145)

Based on document review and interview, the facility failed to follow their policy and procedure for complaints and grievances resulting in the potential for loss of patient rights to all patients served by the facility. Findings include:

On 8/22/2023 at 1500 a document review occurred of the complaints and grievance log. The log encompassed complaints/grievances from 01/01/2023 through 08/21/2023. According to the log two grievances were listed, one in 01/2023 and another 04/2023. Staff A, the director of quality and risk was queried how the facility obtained complaints/grievances, investigated complaints/grievances, and respond to the complainants. Staff A stated that the facility had identified that complaints and grievances were not being recorded or entered in the incident log. Staff A further stated that the position "patient ambassador" had previously been responsible for taking complaints and grievances had been eliminated in June 2023. Staff A was then queried what plan was made with the elimination of the patient ambassador position in order to obtain complaints and grievances. Staff A stated staff were supposed to enter all complaints and grievances into the incident reporting system, but staff had not been entering the information. Staff A acknowledged that complaints and grievances were not being submitted, investigated, and response from the facility was not taking place.

On 8/22/2023 at 1300 a review occurred of the policy titled, "Complaint and Grievance Process," revision date of 2/19 and reviewed date of 1/23 stated the following under subtitle ' Procedure, ' "1. The Patient Compliant is entered into the Incident reporting system for all complaints received, whether concerns/dissatisfaction by end of the shift. Quality Page 5 of 10 Proprietary and Confidential to (facility) and its Affiliates 2. All information/sections in the hospital ' s incident reporting system will be completed when entering in a complaint. If the patient is not the person making the complaint, enter the name, relationship to the patient, and the contact information of the complainant into the incident reporting system to allow for appropriate follow up and contact. 3. Enter all staff involved with the complaint. This may include all staff present in the department, depending on the nature of the complaint. 4. Describe the complaint or issue in the complainant ' s words. 5. Describe the desired resolution as determined with the complainant/patient. 6. Describe the actions taken to resolve the issue/complaint, if applicable. 7. Indicate if the issue was resolved or remains unresolved. Include a brief description of the resolution. 8. If resolved, indicate if the complainant is satisfied with resolution. If not satisfied, include a brief description of the unresolved issue. The DQM (Director Quality Manager) will then proceed with the Grievance procedure process. 9. Enter name of nursing supervisor notified if different from writer. 10. For all Hospital incidents reporting system complaints, once all areas have been completed, & saved, the incident/complaint will automatically be sent to the DQM or designee set up in the system, whom will assign to the appropriate individuals for immediate follow up. If the complaint has not been immediately resolved to the complainant ' s satisfaction, the DQM will consider it to be a Grievance and will follow the grievance process."

Based on interview and document review, the facility failed to follow policy after an allegation of abuse for 1 of 1 patients (P-9) resulting in the potential for abuse for all 25 patients on the unit. Findings include:

On 8/21/2023 at 0955 during the initial tour of the facility a family member of P-9 approached this surveyor and requested to have a conversation to express concerns. The family members of P-9 identified themselves as P-9's mother and aunt. P-9's aunt asked if staff were allowed to continue to provide care if there was an allegation of physical assault. P-9's aunt stated P-9 had called her mother at 0730 and stated that P-9 stated the nurse providing care (staff K) had squeezed P-9's face and told P-9 to "stop acting up." P-9's mother further stated when she arrived at the unit the nurse (staff K) had a verbal exchange with her in the hallway stating she was not going to be accused of anything and P-9 was just wanting pain medication. P-9's aunt stated, "Should staff be removed from providing care in a situation like this?"

On 8/21/2023 at 1015 Staff B, the director of nursing was asked to provide a policy for allegations of physical abuse to patients. On 8/21/2023 at 1020, staff B provided a copy of the policy titled, "Abuse and Neglect," with a revision date of 1/23. The following is stated in the policy under subtitle ' Suspected Abuse: First Responder/Supervisor Responsibilities, #1....The unit supervisor will immediately remove the accused person from the hospital pending further investigation. If the unit supervisor is not readily available, the administrator on call will be immediately notified."

On 8/21/23 at 1100 Staff B was queried if staff K had been immediately removed from care. Staff B responded that he had heard the altercation between staff K and P-9's mother. Staff B stated he had removed staff K from P-9's care assignment to another nurse and had kept staff K on the floor for patient safety concerns of covering adequate nursing staff until he could obtain another nurse. Staff B acknowledged he had not followed the policy.