HospitalInspections.org

Based on record review and interview the facility failed to follow the process outlined in the complaint/grievance policy to acknowledge and investigate 8 complaints/grievances (Patients #11, 12, 13, 14, 15, 16, 17, 18) in a total of 16 complaints/grievances reviewed.

Findings Include:

A review of the facility's policy titled, "Patient/Client Grievance Complaint" last reviewed 08/2022 revealed, "... Upon receipt of the grievance, the Client Rights Specialist shall meet with the grievant or representative... identify the issue and explain the process... The Client Rights Specialist shall proceed with a full investigation of the grievance..."

A review of the complaint titled, "MRN 0050221" filed by Patient #11 to the facility on 04/07/2025 revealed, "Patient did not have the correct dosage of medication." There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey).

A review of the complaint titled, "MRN 0049831" filed by Patient #12 to the facility on 04/07/2025 revealed, "Negative interaction with a specific staff member." There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey).

A review of the complaint titled, "MRN 0035084" filed by Patient #13 to the facility on 04/11/2025 revealed, "Negative interaction with a specific staff member." There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey).

A review of the complaint titled, "MRN 0050521" filed by Patient #14 to the facility on 04/14/2025 revealed, "Unhappy with meds given and needs being met." There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey).

A review of the complaint titled, "MRN 0050331" filed by Patient #15 on 04/14/2025 revealed, "Negative interaction with a specific staff member." There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey).

A review of the complaint titled, "MRN 0050301" filed by Patient #16 on 04/16/2025 revealed, "Negative interaction with a specific staff member." There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey).

A review of the complaint titled, "MRN 0050451" filed by Patient #17 on 04/16/2025 revealed, "Patient wished to have unit restriction removed." There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey).

A review of the complaint titled, "MRN 0050151" filed by Patient #18 on 04/19/2025 revealed, "Missing belongings." There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey).

During an interview on 05/27/2025 at 11:01 AM Director of Quality B stated that the policy is that the timeline is 7-30 days for complaints and grievances to be acknowledged and resolved.

During an interview on 05/27/2025 at 12:00 PM when asked about the missing follow-ups on the complaints, Client Rights Specialist K stated, "I have followed-up with all patients; I have gotten behind on documenting the follow-ups."

Based on record review and interview, facility staff failed to ensure signed informed consent for psychotropic medications (used to treat mood, thoughts, behavior or perception) was obtained prior to administration for 2 of 10 patients (Patients #6, 8) in a sample of 10 records reviewed.

Findings include:

A review of the facility's policy titled, "Informed Consent for Medications" last revised 08/2022 revealed, "... 5. The nurse on the unit will obtain and witness the patient's written consent to take psychotropic medications... 6. The patient will be directed to sign the informed consent form..."

A review of Patient #6's medical record revealed the following: Patient #6 was voluntarily admitted to the facility on 03/21/2025 for alcohol detox. The medication consent form, including "Gabapentin (anti-seizure medication)" and "Lexapro (anti-depressant medication)" was signed by Patient #6 on 03/23/2025 (no time). "Administrations" revealed Patient #6 was first administered Gabapentin on 03/21/2025 (2 days before the consent was signed) and Lexapro on 03/22/2025 (1 day before the consent was signed).

A review of Patient #8's medical record revealed that Patient #8 was voluntarily admitted to the facility on 05/11/2025 for major depressive disorder. The medication consent form, including "Invega (antipsychotic medication" was signed by Patient #8 on 05/15/2025 (no time). "Administrations" revealed Patient #8 was first administered Invega on 05/13/2025 (2 days before the consent was signed) and on 05/14/2025 (1 day before the consent was signed).

During an interview on 05/27/2025 at 1:31 PM Director of Quality B stated that there needs to be signed/written consent prior to psychotropic medication administration.