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Based on record review and interview, the facility failed to ensure a timely response (within 30 days) after a patient grievance was given to staff (H) per facility policy for 1 of 4 patients (patient #1) grievances reviewed in a sample of 28 grievances filed in September 2022.

Findings include:

A review of the facility policy titled, "Patient/Client Grievance Complaint", effective date: 07/01/2021, revealed: "...Policy: C. All complaints and/or grievances are addressed in a timely manner as stipulated below and an appropriate intervention or response is provided to the patient and/or family member ...E. The Client Rights Specialist is the designated individual responsible for the facilitation of patient/family grievances...Time Limits:...B. Processing Grievances in non-emergency situations. The following time limits apply:...2. The Hospital Administrator or his or her designee shall assign a client rights specialist to the grievance within 3 business days after the request for formal process has been made. The client rights specialist shall complete his or her inquiries and submit report under WI DHS 94.41 (4) within 30 days from the date the grievance was presented to a program staff person ..."

During an interview with Client Rights Specialist H on 10/19/2022 at 12:35 PM, when asked about the complaint that Patient (Pt.) #1 submitted, Specialist H stated "[Patient #1] wrote a formal letter that was received on 09/12/2022, I was given the letter on the 15th (09/15/2022)-I called the patient on 09/20/2022 to discuss complaints. I have a 30-day time frame to investigate, if I need to extend the due date I send a letter to the patient; 30 days starts on the day I talk to the patient, which was on 09/20/2022." When asked if he/she has wrote a letter to Pt. #1 yet, Specialist H stated, "I'm writing a letter to [him/her] with my investigation report of findings-what was found and what is pending."

Review of letter dated 10/19/2022 to Pt. #1 by Client Rights Specialist H (generated prior to surveyor exit of facility on 10/19/2022 at 5:30 PM) revealed, "...Our goal at 10/20/2022 is to resolve all complaints immediately, however, some may require time to complete an internal review. The facility is in the process of completing an investigation at this time. The facility will continue to investigate this matter and will respond to you within 25 days. If you have have any questions or concerns, pleases contact the patient advocate..."

The clients rights specialist did not complete his/her inquiries and submit a report within 30 days from the date the grievance was presented to him/her as per facility policy.

Based on record review and interview, the facility failed to obtain informed consent for additional personal search beyond right to search consent on admission for 1 of 5 patient medical records reviewed (patient #1) in a sample of 10 records.

Findings include:

During a phone interview with Pt. #1 on 10/17/2022 at 2:46 PM, Pt. #1 reported at admission he/she was asked to remove his/her scrubs to full nudity while staff examined his/her body. Pt. #1 reported not being informed any of this would be happening and could not recall if there were cameras in the room.

A review of the facility policy titled, "Search for Contraband", effective date: 07/30/2021, revealed: "...POLICY: Upon admission, AWOL (absent without official leave) or at anytime during hospitalization the patient, his/her clothing, belongings or room may be searched. Searches are to be conducted in such a manner as to protect the Constitutional and Statutory rights of a patient to privacy, dignity and ensuring the protection and safety of all persons involved. Searches may not be conducted on a programmatic or routine basis without patient's permission (i.e. a belongings and personal search upon admission). A search may only be conducted to the extent required in order to find suspected contraband. A patient's history of harboring contraband may be considered in the justification for a search but cannot be the sole reason for a search. The witnessed permission of the individual's should be obtained prior to any search. If the individual refuses and probable cause exists, staff may conduct the search only with a physician's order - this is considered a denial of rights and is documented as such...II. Personal Search After receiving the patient's permission or a physician's order: a. Two staff members of the same sex as the patient should perform the search - at no time should a staff member conduct personal search alone on a patient of the opposite sex. b. Take the patient into a room to ensure privacy. c. Explain to the patient the reason for the search. d. Assuring them maximum privacy - ask the patient to remove clothing and provide them with a hospital gown. e. Observe the patient for contraband that is taped or otherwise attached to the body. f. Staff is to then search the patient's clothing for contraband. g. This is to be documented in the patient's chart..."

A review of the facility's "CONDITIONS OF ADMISSION/ADMISSION CONSENT AND ACKNOWLEDGEMENT" form on admission, dated 08/01/2022 at 11:48 AM, revealed: documentation of Patient (Pt.) #1's initials consenting to "RIGHT TO SEARCH: I agree that the facility may search my belongings and remove any items that the facility believes may be potentially dangerous to me or others."

A review of Pt. #1's medical record revealed that an Admission "Safety Search Form" was completed on 08/01/2022 at 1:18 PM, the following was documented: "Pre-Assessment: Secure Belongings: Gloves and Wand for contraband: Yes Belts/strings Removed: Yes Separate and Secure Belongings: Yes Offer food / fluids: Yes; Admission: Safety Search Towel & gown utilized to maintain patient privacy? Yes Have the following been searched for contraband? Hair: Yes Underarms: Yes Behind ears: Yes Tongue: Yes Fingers: Yes Bottom of feet and toes: Yes." Clothing Search revealed: "No" contraband was found and no objects were confiscated.

During an interview on 10/19/2022 at 10:03 AM with Chief Nursing Officer (CNO) A, when asked about body searches done on admission, CNO A stated "Skin checks are done upon admission with two staff members in a private room. Patients are asked to remove their top for a contraband check, they put their top back on-then remove their bottoms for contraband check and then pull up; then staff check their feet. They have scrubs or sweats on at this time." When asked if patients remove their undergarments to full nudity and are touched by staff and buttocks separated, CNO A stated, "They are not asked to take their underpants off, they are asked to take their underwire bra off if they have one on-they are asked to move undergarments over to look at buttocks, we never touch any orifice or separate the buttocks."

During an interview with Registered Nurse I on 10/19/2022 at 3:00 PM, Registered Nurse I stated that skin searches happen on the unit by two staff-one has to be an RN. We look in their mouth, look in their hair; we basically start from top to bottom. Women lift up their bra. We don't touch them, we write down anything we see. They take off pants, take off underwear, and we circle around them to look. They take off their socks and we look between toes." When asked if there is ever a time they need to touch the patient during the skin search, Registered nurse I stated, "We never touch the patient the whole time."

Review of Pt. #1's medical record revealed there was no documentation of a reason (extent required) for a "Personal Search" for contraband; this search was more extensive than needed per policy.

Based on record review and interview, the facility failed to administer medications at scheduled times, failed to notify providers of late medication administration, and failed to document pain response after giving PRN (as needed) pain medications per facility policy for 1 of 5 patient medical records reviewed (patient #1) in a sample of 10 records.

Findings Include:

During a phone interview with Patient (Pt.) #1 on 10/17/2022 at 2:46 PM, Pt. #1 was admitted to the facility on 08/01/2022-08/04/2022, he/she did not receive medications the day of admission to the facility and also did not receive pain medications throughout admission for pain control.

A review of the facility policy titled, "Medication Administration", effective date: 07/30/2021, revealed: "...POLICY: [Facility Name] administers medication in an efficient and safe manner according to hospital policy...2. Providers must order medication before it can administered...21. The Nurse will administer medication at the scheduled time: 21.1 Routine Medication Administration a. Daily 8:00am b. BID (twice daily) 8:00am & 8:00pm c. TID (three times daily) 8:00am, 2:00pm and 8:00pm d. QID (four times daily) 8:00am, 12:00pm. 4:00pm, 8:00pm 21.2 The Nurse will administer medications within the following time frames a. Routine: 1 hour before or after the indicated order time. 21.3 With the exception of time specific medications, the provider will be notified prior to medication administration if the dose is > (greater) 2 hours late...34. The Nurse administers PRN (as needed) Medications accordingly...35.2 The Nurse documents PRN medications accordingly with:...Response to dose..."

Patient (Pt.) #1's medical record was reviewed and revealed:

Date of Admission: 08/01/2022 at 12:19 PM
Date of Discharge: 08/04/2022 at 1:44 PM

A review of H&P (History and Physical) Examination by Nurse Practitioner M on 08/01/2022 at 3:00 PM revealed that Pt. #1 was voluntarily admitted to the Behavioral Health Facility for "Major depressive disorder, recurrent severe without psychotic features after sitting in her running car in her closed garage for 90 minutes. She/he was evaluated and medically cleared at [Facility Name] Hospital prior to admission to [Facility Name] Behavioral Health."

A review of Psychiatry Progress Note by Psychiatrist L on 08/02/2022 at 10:00AM revealed, "ASSESSMENT & MEDICAL DECISION MAKING Diagnosis/Impression (from today's visit): Patient remains unable to safely navigate in community and plan for food, shelter and clothing."

Nurse Practitioner M signed orders for the following Routine Medications on 08/01/2022 at 3:20 PM: Metformin (for Diabetes) 500mg BID (twice daily), Omeprazole (for GERD-acid reflux) 20mg BID, Cyclobenzaprine (for back pain) 10mg BID, Omega-3 (for high triglycerides) 1000mg BID, and Gabapentin (for back pain) 800mg QID (four times daily).

A review of the Medication Administration Record dated 08/01/2022 12:19 PM - 08/04/02022 at 1:44 PM revealed, the first dose of Metformin 500mg was given on 08/02/2022 at 7:58 AM, missed 500mg dose on 08/01/2022 at the 8:00 PM Nurse medication (med) administration time per policy-no documentation that a provider was notified. No other missed Metformin doses during the rest of admission.

A review of the Medication Administration Record dated 08/01/2022 12:19 PM - 08/04/02022 at 1:44 PM revealed, the first dose of Omeprazole 20mg was given on 08/02/2022 at 7:58 AM, missed 20mg dose on 08/01/2022 at the 8:00 PM Nurse med administration time per policy-no documentation that a provider was notified. No other missed Omeprazole doses during the rest of admission.

A review of the Medication Administration Record dated 08/01/2022 12:19 PM - 08/04/02022 at 1:44 PM revealed, the first dose of Cyclobenzaprine 10mg was given on 08/02/2022 at 7:59 AM, missed 10mg dose on 08/01/2022 at the 8:00 PM Nurse med administration time per policy-no documentation that a provider was notified. No other missed Cyclobenzaprine doses during the rest of admission.

A review of the Medication Administration Record dated 08/01/2022 12:19 PM - 08/04/02022 at 1:44 PM revealed, the first dose of Omega-3 1000mg was given on 08/02/2022 at 7:58 AM, missed 1000mg dose on 08/01/2022 at the 8:00 PM Nurse med administration time per policy-no documentation that a provider was notified. No other missed Omega-3 doses during the rest of admission.

A review of the Medication Administration Record dated 08/01/2022 12:19 PM - 08/04/02022 at 1:44 PM revealed, the first dose of Gabapentin 800mg was given on 08/01/2022 at 8:46 PM, missed 800mg dose on 08/01/2022 at the 4:00 PM Nurse med administration time per policy-no documentation that a provider was notified.

Psychiatrist L signed orders for the following Routine Psychiatric Medications on 08/01/2022 at 8:04 PM: LamoTRIgine (for Bipolar) 100mg BID and BusPIRone (for Bipolar) 15mg BID.

A review of the Medication Administration Record dated 08/01/2022 12:19 PM - 08/04/02022 at 1:44 PM revealed, the first dose of LamoTRIgine 100mg was given on 08/02/2022 at 8:01 AM, missed 100mg dose on 08/01/2022 at the 8:00 PM Nurse med administration time per policy-no documentation that a provider was notified. No other missed LamoTRIgine doses during the rest of admission.

A review of the Medication Administration Record for Psychiatric medications dated 08/01/2022 12:19 PM - 08/04/02022 at 1:44 PM revealed, the first dose of BusPIRone 15mg was given on 08/02/2022 at 8:00 AM, missed 15mg dose on 08/01/2022 at the 8:00 PM Nurse med administration time per policy-no documentation that a provider was notified. No other missed BusPIRone doses during the rest of admission.

Nurse Practitioner M signed orders for the following PRN (as needed) Pain Medications on 08/01/2022 at 3:20 PM: Oxycodone 5mg/Acetaminophen 325mg every 4 hours for back pain PRN and Acetaminophen 650mg every 4 hours PRN pain-Not to exceed 3000mg/24 hours of Acetaminophen from all sources.

The following PRN pain medications were given throughout admission:
08/01/2022 6:07 PM Acetaminophen 650mg (lower back pain was rated at 8 out of 10 at 6:07 PM, no response to medication documented)
08/01/2022 9:59 PM Oxycodone 5mg/Acetaminophen 325mg (lower back pain rated 8/10 at 9:59 PM, response to medication documented)
08/02/2022 7:53 AM Oxycodone 5mg/Acetaminophen 325mg (lower back pain rated 7/10 at 7:45 AM, no response to medication documented)
08/02/2022 2:03 PM Oxycodone 5mg/Acetaminophen 325mg (lower back pain rated 4/10 at 2:02 PM, no response to medication documented)
08/02/2022 5:42 PM Oxycodone 5mg/Acetaminophen 325mg (lower back pain rated 5/10 at 5:41 PM, no response to medication documented)
08/02/2022 9:52 PM Oxycodone 5mg/Acetaminophen 325mg (lower back pain rated 7/10 at 9:52 PM, response to medication documented)
08/03/2022 5:54 AM Oxycodone 5mg/Acetaminophen 325mg (headache pain rated 6/10 at 5:45 AM, response to medication documented)
08/03/2022 11:24 AM Oxycodone 5mg/Acetaminophen 325mg (neck pain rated 9/10 at 11:24 AM, no response to medication documented)
08/03/2022 4:42 PM Oxycodone 5mg/Acetaminophen 325mg (neck pain rated 10/10 at 4:41 PM, no response to medication documented)
08/03/2022 9:04 PM Oxycodone 5mg/Acetaminophen 325mg (neck pain rated 7/10 at 9:03 PM, no response to medication documented)
08/04/2022 7:49 AM Oxycodone 5mg/Acetaminophen 325mg (general pain rated 10/10 at 7:49 AM, no response to medication documented)
08/04/2022 11:58 AM Oxycodone 5mg/Acetaminophen 325mg (neck pain rated 10/10 at 11:58 AM, no response to medication documented)

During an interview on 10/19/2022 at 10:40 AM with Director of Quality/Risk Management D, when asked about Nurse Medication administration times, Director D stated that medications are passed at "8:00 AM, 12 Noon, 4:00 PM and 8:00 PM-those are the scheduled times." Director D confirmed that if a medication is held or missed it is documented in the chart.

During an interview on 10/19/2022 at 10:42 AM with Chief Nursing Officer (CNO) A, when asked how medications are dispensed, CNO A stated that there is a Pyxis (automated dispense system) on the unit, the Pharmacist and Pharmacy Technician stocks medications.

During an interview on 10/19/2022 at 1:04 PM with Client Rights Specialist H, when asked about Pt. #1's delay in medication administration, Specialist H stated he/she talked to the CNO (Chief Nursing Officer) about the delays and is still under investigation, the Pharmacist is also involved.

Pt. #1 did not receive prescribed medications (Metformin, Omeprazole, Cyclobenzaprine, Omega-3, LamoTRIgine and BusPIRone) on admission date (08/01/2022), there was no documentation that a provider was notified of missed/late medication administration. Pt. #1 received PRN (as needed) pain medications throughout admission, though pain level was not re-assessed to determine if intervention was effective; there was missing nursing documentation regarding pain response after medication was given in 9 of 12 administration of pain medication.

Based on record review and interview, the facility failed to ensure timely documentation of Interdisciplinary Assessments (Psychosocial Assessment) per facility policy for 1 of 5 patient medical records reviewed (patient #1) in a sample of 10 records.

Findings include:

During a phone interview with Pt. #1 on 10/17/2022 at 2:46 PM, Pt. #1 received meals, medications, and attended group therapy before being assessed by a Therapist; Pt. #1 expressed concerns about how his/her needs could be met when he/she wasn't asked what his/her needs were.

A review of the facility policy titled, "Interdisciplinary Assessments", effective date: 07/30/2021, revealed: "POLICY: All patients participating in the program will receive an integrated interdisciplinary individualized assessment to be completed within specific timeframes for each discipline, as delineated below...4. Complete a psychosocial assessment within 24 hours of admission. To be completed by the Assessment Therapist..."

A review of the facility "PATIENT HANDBOOK", revealed:..."Therapists One of our Therapists will meet with you within 24 hours of admission to complete a Psychosocial Assessment. He or she will work with you to explore other things occurring in your life...Our Therapists will make recommendations for your care here, which may include specific groups to attend, individual therapy, family therapy, or other recommendations..."

A review of Patient (Pt.) #1's medical record revealed, "Psychosocial Assessment" was done on 08/03/2022 at 10:15 AM that was not signed by staff, that included the following areas: "Chief Complaint (in Patient's own words)", "How is the Chief Complaint impacting activities of daily living", "Recommendations for treatment and discharge plan", "Patient's motivations for change and identified barriers to treatment and recommend interventions", "Social Service staff participation and intervention with patient's care and discharge plan."

During an interview with Director of Clinical Services F on 10/19/2022 at 10:49 AM, Director F stated that Social Workers do the Psychosocial Assessment within 24 hours after admission-there are six Social Workers that cover Sunday through Friday (8:00 AM - 4:30 PM), and 2 PRN (as needed) Social Workers scheduled on Saturdays to cover.

During an interview via email on 10/24/2022 at 3:50 PM with Director of Quality/Risk Management D, when asked who completed Pt. #1's Psychosocial Assessment on 08/03/2022 at 10:15 AM (as there was no signature on the assessment), Director D stated that Social Worker (N) completed the assessment.

Pt. #1's Psychosocial Assessment by Therapist (Social Worker N) was not completed within 24 hours after admission-per policy.