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Based on observation, interview, and record review, the hospital failed to ensure the patient grievance was promptly processed as evidenced by:

1. The grievance was not initiated by the Patient Advocate for one of 12 patients (Patient 1) as per the hospital's P&P.

2. The Patient Advocate's phone number posted in the lobby was not available for the patients or visitors to leave message to file a grievance.

These failures created the risk of unresolved safety and quality concerns, and substandard patient care to the patients.

Findings:

Review of the hospital's P&P titled Grievances and Complaints dated October 2023 showed the following:

* The definition of the complaint is the written or verbal expression of concern that can be resolved promptly by staff who are present at the time of the complaint. Complaints typically involve minor issues, such as room, housekeeping, or food preferences, which may not require investigation or peer-review processes.

* The definition of the grievance is the written or verbal report of issues that cannot be addressed immediately, may concern an alleged violation of patient rights, hospital compliance with regulatory agencies, or if the patient requests a formal written response to their concern.

* All complaints and grievances are to be submitted verbally or in writing to the Patient Rights Representative, either by the patient, the patient's representative, or a staff member if a patient is unable to execute a written complaint.

Review of the Patient Advocate's Job Description showed the following key responsibilities as the Patient Advocate:

* Act as in house Patients' Rights Representative.
* Meet with the patients within two working days of receiving a grievance.
* Document the patient meeting in the patient grievance form.
* Complete the patient complaint log when finished addressing the patient's needs in a timely manner.
* Report back to the administrator all crisis investigations within 48 hours.
* Handle post-patients' complaint letters and responses.

1. On 10/14/24, an interview and concurrent closed medical record review was conducted with the CNO.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 9/9/24, and discharged on 9/12/24.

Review of the Progress Note dated 9/12/24 at 1007 hours, showed Therapist 1 and the Patient Advocate had three-way phone call with Patient 1's family member regarding Patient 1's discharge planning.

Review of the Call Log dated 9/12/24 at 1041 hours, showed Patient 1's family member called the Patient Advocate.

On 10/14/24 at 1007 hours, an interview was conducted with Therapist 1. When asked, Therapist 1 stated she recalled Patient 1's family member voiced concerns about Patient 1's care during the three-way call with the Patient Advocate.

On 10/14/24 at 1123 hours, the CNO and Director of PI and Risk Management were interviewed. When asked, the CNO and Director of PI and Risk Management stated if the patient or patient representative's concerns were resolved at the moment, it was considered as complaint and not grievance. When asked, the CNO and Director of PI and Risk Management stated there was no grievance filed related to Patient 1. The CNO and Director of PI and Risk Management stated the concerns Patient 1's family member voiced might be considered as a complaint not grievance. When asked, the CNO and Director of PI and Risk Management stated the Patient Advocate had no longer worked in the hospital, so they were not able to identify the concerns were resolved at the moment.

On 10/15/24 at 1223 hours, the CNO verified the above findings.


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2. On 10/14/24 at 1110 hours, during an observation in the main hospital lobby, a posting showed the name and phone number of the Patient Advocate.

On 10/14/24 at 1113 hours, a phone call was made to the posted number of the Patient Advocate. The call was gone directly to the recorded voice mail saying the mailbox was full and could no longer accept messages.

On 10/15/24 at 1150 hours, an interview was conducted with Receptionist 1. Receptionist 1 stated the only number for the Patient Advocate was the one listed on the posting in the main hospital lobby.

On 10/15/24 at 1348 hours, the CNO was notified and acknowledged the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the patients received care in a safe setting when the reusable blood pressure cuff was not cleaned between the patient use. This failure had the potential to result in unsafe care and poor clinical outcomes to the patients.

Findings:

Review of the Reusable Blood Pressure Cuffs' Instructions For Use dated February 2021 showed the following types of wipes are compatible for use on the reusable cuffs. The user must inspect after cleaning to verify that removal of soil and contaminants is complete. Use one or more of the following methods and allow to air dry:

* Wipe with enzymatic cleaner per manufacturer's instruction. Rinse with a damp cloth.
* Wipe with 0.5 % bleach and water solution. Rinse with a damp cloth.
* Wipe with 70% isopropyl alcohol. Rinse with a damp cloth.

On 10/14/24 at 0851 hours, a tour of the Specialty Unit was conducted. The following was observed:

* MHW 1 was observed checking a patient's BP by using a reusable BP cuff. The reusable BP cuff was directly placed to the patient's bare arm.

* The patients were observed in line waiting for their turns to have their BPs be taken.

* MHW 1 was observed not cleaning the reusable BP cuff between the patient use. Upon completion of the BP measurement, MHW 1 was asked to provide a copy of the Vital Signs sheet.

Review of the Vital Signs sheet for Specialty Unit dated 10/14/24, showed 19 patients had their BPs be measured.

On 10/15/24 at 1223 hours, the CNO was interviewed. When asked, the CNO stated the reusable BP cuff was to be cleaned between the patient's use.

The CNO verified the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the staff monitored the vital signs, nutrition, hydration, hygiene, and elimination needs in accordance with the hospital's P&P for two of 12 sampled patients (Patients 8 and 9) when they were restrained or secluded. This failure posed the potential to result in unsafe care to the patients.

Findings:

Review of the hospital's P&P titled Seclusion and Restraints dated March 2024 showed seclusion is the involuntary confinement and isolation of a person, alone in a room or an area, where the patient is physically prevented from leaving. The clinical staff completes documentation on the seclusion and restraints flowsheet. The following patient needs are assessed on a continuous 1:1 basis and documented in the medical record every 15 minutes: vital signs, nutrition and hydration needs, and hygiene and elimination needs.

1. On 10/14/24 at 0831 hours, a tour of the 2W Unit was conducted with the House Supervisor. Patient 8 was observed in the seclusion room in the 2W Unit. MHW 3 was observed conducting 1:1 direct observation of Patient 8 from the outside of the seclusion room door. The House Supervisor stated Patient 8 was a danger to self and others and placed in the seclusion room due to displaying poor boundaries with peers, lunging at staff, and unsuccessful attempts at de-escalation.

On 10/15/24 at 1000 hours, an interview and concurrent medical record review was conducted with the CNO.

Patient 8's medical record showed Patient 8 was admitted to the hospital on 10/12/24.

Review of Patient 8's Seclusion/Restraint Record showed Patient 8 was placed in seclusion on 10/14/24 at 0753 hours, and remained there until 10/14/24 at 0930 hours. There was no documentation in the Seclusion/Restraint Record to show the following patient needs were assessed and documented every 15 minutes as per the hospital's P&P: vital signs, nutrition, hydration, hygiene, and elimination needs.

On 10/15/24 at 1000 hours, the CNO verified the findings and stated there was no section on the Seclusion/Restraint Record for staff to document the assessment of patient's needs (nutrition, hydration, hygiene, and elimination) every 15 minutes.

2. On 10/14/24 at approximately 0855 hours, a Code Grey in the 1W Unit was announced overhead during the hospital tour with the House Supervisor.

On 10/14/24 at 0900 hours, Patient 9 was observed in the seclusion room in the 1W Unit.

On 10/15/24 at 1030 hours, an interview and concurrent medical record review was conducted with the CNO. Patient 9's medical records showed Patient 9 was admitted to the hospital on 10/8/24.

Review of Patient 9's Seclusion/Restraint Record showed Patient 9 was placed in seclusion on 10/14/24 at 0900 hours, and remained there until 1100 hours on the same day. The record showed Patient 9 refused vital sign measurements from 0915 to 1015 hours; however, there were no documented attempts to obtain their vital signs every 15 minutes from 1015 to 1100 hours. Additionally, the record lacked documentation showing the patient's needs were assessed and recorded every 15 minutes in accordance with the hospital's P&P, specifically for nutrition and hydration needs, as well as hygiene and elimination needs.

On 10/15/24, the CNO verified the findings and stated there was no section on the Seclusion/Restraint Record for staff to document the assessment of patient needs (nutrition, hydration, hygiene, and elimination) every 15 minutes.

Based on observation, interview, and record review, the hospital failed to ensure the face-to-face evaluation for one of 12 sampled patients (Patient 9) was completed within one hour of the initiation of restraint or seclusion. This failure to conduct the face-to-face evaluation in a timely manner had the potential to prolong seclusion and could lead to unsafe care.

Findings:

Review of the hospital's P&P titled Seclusion and Restraints dated March 2024 showed the physician, licensed independent practitioner (LIP), or trained RN will conduct a face-to-face assessment of the patient and document the physical behavioral assessment in the patient's medical record within one hour of the initiation of seclusion or restraint. Telehealth methodology cannot be used to conduct the face-to-face evaluation. Evaluation includes the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion.

On 10/14/24 at approximately 0855 hours, a Code Grey in the 1W Unit was announced overhead during the hospital tour with the House Supervisor.

On 10/14/24 at 0900 hours, Patient 9 was observed in the seclusion room in the 1W Unit.

On 10/15/24 at 1030 hours, an interview and concurrent review of Patient 9's medical record was conducted with the CNO. Patient 9's medical record showed Patient 9 was admitted to the hospital on 10/8/24.

Review of Patient 9's Attending Clinician Order for Seclusion/Restraint dated 10/14/24 at 0857 hours, showed the seclusion/restraint was indicated because of the patient's homicidal behavior or threats with the plan and imminent danger to self or others due to their thought disorder.

Review of Patient 9's Seclusion/Restraint Record showed Patient 9 was placed in seclusion on 10/14/24 at 0900 hours, and remained there until 1100 hours on the same day.

Review of the Seclusion/Restraint Post Conference for Staff showed the face-to-face assessment was conducted on 10/14/24 at 1200 hours, which was not within one hour of the initiation of seclusion.

On 10/15/24 at 1030 hours, the CNO verified the face-to-face assessment was not conducted within one hour of when Patient 9 was placed in seclusion.

Based on interview and record review, the hospital failed to ensure the staff monitored one of 12 sampled patients (Patient 9) at the frequency as ordered by the physician. This failure could compromise the patient's safety.

Findings:

On 10/15/24 at 1030 hours, an interview and concurrent review of Patient 9's medical record was conducted with the CNO.

Patient 9's medical record showed the patient was admitted to the hospital on 10/8/24.

Review of the physician's order dated 10/8/24, showed Patient 9's required level of observation was every five minutes, around the clock.

Review of Patient 9's Psychiatric Evaluation dated 10/9/24 at 0700 hours, showed Patient 9 was admitted on a 5250 legal hold for Gravely Disable (GD), bizarre behaviors and a disorganized thought process, presenting with non-redirectable manic behaviors. The Plan of Care section showed Patient 9 had auditory and visual hallucinations and aggressive and violent behaviors; posed a danger to self; and level of observation was to be conducted every 15 minutes.

Review of the Patient Observation Record dated 10/14/24, showed documentation of Patient 9's specific location and activity/behavior (such as walking/pacing, withdrawn, etc.) at specified intervals. However, the documentation showed Patient 9 was not monitored every five minutes as ordered; instead, the staff monitored Patient 9's location and activity every 15 minutes.

On 10/15/24 at 1030 hours, and interview was conducted with the CNO. The CNO stated the physician's order dated 10/8/24, for required level of observation every five minutes was still active and in effect despite the psychiatric evaluation showing the level of monitoring was every 15 minutes. The CNO stated the frequency of monitoring should be based on the physician's orders. The CNO verified Patient 9 was monitored every 15 minutes instead of every five minutes.

Based on interview and record review, the hospital failed to ensure the nursing staff completed the AMA form for one of 12 sampled patients (Patient 1) as per the hospital's P&P. This failure had the potential to result in unsafe care and poor clinical outcomes to the patient.

Findings:

Review of the hospital's P&P titled AMA (Against Medical Advice) Discharge dated June 2024 showed if the patient is to be discharged AMA, the patient or guardian should be asked to sign the AMA documentation form in the presence of at least one witness. If the patient or guardian refuses to sign, the unit nurse is to write "patient refuses to sign" on the signature line and then sign their own name and title with date and time.

On 10/14/24, Patient 1's closed medical record was reviewed with the CNO.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 9/9/24, and discharged on 9/12/24.

Review of the Request for Discharge by Voluntary Patient or Representative (AMA) dated 9/12/24, showed Patient 1 did not sign the AMA form. Further review of the Request for Discharge by Voluntary Patient or Representative (AMA) form showed the sections for "if patient did not sign, please indicate the reason" and "witness" signature and date/time were blank.

On 12/15/24 at 1223 hours, the CNO verified the above findings.

Based on interview and record review, the hospital failed to ensure the short and long-term goals were included in the Master Treatment Plan for 11 of 12 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) as per the hospital's P&P. This failure created the increased risk of poor health outcomes to the patients in the hospital.

Findings:

Review of the hospital's P&P titled Master Treatment Plan dated October 2023 showed the Master Treatment Plan shall contain specific Short-and Long-Term Goals which are individualized specific to the patients' ages, diagnoses, circumstances, and needs.

1. On 10/14/24, Patient 1's closed medical record was reviewed with the CNO.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 9/9/24, and discharged on 9/12/24.

Review of the Psychiatric Problem Sheet initiated by the RN on 9/9/24 at 2355 hours, showed the short and long-term goals and interventions for the problem related to suicidal ideation and danger to self.

Review of the Master Treatment Plan dated 9/10/24, showed the treatment plan was formulated by the multi-disciplinary team including nursing, physician, and social services. However, the Master Treatment Plan failed to show the short and long-term goals as per the hospital's P&P.

2. On 10/14/24, Patient 2's medical record was reviewed with the CNO.

Patient 2's medical record showed Patient 2 was admitted to the hospital on 10/7/24.

Review of the Master Treatment Plan for Patient 2 failed to include the short and long-term goals as per the hospital's P&P.

3. On 10/14/24, Patient 3's medical record was reviewed with the CNO.

Patient 3's medical record Patient 3 was admitted to the hospital on 9/20/24.

Review of the Master Treatment Plan for Patient 3 failed to include the short and long-term goals as per the hospital's P&P.

4. On 10/14/24, Patient 4's closed medical record was reviewed with the CNO.

Patient 4's clsoed medical record showed Patient 4 was admitted to the hospital on 9/2/24, and discharged on 9/12/24.

Review of the Master Treatment Plan for Patient 4 failed to include the short and long-term goals as per the hospital's P&P.

5. On 10/14/24, Patient 5's closed medical record was reviewed with the CNO.

Patient 5's closed medical record showed Patient 5 was admitted to the hospital on 9/7/24.

Review of the Master Treatment Plan for Patient 5 failed to include the short and long-term goals as per the hospital's P&P.

On 10/15/24 at 1314 hours, the CNO and Director of the Clinical Services verified the above findings.



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6. On 10/15/24, Patient 7's closed medical record was reviewed with the CNO.

Patient 7's closed medical record showed Patient 7 was admitted to the hospital on 9/13/24, and discharged on 9/19/24.

Review of Patient 7's Master Treatment Plan, signed by the patient on 9/15/24, did not include the patient's individualized short and long-term goals as per the hospital's P&P.

7. On 10/15/24, Patient 8's medical record was reviewed with the CNO.

Patient 8's medical record showed Patient 8 was admitted to the hospital on 10/12/24.

Review of Patient 8's Master Treatment Plan, signed by the patient on 10/13/24, did not include the patient's individualized short and long-term goals as per the hospital's P&P.

8. On 10/15/24, Patient 9's medical record was reviewed with the CNO.

Patient 9's medical record showed Patient 9 was admitted to the hospital on 10/8/24.

Review of Patient 9's Master Treatment Plan signed by the patient on 10/10/24, did not include the patient's individualized short and long-term goals as per the hospital's P&P.

On 10/15/24 at 1050 hours, the CNO verified the findings and stated the patients' short and long-term goals were documented on their problem sheets but was not included on their Master Treatment Plans.


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9. On 10/15/24, Patient 6's medical record was reviewed.

Patient 6's medical record showed Patient 6 was admitted to the hospital on 10/3/24.

Review of the Master Treatment Plan for Patient 6 failed to include the short and long-term goals as per the hospital's P&P.

10. On 10/15/24, Patient 10's medical record was reviewed.

Patient 10's medical record showed Patient 10 was admitted to the hospital on 10/10/24.

Review of the Master Treatment Plan for Patient 10 failed to include the short and long-term goals as per the hospital's P&P.

11. On 10/15/24, Patient 11's medical record was reviewed.

Patient 11's medical record showed Patient 11 was admitted to the hospital on 10/11/24.

Review of the Master Treatment Plan for Patient 11 failed to include the short and long-term goals as per the hospital's P&P.

On 10/15/24 at 1314 hours, the CNO verified the above findings.

Based on interview and record review, the hospital failed to ensure the master treatment plan was developed for one of 12 sampled patients (Patient 1) as per the hospital's P&P. This failure created the increased risk of poor health outcomes to the patients in the hospital.

Findings:

Review of the hospital's P&P titled Master Treatment Plan dated October 2023 showed the following:

* Each patient admitted to the hospital shall have a written, individualized master treatment plan (MTP) that formulates a plan of care that meets the patient's objectives and needs. Treatment shall be planned, reviewed, and evaluated at regular intervals by a multidisciplinary treatment team. This team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate. Ultimate responsibility for the development and implementation of the master treatment plan shall rest with the physician.

* Within eight hours of admission, the RN will initiate the mater treatment plan. This initial plan shall include high risk and critical medical problems and appropriate physician and nursing interventions as determined by the initial assessments, the physician's treatment plan, and the physician's order.

* Within 72 hours of admission, member of the treatment team shall further develop the master treatment plan that is based on a comprehensive assessment of the patient's presenting problems, physical health, emotional and behavioral status. The team will consist of the physician, nursing staff, social services staff, adjunctive therapy staff, and other clinical disciplines, as appropriate.

* The treatment plan is developed and reviewed on the same day as the treatment team meeting.

On 10/14/24, Patient 1's closed medical record was reviewed with the CNO.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 9/9/24 at 2010 hours, and discharged on 9/12/24.

a. Review of the Nursing Admission Assessment dated 9/9/24 at 2257 hours, showed RN 8 developed the initial treatment plan for Patient 1.

Review of Patient 1's Psychiatric Evaluation dated 9/10/24 at 0700 hours, showed the Psychiatric Evaluation for Patient 1 was conducted.

On 10/15/24 at 1324 hours, the CNO was interviewed. When asked, the CNO stated the nursing admission assessment included the initial treatment plan. The CNO verified RN 8 developed the initial treatment plan prior to physician's treatment plan.

b. Review of the Master Treatment Plan showed the following treatment team's signatures:

* The physician signed on 9/10/24 at 0738 hours,
* The Social Services staff signed on 9/10/24 at 1519 hours.
* The nursing staff signed on 9/10/24 at 1522 hours.
* Patient 1 signed on 9/10/24 at 1519 hours.

On 10/15/24 at 1324 hours, the CNO was interviewed. When asked when the members of the team including physician, social services staff, and nursing staff had met for the master treatment plan, the CNO was not able to answer.

The CNO verified the above findings.