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Based on the review of patient records, the review of hospital admission documentation, policy and procedure review, and a staff interview, it was determined that in 21 of 21 patient records (patient record #s 1-21), the hospital failed to inform each patient, or when appropriate, the patient's representative (as allowed under State law), of all of the patient's rights, in advance of furnishing patient care as required by this regulation; patient rights documents provided to patients were disorganized and therefore failed to ensure that patients and/or their representatives had the information necessary to exercise their rights.

Findings include:

The policy and procedure titled "Notification of Client Rights," Effective 11/01/09, was received. Review of the documentation contained in the policy reflected "All clients will be read the Summary of Client Rights during the admission process and this will be documented in the Progress Notes...1. Following the admission interview, the admitting MHT [Mental Health Therapist] shall advise the client of his/her basic rights by reading form # 0104 Summary of Client Rights...Provide the client with a copy of form # 0104 Summary of Client Rights...5. Have the client sign Notification of Client Rights Acknowledgment Receipt form #104A." Although the procedure included providing patients with the "SUMMARY OF CLIENT RIGHTS" form, none of the documentation contained within that form included the patient rights to participate in the development and implementation of his or her plan of care; the right to personal privacy; the right to receive care in a safe setting; the right to be free from seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff; the right to be free from corporal punishment; and the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

The policy and procedure titled "Client Rights, EOPC," Effective 04/12/05, was received on 08/01/11 at 1535. Review of the documentation contained in the policy reflected "...All persons served at Eastern Oregon Psychiatric Center, or their guardians will be informed of client rights...B. The Chief Medical Officer will be responsible for insuring...that all persons admitted to this institution or their guardians are informed of client rights. C. A copy of 'Client Rights' ORS 426.385...will be presented to all clients at the time of their admission. D. A copy of the 'Summary of Client Rights'...will be presented to all clients at the time of admission."

An interview was conducted with the Chairman of the Client Rights Committee on 08/02/11 at approximately 1000. He/she said that the document titled "SUMMARY OF CLIENT RIGHTS," dated 01/2006, along with a "brief discussion" of patient rights was provided to patients during the admission process in order to inform patients of their rights. He/she further said that additional patient rights information may also be provided to patients during the admission process and contained within the "admission packet" and "welcoming packet."

A patient "admission packet" and "welcoming packet," titled "WELCOME TO BLUE MOUNTAIN RECOVERY CENTER," was received from the Chairman of the Client Rights Committee on 09/02/11 at 1030. A form titled "Blue Mountain Recovery Center Notification of Client Rights Acknowledgement Receipt," dated 04/2006 was contained within the admission packet. Review of the form reflected the following: "I have been given the Summary of Client Rights. The following have been explained to me...*Visitation Rights, *Personal Property Rights, *My right to file a grievance; how to complete a grievance form and the Grievance Process. *Consent to Treatment Rights, *My right to be protected from physical or mental abuse of any kind." The "SUMMARY OF CLIENT RIGHTS" form, dated 01/2006 was contained within the admission packet. The contents of the welcoming packet and admission packet, including the "SUMMARY OF CLIENT RIGHTS" were reviewed and lacked documentation that patients were informed of the following patient rights: The right to participate in the development and implementation of his or her plan of care; the right to personal privacy; the right to receive care in a safe setting; the right to be free from seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff; the right to be free from corporal punishment; and the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. Additionally, several of the patient rights that were contained within the admission packet and welcoming packet lacked organization for patient notification and review. For example, the "Right to See and Get Copies of Your Records" and "BLUE MOUNTAIN RECOVERY CENTER CLIENT RIGHTS" were contained in separate sections of the "Blue Mountain Recovery Center Client Handbook" and located within the welcoming packet, whereas the "SUMMARY OF CLIENT RIGHTS," dated 01/2006 was contained within the admission packet, and therefore failed to ensure that patients and/or their representatives had the information readily available and necessary to exercise their rights.

Twenty-one patient records were reviewed. None of those records contained documentation that the patients were informed of the following patient rights: The right to participate in the development and implementation of his or her plan of care; the right to personal privacy; the right to receive care in a safe setting; the right to be free from seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff; the right to be free from corporal punishment; and the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

Based on the review of policies and procedures, the review of documentation, and a staff interview, it was determined that the hospital failed to establish a clearly explained procedure for the submission of a patient's verbal grievance to the hospital; the hospital also failed to include in their grievance policy, a procedure for informing patients/patient representatives of the State agency telephone number.

The policy and procedure titled "Patient Grievance Procedure," Effective 03/04/06 was reviewed and reflected A. Staff Role in Grievance Procedures...3. The Superintendent and other employees of BMRC/EOPC shall cooperate with the Grievance Representative and the Patient Rights Committee in the resolution of written and verbal grievances...E. Grievance Procedures: Grievances may be resolved informally or may be referred to a four level Grievance Procedure...1. INFORMAL RESOLUTION: Whenever possible, a patient, advocate or representative should attempt to resolve grievances informally with the person or persons causing or involved in the area of complaint. a. Any complaint of any kind can be brought by a client to the attention of any member of the BMRC staff at any opportunity. b. If as part of the discussion of a particular complaint, any BMRC employee feels the complaint should be put in writing for a written response to the client, the client will be provided with a Grievance statement form. c. If the client chooses to fill out the Grievance statement form, it is routed to the client's licensed medical professional (LMP). The LMP makes an initial decision whether the grievance should proceed to the Treatment Team. All written grievances should go to the Treatment Team unless the LMP determines that it is so irrational as to be impossible for BMRC to resolve...2. LEVEL ONE:..a. A formal grievance must be in writing and may be on the form provided by the Hospital...LEVEL TWO...The second step is to appeal the Treatment Team decision to the Patient Rights Committee...The procedure shall be as follows: a. A request for review must be in writing and may be on the Grievance Statement form...LEVEL THREE...The patient or advocate may request the Superintendent to review the grievance...a. A request for review must be in writing..."

Stapled to the back of the policy and procedure was a two page document titled "EASTERN OREGON PSYCHIATRIC CENTER CLIENT GRIEVANCE STATEMENT," dated 04/2005. Review of page 2 of the document stated: "LEVEL 1-THE TREATMENT TEAM: The first step is to file a written grievance with the treatment team. The grievance must be in writing...Staff should help a person who wants to file a grievance or appeal a decision but is unable to write." During an email correspondence received from the Superintendent, he/she revealed that the form was no longer being used by the hospital even though it was attached to the policy and procedure. A black binder titled "Client Grievances 2010-2011" which contained patient grievances was reviewed. The grievances were on a form titled "BLUE MOUNTAIN RECOVERY CENTER GRIEVANCE STATEMENT," dated 02/2008. The forms did not include that staff should help a person who wants to file a grievance or appeal a decision but is unable to write. Review of the documentation determined there was no clear procedure for the submission of a patient's verbal grievance to the hospital. None of the documentation included information for providing patients/patient representatives of the State agency telephone number.

A document titled "SUMMARY OF CLIENT RIGHTS," dated 01/2006 was received from the Chairman of the Client Rights Committee on 08/02/11 at 1030. He/she said the form was contained in the admission packet and provided to patients during the admission process. The form reflected the following: "GRIEVANCE RULE: If you have a complaint or a concern about your care, treatment, training or rights, there is a way to handle it. Any staff member can help you file a grievance or you can request a copy of a grievance form and file it yourself. You can present a grievance to your treatment team if you cannot solve your problem by dealing directly with the people involved." Although the documentation stated that staff could assist with filing a grievance, there was no clear procedure for how staff would assist the patient with a verbal grievance, and whether or not staff would document a verbal grievance, in order to facilitate the submission of a verbal grievance to the hospital. None of the documentation included information for providing patients/patient representatives of the State agency telephone number.

Based on the review of policies and procedures and the review of 2 of 4 patient (Patient #s 22, 23, 24, and 25) grievances, it was determined that the hospital failed to establish a grievance process that included specific time frames for review of grievances and the provision of a prompt response including grievances about situations that may endanger the patient, such as abuse or neglect.

The policy and procedure titled "Patient Grievance Procedure," Effective 03/04/06 was reviewed and reflected "c. Within 20 days after receiving the grievance statement, the Treatment team shall prepare a written response to the grievance containing at least finding of fact and the Team's resolution of the grievance. The resolution shall be written on back of white treatment team copy. Review of the policy and procedure lacked documentation that specified time frames for the review of grievances and about situations that may endanger the patient, such as abuse or neglect.

A two-sided grievance form titled "BLUE MOUNTAIN RECOVERY CENTER GRIEVANCE STATEMENT" for patient #22 was reviewed. The form revealed the patient's signature, and was dated 4/14/11." Side two of the form was titled "LEVEL 1-GRIEVANCE RESPONSE." The areas on the form that were designated "Date of Original Grievance," "Date Grievance Received," "Level 1 (Treatment Team) Response Treatment Team members present," "Date of Review," "Witnesses or others present," "Resolution," "Client satisfied with resolution," Client Signature" "Form Completed/Submitted by," and "Date" were blank. Although there was documentation that reflected "Findings of Fact: enc [Encourage] to call Oregon Advocacy not [grievable]," there was no documentation that the grievance process included time frames for review of the grievance.

A two-sided grievance form titled "BLUE MOUNTAIN RECOVERY CENTER GRIEVANCE STATEMENT" for patient #23 was reviewed. The form revealed the patient's signature and reflected "Date Unit Received: 04/19/11." Side two of the form was titled "LEVEL 1-GRIEVANCE RESPONSE." The areas on the form that were designated "Date of Original Grievance," "Date Grievance Received," "Date of Review," "Form Completed/Submitted by," and "Date" were blank. Although there was documentation that reflected "FINDINGS OF FACT: Client felt staff was being rude..." and "RESOLUTION: Manager will talk 2 [to] staff about situation," there was no documentation that the grievance process included time frames for review of the grievance and the provision of a prompt response.

Based on the review of documentation, policy and procedure review, a staff interview, and the review of 4 of 4 patient (Patient #s 22, 23, 24 and 25) grievances , it was determined that the hospital failed to establish a grievance process that included the requirement that in its resolution of grievances, the hospital must provide the patient with a written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

The policy and procedure titled "Patient Grievance Procedure," Effective 03/04/06 was reviewed and reflected "c. Within 20 days after receiving the grievance statement, the Treatment team shall prepare a written response to the grievance containing at least finding of fact and the Team's resolution of the grievance. The resolution shall be written on back of white treatment team copy. d. The Treatment Team Coordinator shall provide a copy of the report to the patient, advocate or representative and to the Superintendent and the Patient Rights Committee." Review of the policy and procedure lacked documentation that contained the name of the hospital contact person, the results of the grievance process, and the date of completion.

A two-sided grievance form titled "BLUE MOUNTAIN RECOVERY CENTER GRIEVANCE STATEMENT" for patient #22 was reviewed. The form revealed the patient's signature and was dated 06/03/11. There was no documentation contained within the form that the hospital provided the patient with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
A two-sided grievance form titled "BLUE MOUNTAIN RECOVERY CENTER GRIEVANCE STATEMENT" for patient #23 was reviewed. The form revealed the patient's signature and was dated 04/19/11. There was no documentation contained within the form that the hospital provided the patient with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, and the date of completion.
Review of grievance documentation for patient #s 24 and 25, dated 01/05/11 and 05/13/11 respectively, revealed similar findings.

An interview and review of the form titled "BLUE MOUNTAIN RECOVERY CENTER GRIEVANCE STATEMENT" was conducted with the Chairman of the Client Rights Committee on 08/02/11 at approximately 1030. Side two of the form was titled "LEVEL 1-GRIEVANCE RESPONSE." The bottom of side two of the form stated: "Distribute Two Sided Copies To...Client." He/she said that patients are normally provided a copy of side one of the form, and not provided a copy of side two as directed by the hospital's policy and procedure. None of the documentation on side one of the form contained the requirement that in its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion as directed by this regulation.

Based on the review of documentation, the review of the hospital dietary manuals, and staff interviews, it was determined that the hospital failed to ensure that the responsibility for daily management of the dietary services was effectively implemented; adequate training programs for dietary staff was not conducted and documented; and the dietary services were not incorporated into the hospital-wide QAPI (Quality Assurance Performance Improvement) program.

Findings include:

During an interview with the Manager of Dietary Services on 08/02/11 at 1445, he/she was unable to locate any documented evidence of dietary staff training. He/she further checked computer records and verified that there were no dietary staff training records located in the computer. He/she said that the dietary department staff receives only "informal" training from the dietician, however he/she further revealed that those "informal" trainings were not scheduled; there was no tracking of staff attendance or involvement in those trainings; there was no documentation of the content of those trainings; and he/she was unaware of any future plans for implementing staff training programs that may be needed for dietary staff. Additionally, he/she was unaware of any dietary department involvement with the hospital-wide QAPI program. He/she was asked to provide dietary department policies and procedures and the diet manual. He/she provided a black binder that contained 27 pages of diets, recipes, and dietary information from various on-line computer sources. None of the documentation contained within the binder included evidence that the diets had been approved by the registered dietician and the medical staff. None of the documentation contained in the binder included dietary department policies and procedures. He/she further checked his/her computer records and was unable to locate any additional diet manuals or dietary department policies and procedures. He/she said dietary department policies and procedures may be located in the previous dietary department manager's computerized files, however he/she was unable to access those files.

These findings were reported to the Superintendent on 08/02/11 at 1730. He/she verified that the dietary department was not involved in the hospital-wide QAPI program. No documentation of training programs for dietary staff was received for the duration of the survey. A 2010 diet manual, approved by the dietician and medical staff was received and reviewed on 08/03/11 at 0745, however the Manager of Dietary Services was unaware of the 2010 diet manual, and was unable to access dietary department policies and procedures in order to provide daily management of the dietary services.

Based on the review of policies and procedures and staff interviews, it was determined that the hospital failed to establish a current policy and procedure that included the requirement for ensuring that the hospital works cooperatively with the designated organ procurement organization, tissue bank and eye bank in educating staff on donation issues.

Findings include:

Director of Nursing Services on 8/2/11 at 1600. He/she provided a hospital policy and procedure titled "Organ Donation," Effective 8/2/11. He/she reported that he/she was unable to locate a policy that was in place prior to the policy's effective date of 8/2/11.

Review of the hospital policy titled: Organ Donation," Effective 8/2/11, directed "BMRC shall work with its designated organ procurement organizations, Lions Eye Bank of Oregon and Community Tissue Services-Portland, to provide education on donation issues to medical staff."

An interview was conducted with the hospital Superintendent on 8/2/11 at 1730. He/she said that he/she believed the hospital had a policy and procedure for organ, tissue and eye procurement that was in place prior to 8/2/11. He/she further said that no education had been provided to the staff regarding donation issues as required by this regulation and the hospital policy and procedures.

On 8/3/11, the hospital Superintendent provided an "EASTERN OREGON PSYCHIATRIC AND TRAINING CENTERS" policy and procedure, titled "Organ Donation." The policy stated "C. Training: Eastern Oregon Psychiatric Center will utilize training materials provided by the Organ Donor Program to promote the proficiency of all persons assigned the responsibility for complying with this policy." Further review of the documentation revealed that the policy had been approved and signed by the Superintendent, however the documentation lacked evidence of an effective date in order to determine whether or not the policy was in effect prior to 8/2/11.