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Based on policy review, record review and interview, the facility failed to instruct or assist one patient (#25) to complete a grievance form and failed to provide the patient with a written response. In addition, the facility failed to provide a written response following the hospital's procedure within the proper time frame for one other patient (#63). Six grievances were reviewed. The facility census was 45.

Findings included:

Review of facility policy "Grievances: Patient & Family; The Role of the Patient Advocate", dated 8/04/09, documents in part the following:

- The purpose of the policy is for the facility to provide an effective mechanism for handling patient/family grievances which are an important part of providing quality care and service to patients. All patients and their families have access to a clear process by which they may be heard if they believe their rights or other privileges have not been respected or responded to appropriately by the facility.
- The facility staff person should express concern and empathy for the patient's condition and assure him/her that immediate attention will be given to the problem. If the complaint cannot be resolved the staff person should instruct the patient to complete a Grievance form, or assist the patient in completing the form, and assist the patient to call the patient advocate line if necessary.
- The staff Person responding to the grievance should speak with the patient or patient's representative within 24 hours of the receipt of the complaint to clarify the issues and inform the patent of the time frame for investigation and written response. Once the issue has been resolved the staff person responsible for investigating and resolving the grievance will provide a written response within seven days of the grievance/complaint being stated.

However, review of the facility internal investigation of discharged Patient #25 showed the following:
- The facility received a verbal complaint on 12/11/09 from Patient #25 regarding an alleged staff/patient boundary issue by Staff X.
- There is no evidence that a grievance form was completed by the patient or by staff.
- There is no evidence of a written response to the patient.

Review of the grievance file of discharged Patient #63 showed the following:
- The facility received a complaint by telephone on 12/18/09 from Patient #63 that a disability letter had not been received.
- The facility responded to the patient with a letter dated 1/12/10. The facility sent the letter 25 days after the receipt of the grievance.

During an interview on 1/21/10 at 2:30 PM the director of nursing Staff H, said that no letter had been sent to Patient #25 and the facility did not respond in writing to Patient #63 within seven days of the patient's complaint.

Based on policy review, interview and record review, facility staff failed to ensure each patient and/or patient's representative was offered the opportunity to establish an advance directive for five (Patient #2, #5, #52, #53 and #54) of eleven patients records reviewed for advance directives and the facility failed to document in the medical record the substance of an existing advance directive for one patient (#25) of one existing advanced directive record reviewed. The facility census was 45 patients.

Findings included:

1. An advance directive refers to a patient's right to make decisions regarding his or her own medical care should he or she no longer be physically or mentally capable of doing so him or herself. For example, in an advance directive, the patient may say if he or she wants to be resuscitated if their heart should stop, if he or she wants to be fed through other means if no longer able to eat, etc.

2. Record review of the facility policy titled "Advance Directives Protocol/Do Not Resuscitate (DNR)", dated 08/06/09 and provided during the survey, directed in part the following:
-The purpose of the policy was to recognize the patient's right (patient or their surrogate acting on behalf of the patient) under Federal and State law to make informed decisions regarding their medical treatment.
-The right included the right to accept or refuse medical treatment through the use of advance directives.
-The facility policy was to inform patients of their right to make informed decisions regarding their medical or psychiatric treatment (right to accept or refuse treatment).
-To explain the right, under Federal and State law, to formulate advance directives.
-To inquire of patients if they have executed an advance directive.
-To document the existence of any advance directive executed by a patient.
-To implement their wishes as stated in the advance directive as appropriate.
-To provide assistance to any patient who does not have an advance directive but wishes to formulate one.
-Advance directives were not limited to end-of-life decisions. In a mental health setting, a person may form an advance directive related to what should be done in a psychiatric crisis (name a facility, a provider, specify medications and methods to be used to de-escalate crisis or avoid seclusion or restraint).
-The policy directed staff to inform all patients of their rights during the admission process.
-The policy directed specific staff to inquire about and document if the patient being admitted had executed an advance directive, request a copy of the advance directive and in the event an executed advance directive was not obtained within seventy-two hours of admission, document a follow up call to obtain the advance directive.
-The policy directed if a patient wanted to execute an advance directive, change or revoke an existing advance directive; the patient would be provided information regarding appropriate available resources.

3. Record review of closed Patient #2's admission history and physical revealed staff admitted the patient on 12/26/09 with chief complaint of behavioral problems.

Record review of the patient's admission forms revealed staff failed to document and obtain information regarding if the patient had executed an advance directive.

During an interview on 01/21/10 at 11:00 AM the Director of Health Information Management, (HIM), Staff S reviewed the patient's medical record and admission forms and stated staff had failed to document and obtain information regarding execution of an advance directive.

4. Record review of closed Patient #5's admission history and physical revealed staff admitted the patient on 11/20/09 with chief complaint of assaultive behaviors.

Record review of the patient's admission forms revealed staff failed to document and obtain information regarding the patient's execution of an advance directive.

During an interview on 01/21/10 at 11:04 A.M. the Director of HIM, Staff S reviewed the patient's medical record and admission forms and stated staff had failed to document and obtain information regarding execution of an advance directive.


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5. Review of current Patient #52, 53, and 54's admission forms showed staff failed to document and obtain information regarding these patient's execution of an advance directive.

6. Review of discharged Patient #25's Advance Directives Acknowledgement Form showed the patient informed staff of the existence of an advance directive. However, review of the medical record showed no advance directive in the chart, no documentation of the substance of the patient's advance directive, or documentation of a follow-up with Patient #25 within seventy-two hours of admission of an attempt to obtain the advance directive.

During an interview on 1/20/10 at 3:15 PM the Nurse Manager of the trauma unit, Staff D reviewed the patient's medical record and admission forms and stated staff had failed to document and obtain information regarding an attempt to obtain the advance directive.

Based on policy review, observation and interview, the facility failed to follow their policy regarding camera and video surveillance by not posting signage in all areas where camera monitoring occurs. The facility census was 45.

Findings included:

Review of facility policy "Camera & [and] Video Surveillance", dated 6/17/09, documents in part the following:
-The purpose of the policy is to promote a safe environment for all patients and staff.
- The camera surveillance system being utilized is a system where information is recorded into a secure system for the purpose of retrospective review. Additionally, active, real-time monitoring of patient/staff area is possible.
- Signage is placed on the hospital door and the doors to the units where camera monitoring/recording is occurring.

Observation outside and inside of the main hospital door showed no signage informing patients or visitors that the facility uses both camera and video surveillance.

Observation of the entrance waiting /reception area showed cameras mounted on the wall but no signage informing patients or visitors of the camera/video surveillance.

Observation of the dining room used for patient/family visiting showed cameras mounted on the wall but no signage informing patients or visitors of the camera/video surveillance.

During an interview on 1/21/10 at 2:00 PM, Staff H, the Director of Nursing, said there are no signs on the outside or inside door of the hospital or in the waiting/reception area notifying patients or visitors of camera and video surveillance.

During an interview on 1/21/10 at 3:40 PM, Staff G, the interim Chief Executive Officer, said there are no signs in the dining room informing patients or visitors of camera and video surveillance.

Based on observations, record reviews and interviews, the facility failed to provide a safe patient environment for all patients when staff:
- failed to lock the door to a storage room on the trauma unit that contained items which could be dangerous to patients;
- failed to monitor a plan of action for one employee (Staff X) who the facility previously counseled for staff/patient boundary issues (the employee again crossed boundary issues with a patient and the facility terminated the employee); and
- failed to conduct a patient body safety check for Patient #4 per their policy.

Three personnel files were reviewed and 64 patient records were reviewed. The census on the trauma unit was five and the facility census was 45.

Findings included:

1. Observation on 1/19/10 at 2:20 PM of the trauma unit showed a group room with a closed and locked door. Inside the group room are two additional doors, one for electrical panels and one to a storage room. The storage room door was unlocked and contained electrical equipment with cords and other pieces of equipment too numerous to list. The equipment and/or the cords could potentially be used by patients to harm themselves.

A sign posted on the outside of the group room door reads, "Please keep door closed and locked when not in use."

During an interview on 1/19/10 at 2:25 PM, the trauma unit nurse manager, Staff D, said both inner doors are always locked and he/she didn't know why staff did not lock the storage room door. Staff D said the storage room contains equipment patients should not have access to without staff being present. Staff D said the outer door to the group room is always locked when the group room is not being used and patients are not allowed in the group room without a staff member present.

However, observation the next day, on 1/20/10 at 8:58 AM, showed the outside door to the trauma group room open, unlocked and no staff in the room. Further observation at 9:05 AM showed Staff D close and lock the group room outer door.

During an interview on 1/21/10 at 2:00 PM, trauma staff nurse V said the outer door to the group room is sometimes open and not locked so patients can access the room to be alone or visit quietly with other patients. Staff V said that patients on the trauma unit may go into the group room if they want some quiet time. Staff V said staff does not go in the room with the patients unless there is a group meeting or unless patients are on a precaution where staff must keep the patients within their line of sight.

2. Review of a complaint/grievance showed on 12/11/09 Patient #25 reported to the facility that Staff X talked to him/her about lesbianism and that Staff X had been thinking about "going that way." Patient #25 reported that Staff X told the patient he/she had a couple of other lesbian patients hit on him/her, but that he/she wasn't attracted to them the way he/she is attracted to Patient #25. Staff X also told the patient if he/she won the lottery he/she would take the patient to France.

Review of facility "Employee Corrective Action Report" dated 12/17/09 showed the facility had counseled or disciplined Staff X for the same or similar reasons in December 2008 and October 2009:

- Review of the facility employee Corrective Action Report dated 10/08/09 showed a corrective action of preventative counseling with Staff X. The facility documented, "Patients are reporting feeling uncomfortable that employee [Staff X] is disclosing/discussing too much personal information about him/herself. Patients feeling that some boundaries are being crossed." The facility documented a plan of action as, "Employee will refrain from discussing his/her personal life/history with patients. Employee will review therapeutic boundaries packet/education." Further review of Staff X's personnel record showed no follow up from facility on the action plan and no documentation of training on therapeutic boundaries.

- Review of the annual employee appraisal for Staff X dated 12/10/08 showed an area in need of improvement as: "Be aware of personal boundaries and avoid becoming overly involved with the patients - allow patients to develop their coping skills." The facility listed on the employee appraisal the goals for 2009 to be: "Continue to read and learn more about DBT [Dialectical Behavioral Therapy, a skills focused therapy that balances change with acceptance] PTSD [Post Traumatic Stress Disorder, a severe anxiety disorder], etc. and improve and expand your knowledge base." Review of Staff X's personnel record showed no follow up from facility on the area the facility documented needed improvement.

- Review of the facility employee Corrective Action Report dated 12/17/09 showed, "After reviewing the fact that employee had been counseled on two separate occasions regarding therapeutic boundaries, received training in the fall of 2009 on therapeutic boundaries and the seriousness of the situation the facility has made the difficult decision to terminate employee's employment effective 12/17/09."

Review of therapeutic boundaries training showed Staff X attended training on 12/09/09 presented to all staff members on the trauma unit. During an interview on 1/19/10 at 2:25 PM the nurse manager of the trauma unit, Staff D said he/she presented the training to the staff of the trauma unit at the time he/she became the manager of the unit because he/she felt there were boundary issues with staff. The nurse manager said that he/she did not offer the training for Staff X only and was not aware at the time of the training that Staff X had boundary issues with patients. The nurse manager said the boundary issues with Staff X and Patient #25 occurred after the therapeutic boundaries' training.

During an interview on 1/21/10 at 12:40 PM the Director of Nursing, Staff H, said in reviewing the personnel record of Staff X that there is no record of Staff X receiving therapeutic boundaries training in the fall of 2009, that the training occurred in December 2009. Staff H said there is no documentation in the personnel record of management following up with the action plan given to Staff X during the corrective action dated 10/08/09.


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3. Record review of Patient #4's medical chart revealed the patient was admitted to the facility on 11/25/09 with suicidal ideation. The patient had a plan to overdose on medication.

Record review of the Psychiatric Evaluation dated 11/26/09 revealed in part the following information:
-Justification for Hospitalization (check all that apply)]
a. Dangerous to self, others or property with need for controlled environment
-Past Psychiatric History:
a. Multiple suicide attempts; OD (overdose)

Record review of the Physician Order Form dated 11/28/09 at 8:30 p.m. revealed the physician gave an order to search the patient's room and the patient for suspected drug possession.

Record review of Nursing Progress Note dated 11/28/09 at 8:45 p.m. revealed the following information: The nursing staff was told by several patients that Patient #4 was trying to sell them Vicodin. The physician was notified and ordered a search of the patient and his/her room. At 8:30 the Registered Nurse (RN) informed the patient and he/she gave permission to search his room. The RN documents that the patient was asked to turn his/her pockets inside out and staff found no Vicodin or pills. However, documentation states that food and drinks were found in the room. The RN documents that a "strip search was not conducted so it is possible that the patient has Vicodin on [his/her] body."

Record review of the Discharge Summary dated 12/20/09 revealed in part the following information: "A strip search was also conducted with two staff and the patient and no Vicodin was found but a staff badge was found in the room that would open the door to the storage closet."

Record Review of the Master Treatment Plan dated 11/26/09 revealed no updating of the treatment plan to include the search of the patient's room or of the patient.

During an interview with the Director of Nursing on 1/21/10 at 1:05 p.m., he/she stated a review of the chart was done and confirmed the physician did write "strip search" in the Discharge Summary but that was not done by the staff. He/she stated the RN carrying out the search, asked the patient if the room could be searched and the patient agreed. The RN also asked the patient to pull out the pockets of his clothing and it was done. The DON stated the RN should have contacted the physician to do other than what the orders stated and the RN did not follow the order or the policy of body searches. The DON also stated the other components of the body search policy were not followed.

Record review of the facility's policy on Body Safety Checks, dated 11/03/2009, revealed in part the following:
-Purpose: To define the clinical staff's responsibilities for conducting body safety checks.
-Procedure: A body safety check is a restriction of a patient's rights. Prior to this restriction occurring the following less restrictive measure should be taken:
1. Interview the patient and request their cooperation to ensure their own safety and the safety of others on the unit.
2. Explain the process that will occur if a body safety check is required.
3. Ask them to remove jackets, sweaters, or other outer wear, shoes, socks, headwear, and have the patient turn their pockets inside out.
4. Wand the patient for contraband.
5. Search the patient's room.

Body Safety Check:
1. A body safety check will be conducted on all patients for cause when less restrictive measures have been taken and fail to address the identified safety concern:
a) During the hospital stay when there is a reasonable belief that patient has drugs, alcohol, contraband and/or a weapon (Requires a physician order and is a restriction of patient rights).
2. During the body safety check, the patient well be instructed to remove all clothing and put on a hospital gown. This will take place in a private area unobserved.

Documentation:
2 Update the patient's treatment plan
3 An incident report will be completed by the Charge Nurse of staff member performing the search.
4 The Patient Advocate will be notified.

Record review of the hospital's policy "Patients' Rights: Restriction of", dated 11/03/09, in part revealed the following:
Procedure:
7. Monitoring
- The Nursing Manager or Charge nurse must report each shift to the DON [Director of Nursing]/Nursing Supervisor and the Patient Advocate any initial physician order that by criteria is a patient right restriction, and file an incident report.
- The Patient Advocate or designee will review the patient's rights restriction within 4-hours of notification to ensure that the criteria has been met and documented appropriately in the medical record.
-Any patient rights restriction will be reviewed every two weeks in the Sub-Committee on Patient Rights.
-Any patient rights restriction must be reported to the CEO [Chief Executive Officer] and in the morning Leadership Meeting.
-The medical record and treatment plan will be reviewed by the Patient Advocate to ensure policy compliance. Any deficiencies will be reported directly to the CEO.

Based on record review, the facility failed to ensure physicians properly authenticated all entries in the medical record for three patients (#4,#25, and #45) of 64 records reviewed when the physicians failed to include the time of the entry in the medical record. The facility census was 45.

Findings included:

1. Review of the history and physical for discharged Patient #25 showed the patient entered the facility 11/28/09 with suicidal and homicidal ideations. Review of the psychiatrist's progress notes showed the physician signed the notes but did not time the entries dated 11/30/09, 12/01/09, 12/02/09, 12/09/09, 12/10/09 and 12/13/09.


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2. Record review of Patient #4's medical chart revealed the patient was admitted to the facility on 11/25/09 for suicidal ideation with a plan to overdose. Record review of the Psychiatric Evaluation dated 11/20/09 revealed no time of authentication. In addition, record review of the Psychiatrist Progress Notes dated 11/27/09, 11/28/09, and 11/29/09
revealed no time of authentication.

3. Record review of Patient #45's medical chart revealed the patient was admitted to the facility on 1/08/10 with chief complaint of dementia and agitation. Record review of the History and Physical dated 1/11/10 revealed no time of authentication.