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Based on review of records, interviews with staff, and review of policies, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent in the hospital's grievance process. One of one (Patient Record #5) complaint, documented in the medical record had not been identified, reviewed and resolved.

Findings:

1. On 1/23/11 Patient # 5's chart was reviewed. The documentation in the chart indicated the patient complained to staff about a male peer. The documentation stipulated "he has violated every woman in here, I don't want him to touch me". Physician and nursing documentation did not indicate Patient #5 was hallucinating or delusional at the time of the complaint. Further in the documentation Patient #5 was threatening to commit suicide if the male peer was not removed from the patient's side of the unit. There was no evidence to indicate the complaint/incident had been investigated or action taken at the time, or after, the complaint was voiced. There were no Event/occurrence reports for this complaint/incident.

2. The grievance log did not contain the complaint/grievance voiced by Patient #5, voiced to staff about another patient ' s behavior toward peers and requests to be separated from the patient.

3. When the surveyors asked about the complaint, Staff B stated he had not heard about the complaint. Staff A, B, C, and D stated they would have to do more education with staff on the complaint/grievance process.

1. On the afternoon of 1/23/11, October and November 2010 incident reports were reviewed by surveyors. The incident reports provided indicated two instances of sexual encounters between residents and a altercation/fall that were not investigated. Incident One: Patient #1 was reported having oral sex with an unnamed female patient in a group meeting area. The incident report did not indicate any physical exam or follow up evaluation of the unnamed female patient. There was no documentation the encounter had been reported to the unnamed female patient's physician. Incident Two: Another incident occurred in a patient room. The incident form indicated Staff E found Patient #6 and Patient #10 in bed having intercourse. The incident report did not indicate any physical exam or follow up evaluation of Patient #10. There was no indication in the incident report the patient's physician had been notified. Incident Three: Patient #2 (one of the patient's mentioned in the complaint) was reported in an altercation with a staff member in which she received a bloody nose. Patient #2 alleged a she was "assaulted and hit her nose on the floor and it began to bleed heavily". The incident report completed by the Mental Health Tech involved indicated the patient had a "slight bloody nose". There was no further assessment of Patient #2 documented in the incident report or in Patient #2's chart. There was no indication the physician was notified.

2. On 1/23/11 Patient # 5's chart was reviewed. The documentation in the chart indicated the patient complained to staff about a male peer. The documentation stipulated "he has violated every woman in here, I don't want him to touch me". Physician and nursing documentation did not indicate Patient #5 was hallucinating or delusional at the time of the complaint. Further in the documentation Patient #5 was threatening to commit suicide if the male peer was not removed from the patient's side of the unit. There were no incidents, complaints, or grievances listed in any of the logs for the complaint or for patient #5. There was no evidence to indicate the complaint/incident had been investigated.

3. Review of the quality council and patient safety meeting minutes for 2010 did not demonstrate grievances, complaints, and incidents were part of the quality improvement program with analysis to improve hospital practices. Staff B told surveyors on the morning of January 24, 2011, grievances and complaints were reviewed in a separate greivance committee. Staff B stated there were no minutes taken at these meetings. Staff B also told surveyors the grievances/complaints are reviewed individually and there is no analysis and trending to identify potential performance improvement areas. Surveyors reviewed patient safety committee minutes for 2010. The data presented reflected volumes of complaints/grievances per department and did not have any other trending or analysis.

Based on record review and interviews with hospital staff, the hospital does not ensure that patients receive adequate discharge planning. 3 of 3 (Pt#s 1,2,5) patients did not have evidence that post hospital needs were identified and implemented and the patients were provided with adequate assistance to assure the patients have appropriate continuing care.

Findings:

1. Patient #1 was involuntarily admitted to the hospital. Patient #1's medical record did not have evidence that the patient had a safe place to return after discharge. The record stated on admission, 11/1/10, that the patient lived with his girlfriend and would be returning there. An address was listed on the face sheet, but was not identified who's address it was. There was no evidence that the girlfriend had been contacted to verify that was where the patient would be returning. The admission sheet stated that they were unable to get much information from the patient due to his manic condition. No evidence in the medical record showed further evaluation of the patients living arrangements.

2. Patient #1's medical record stated on the day of discharge, 11/01/10, that the patient was discharged by taxi. It did not document where the taxi was taking the patient.

3. Patient #1 had been a patient at an outpatient mental health clinic prior to admission to the hospital. The medical record progress note stated "followup care with "clinic name", but no times or appointments were documented.

4. Patient #1 medical record documented the patient was discharged with prescriptions, but there was no information evaluating the patient's ability to pay for or obtain the medication.

5. Patient #2's discharge plan was to return home where she lives alone. According to documentation in the chart, the patient lived alone and her only means of transportation was her ex-mother-in-law. Patient #2's medical record documented on 11/02 and 03/2010, the patient expressed anxiety and concern about returning home alone -a disagreement with the discharge plans. The medical record did not reflect anyone addressed this concern/problem with the patient.

6. Documentation in Patient #5's chart 11/22/2010 indicated at "0805 the pateint was agitated with other patients and confrontational", at 1000 was "excited, intrusive and upset". The medical record did not reflect anyone addressed the agitation and confrontational behaviors. Documentation at 1535 indicates "patient's family here to pick up, personal belongings already packed up". There was no documentation the patient was ready for discharge. The documentation did not reflect the pateint was functioning at the highest level or the patient's mood had been stabilized.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital's Mental Health discharge criteria requirements are met. Three (#'s 1, 2 & 5) of nine (#'s 1 through 9) patients' records who were discharged from Deaconess-Bethany did not meet the hospital's Mental Health discharge criteria requirements.

Findings:

1. The hospital's mental health discharge criteria as documented in Nursing Guideline # MH-025 states the following:
A. Assess patients to determine if the following criteria are met for discharge as indicated:
a. No longer present as danger to self/others
b. Compliance with mediations and treatment
c. Special treatment modalities in the hospital resolved/stabilized
d. Achieved a safe medical detox
5. Demonstrates improved mood stability
6. Demonstrates increased ability to care for basic needs
7. Functions at highest level in least restrictive environment

2. Patient #1's record documented the patient was continuing to exhibit anxiety and agitation on the morning of the patient's discharge at approximately 10 AM. The previous day early in the morning the patient was observed having oral sex with another hospital patient. The patient was noncompliant with staff directions after being ordered by staff multiple times to exit the room.

3. Patient #1 was given an antipsychotic medication injection at 10:20 AM on the day of discharge because of behavioral symptoms and was discharged at 1200 PM.

4. Patient #2's discharge plan was to return home where she lives alone. According to documentation in the chart, the patient lived alone and her only means of transportation was her ex-mother-in-law. Patient #2's medical record documented on 11/02 and 03/2010, the patient expressed anxiety and concern about returning home alone -a disagreement with the discharge plans. The medical record did not reflect anyone addressed this concern/problem with the patient.

5. Documentation in Patient #5's chart 11/22/2010 indicated at "0805 the pateint was agitated with other patients and confrontational", at 1000 was "excited, intrusive and upset". There was no documentation the patient was ready for discharge. Documentation at 1535 indicates "patient's family here to pick up, personal belongings already packed up". The medical record did not reflect anyone addressed behaviors.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to include, analyze and track grievances as part of the quality process to improve patient care and hospital services.

Findings:

Review of the quality council and patient safety meeting minutes for 2010 did not demonstrate grievances, complaints, and incidents were part of the quality improvement program with analysis to improve hospital practices. Staff B told surveyors on the morning of January 24, 2011, grievances and complaints were reviewed in a separate greivance committee. Staff B stated there were no minutes taken at these meetings. Staff B also told surveyors the grievances/complaints are reviewed individually and there is no analysis and trending to identify potential performance improvement areas. Surveyors reviewed patient safety committee minutes for 2010. The data presented reflected volumes of complaints/grievances per department and did not have any other trending or analysis. This information was presented to administration and no further documentation was provided.