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Based on interviews and record reviews it was revealed that the facility failed to ensure that the Grievance Procedure was effectively implemented. A hand-written grievance letter was noted in Patient's #1 record. Patient #1 had been admitted to the Psychiatric Emergency Services (PES) Unit on 10/14/15.There were nine specific items identified in the letter which was signed by the patient. There was no evidence that the grievances had been reported to the Director of Risk Management. There was no evidence that the grievances had been reviewed or resolved.

Record review of the hand-written letter signed and dated by Patient #1 contained the following: dated 10/14/2015, had Patient #1's address and phone number for contact. The areas of grievance were in the area of:
1. Room temperature, "Temperatures were 64 degrees" and it was too cold.
2. No clock.
3. Locked bathrooms. Staff opened the bathrooms upon asking.
4. Sandwiches for every meal. Patient reported he was a diabetic and did not receive his special diet.
5. Phone not available. Unable to file a grievance or call family.
6. No access to water. Drank from a dixie cup when he had access to the sink.
7. Restraint issues. (at another facility).
8. Physician services, had to wait to see the doctor.
9. Lack of clean socks available.

Interview with the Registered Nurse (RN) staff who worked on the Psychiatric Emergency Services on 4/6/16 at 9:30 AM revealed that she had never heard Patient #1 make any allegations or grievances about the (PES)Unit. The RN stated that she had never seen the hand-written letter and did not know how it got placed in the record. RN #1 stated that she had been trained and was aware of the grievance procedures.

Interview with RN #2 on 4/6/2016 at 11:20 AM, revealed that she was aware of the grievance procedures and did not know of any patient's filing a complaint or grievance.

Interview with Mental Health Worker (MHW) on 4/06/16 at 10:50 AM revealed that she had not heard of any patients filing a grievance or a hand witten grievance letter. MHW stated that phones are made available to all patients. The phone is available in order for any patient to file a grievance.

Interview with the Physician for Patient #1, on 4/6/16 at 10:10 AM, revealed that the patient had not verbalized any grievances to her about the areas he identified. The Physician stated she had not seen the hand-written letter prior to 4/6/16. Patient #1 only stayed in the hospital for one day.

Interview with the facility's Director of Risk Management on 4/5/16 at 12:45 PM, revealed that there were no grievances noted in the Grievance Log for Patient #1. The Director of Risk Management stated that she saw a hand-written grievance letter scanned into Patient #1's medical record on 4/5/16. The letter was noted while the record was photocopied for the investigators. The Director stated that no staff had reported any grievances, complaints or allegations made by Patient #1.

Record review of the facility's Policy titled "Patient Complaints and Grievances" dated 02/1996 with a Review date of 11/2013, identified the purpose, definitions, and procedures. The policy documented, " A grievance is a substantive quality of care issue or a perceived violation of a patient's rights, which may arise when resolutions are deemed unsatisfactory by the patient or family or related party. Any unresolved concern will be considered a grievance and will require an investigation and a written response by the risk manager." The policy also documented, " Every employee has responsibility for addressing patient complaints and forwarding grievances to the Quality/Risk Department."

Based on observations and interviews it was revealed that the facility's air conditioning thermostat in the Psychiatric Emergency Services (PES) unit was set at an uncomfortable setting for the patient's who resided in that unit.

A grievance letter dated 12/29/2015 and submitted by Patient #1 documented that the "room air conditioner was set at 64 degrees". Patient #1 documented that he complained that it was too cold. Patient #1 described the unit he was in as PES, Psychiatric Emergency Services", in October 2015.
Observation on the PES unit on 04/05/16 at 12:00 PM, revealed that the physical temperature in the main hallway was 55 degrees. The temperature was taken by the Physical Plant Operations Director, (PPD) with a digital thermometer. The temperatures taken in the patients's bedrooms ranged from 67 degrees to 77 degress. The thermostat was set at 62 degrees. The Physical Plant Director stated that there should be a key in the nurses station to decrease or increase the temperature for the patient's needs and requests. The nurse at the nurse's station stated that the key was on the security's staff key ring. The PPD directed the staff to set the thermostat at 73 degrees.