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Based on record review and interview, the facility staff failed to ensure that grievances were fully investigated per facility policy, in 7 of 7 patient grievance files reviewed out of a total of 12 grievances filed since opening in August 2021.

Findings include:

A review of the facility policy, titled "Patient/Client Grievance Complaint", dated 7/1/2021, revealed: "Policy: C. All complaints and/or grievances are addressed in a timely manner as stipulated below and an appropriate intervention or response is provided to the patient and/or family member. Filing a complaint or grievance shall not limit a patient's access to care. E. The Client Rights Specialist is the designated individual responsible for the facilitation of patient/family grievances.... A 'patient complaint' is an allegation or source of dissatisfaction expressed verbally or in writing. A 'patient grievance' is defined as a formal, written, verbal communication that is filed by a patient, usually presented when a patient issue cannot be resolved promptly by staff present....Any written complaint or concern will be classified as a grievance. The Informal Resolution Process: D. The Clients Rights Specialist shall prepare a brief report indicating the nature of the resolution and provide copies to the Hospital Administrator or designee, to the client and any person acting on behalf of the client. The Formal Resolution Process: D. The Client Rights Specialist shall proceed with a full investigation of the grievance...."

A review of the facility documents, titled "Compliment, Suggestion, Complaint Form" seven forms dated from 11/8/2021-3/25/2022, revealed: "Leader Response to Compliment/Suggestion/Complaint: This area is blank for all 7 Forms completed, with no signatures in the Patient Advocate line, Risk Director line and Department Leader line."

During an interview on 4/6/2022 at 2:15 PM, Interim Chief Operating Officer (COO) I confirmed that the Leader response area and signature lines are blank for all seven forms. COO I stated "We are looking into a new reporting system."

Based on interview and record review the facility failed to update their visitation policy to reflect COVID 19 visitor restrictions in 3 of 3 facility documents related to Patient Rights.

Findings include:

A review of the facility policy, titled "Patient Rights and Responsibilities", dated 7/1/2021, revealed: "Procedure: 24. The right to receive the visitors designated by the patient, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. Also included is the right to withdraw or deny such consent at any time."

A review of the facility policy, titled "Patient & Family Rights", dated 7/1/2021, revealed: "Procedure: 2. Admissions provides to patient and family (if present) patient handbooks that explains rights, contraband, visitation, phone and programming schedules. Documentation of these conversations will be documented in the medical record consents and acknowledgements regarding who will be involved in the patient's treatment; to initiate discussion of any ethical dilemmas or concerns; to privacy and confidentiality. 4. Families will be provided with information regarding how and when to contact the patient and regarding visitation guidelines."

A review of the facility document, titled "Patient Handbook", not dated, revealed: "Visitation: Visitation times vary dependent upon the unit assigned. Please see the program schedule for designated hours....Family Involvement & Support: Your family is an important part of your recovery and will be involved in your treatment as you request. Concerns or questions that you or your family may have about your treatment can be discussed with the treatment team members. Your family may be involved during the assessment, family therapy, educational sessions, discharge planning, and continuing care."

During an interview on 4/5/2022 at 2:15 PM, Director of Clinical Services H stated, "We have not allowed visitors since we open in August 2021 because of the COVID 19 pandemic. The facility staff offer a 'family session' prior to discharging a patient. This is when a family member is allowed to come inside the facility to go through the discharge/after-care documentation and process with the patient and a therapist/clinician. This could also occur via phone with family member."

During an interview on 4/5/2022 at 3:10 PM, A/R (Assessment/Referral) Director J stated, "During the intake process with patients they are informed that due to COVID 19 they (facility) are not allowing visitors." When asked if there was an updated visitor policy reflecting the limitation, A/R Director J stated, "I don't think so."

Based on record review and interview, facility staff failed to complete an incident report for 1 of 1 patient (Patient #1), in a total universe of 10 medical records reviewed.

Findings include:

A review of the facility policy, titled "EOC (Environment of Care) & Safety Committee", dated 7/1/2021, revealed: "Purpose: To report and investigate all incidents related to patients, staff, or visitors to the hospital. A. Incidents related to patients or visitors: 1. All incidents and injuries to patients or visitors will be reported on an Incident Report. 2. This report is to be completed by the person at the point of incident occurrence."

A review of Patient #1's Nursing Progress Note, completed on 1/23/2022 at 3:51 AM, revealed: "He slept well but woke up at 3:40 AM with reports of pain in his head and left hand, upon further investigation, patient reports he fell on AM shift on 1/22/2022 in the bathroom and while trying to catch himself he hit his head and caught his finger. Patient reports pain in left hand and states 'I feel like my finger is broken' writer examined patient and noted left middle and ring finger to be slightly swollen, patient applied ice and PRN (as needed) Tylenol was administered at 3:44 AM. Writer also examined patients head and noted a small bump and tender area on the back, right side. Patient states he did not tell anyone he fell because he didn't think it was a big deal. Patient is on list to be seen by medical Dr (doctor)."

A reivew of Patient #1's Nursing Progress Note, completed on 1/25/2022 at 12:22 AM, revealed: "Pt (patient) reported that another pt (patient) came into his room and grabbed his foot. Staff talked to other patient, and other patient was diverted to day room to be monitored. Pt reported that no harm was done to his foot."

A review of Patient #1's Nursing Progress Note, completed on 1/25/2022 at 5:57 PM, revealed: "Complained of not getting enough sleep last night due to another pt entering his room several times, sat on his legs and pulling his legs."

A review of the facility document, titled "Patient Incident Log", from 9/1/2021 to 1/27/2022 revealed: No incident reports filed for Patient #1.

During an interview on 4/5/2022 at 9:30 AM, Quality & Risk Specialist O stated, "I would expect staff to complete an incident report if a patient enters another patients room and if a patient reports a fall. All employees receive this information during orientation."

Based on record review and interview the facility failed to develop a contingency plan for staff who are not fully vaccinated for COVID 19, in 1 of 1 COVID 19 Mandatory Vaccination policy.

Findings include:

A review of the facility policy, titled "COVID 19 Mandatory Vaccination", dated "1/202/22, revealed: "Scope: Regardless of clinical responsibility or patient contact, this policy applies to all Facility staff who provide any care, treatment, or other services for the hospital and/or its patients.....*Staff may be legally entitled to a reasonable accommodation if they cannot be vaccinated because of a disability or clinical contraindication, or if the vaccination conflicts with a sincerely held religious belief, practice, or observance. Requests for reasonable accommodations must be initiated in writing utilizing the Facility's approved form with the appropriate justifications and signatures to the Human Resource Department."

Further review of the policy revealed no evidence of documented additional precautions or contingency plans for unvaccinated workers.

During an interview on 4/6/2022 at 1:30 PM, Interim DON (Director of Nursing) and Interim ICP (Infection Control & Preventionist) E stated, "If staff have a cough we recommend that they wear a K-N95, we don't have the capability to do fit tests for N95's." When asked what is the contingency plan for staff that are not vaccinated due to an exception, DON/ICP E stated, "We are not requiring any COVID 19 testing on a regular basis." Confirmed with DON/ICP E that the current facility policy does not include a contingency plan for unvaccinated staff.

Based on record review and interview, facility staff failed to reconcile medications prior to discharge in 1 (Patient #1) of 6 discharged patients, in a total universe of 10 medical records reviewed.

Findings include:

A review of Patient #1's Discharge Medication Summary for Patient, from Facility, printed on 4/11/2022 at 12:30 PM, not signed or dated, revealed: "Medications to take after Discharge: Norvasc (high blood pressure), Dose: 5 mg TAB (tablet), Route: Oral, Frequency: at bedtime; Hydrochlorothiazide-lisinopril 12.5 mg-20 mg TAB (tablet), Dose: 1 TAB, Route: Oral, Frequency: daily; Flexeril (muscle relaxant) 10 mg TAB, Dose: 20 mg, Route: Oral, Frequency: at bedtime, as needed; Mobic (arthritis) 15 mg TAB, Dose: 15 mg, Route: Oral, Frequency: at bedtime; Mirapex (Parkinson's symptoms) 1 mg TAB, Dose: 1 mg, Route: Oral, Frequency: at bedtime; Topamax (seizures) 100 mg TAB, Dose: 100 mg, Route: Oral, Frequency: Twice daily; Biofreeze (topical for pain) 4% GEL, Dose: 1 application, Route: Topical, Frequency: PRN as needed; Naltrexone HCL (pain), Dose: 4.5 mg; Route: Oral, Frequency: at bedtime; Trimicinolone acetonide 0.1% (psoriasis), Dose: 1 application, Route: Topical, Frequency: PRN as needed."

A review of Patient #1's Discharge Medication Summary for Patient, from Complainant A, printed on 1/27/2022 at 11:54 PM, revealed: "Do not continue these Medications at Home: Norvasc (high blood pressure), Dose: 5 mg TAB (tablet), Route: Oral, Frequency: at bedtime; Hydrochlorothiazide-lisinopril 12.5 mg-20 mg TAB (tablet), Dose: 1 TAB, Route: Oral, Frequency: daily; Flexeril (muscle relaxant) 10 mg TAB, Dose: 20 mg, Route: Oral, Frequency: at bedtime, as needed; Mobic (arthritis) 15 mg TAB, Dose: 15 mg, Route: Oral, Frequency: at bedtime; Mirapex (Parkinson's symptoms) 1 mg TAB, Dose: 1 mg, Route: Oral, Frequency: at bedtime; Topamax (seizures) 100 mg TAB, Dose: 100 mg, Route: Oral, Frequency: Twice daily; Biofreeze (topical for pain) 4% GEL, Dose: 1 application, Route: Topical, Frequency: PRN as needed;Trimicinolone acetonide 0.1% (psoriasis), Dose: 1 application, Route: Topical, Frequency: PRN as needed. with the words DO NOT CONTINUE stamped across the list."

A review of Patient #1's Discharge Medication Summary for Patient, from Complainant A, printed at 1/27/2022 at 11:54 AM, revealed: "Medications to take after Discharge: Naltrexone HCL (pain), Dose: 4.5 mg; Route: Oral, Frequency: at bedtime"

During email correspondence on 3/25/2022 at 11:35 AM, Complainant A stated, "They (facility staff) discontinued both BP (blood pressure) medications at discharge. I am a CMA (certified medical assistant) and knowing he was off both med's I monitored it (blood pressure). He is a 90 day settlement agreement and is court ordered to comply with medications, since they discontinued them, he was afraid to restart them."

During an interview on 4/5/2022 at 10:00 AM, when asked why there was a discrepancy between what the complainant provided and what the facility has recorded for medications at discharge, DON E stated, "I don't know."