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Based on facility document review and staff interview, it was determined the facility failed to provide evidence that the complaint and grievance process is implemented in accordance with facility policy.

Findings include:

Facility policy titled "Complaint and Grievance Process" dated 6/14/21, states, "...If an issue cannot be resolved at the time of the complaint by Hospital staff or it is postponed for later resolution, requires investigation, and/or requires further action, then the complaint becomes a grievance. Staff members shall notify his/her supervisor and complete the complaint form... The Manager/Director of the Department involved in the grievance will investigate the circumstances surrounding the concern or complaint and report the issue (s) and results of the investigation to the Patient Advocate... A letter response will be sent within 7 calendar days. If the resolution cannot be completed within 7 calendar days due to the complicated nature of the grievance, an acknowledgement letter will be issued to inform the patient or their representative that a final resolution letter will be completed within 30 calendar days from the receipt of the grievance. ...Complaints/Grievances will be monitored monthly for the previous month... Monthly data will be collected for the PI[performance improvement] Report Card... ."

On 7/2/24 at 10:45 AM during an entrance conference with S3, Board Advisor, and S4, Director of Nursing (DON), the documentation for the complaint and grievance process, including the complaint and grievance log for 6/1/24 to 7/2/24, complaint forms, and facility letters, were requested for review. S3 stated the facility could not provide documentation of the complaint and grievance process to the surveyors for review, as per a recommendation from their legal department.

On 7/2/24 at 12:10PM, S3 confirmed they could not allow the review of documents related to the facility's complaint and grievance process as requested. It was explained to S3 and S4 that the complaint and grievance process is a patient's right and the failure to provide documentation to the surveyors, would prevent the surveyors from assessing compliance with this regulation.

During medical record review conducted on 7/2/24 and 7/3/24, documentation of incidents occurring between patients and between patients and staff, were identified. They include the following:

On 7/3/24, the review of MR 2 was conducted with S4. The "Nursing Admission Assessment" notes, dated 6/5/24, state, "... During the intake/admission process, patient repeatedly threatened me stating, "I'll slap the [expletive] out of you." On several occasions the patient entered the nurses' station after being asked several times to stay outside of the nurse's station. ...Following this, the other patients were asked to remain in the dayroom because they did not feel safe... ."

The "Daily Nursing Assessment 7a - 7p" found in MR2, dated 6/9/24, states, "10:20 [AM] pt [patient] hit on the upper body by another patient... 10:25 [AM] [staff name] rn [Registered Nurse] apn [Advanced Practice Nurse] made aware of incident 10:45 am patient seen by house officer [staff name] rn apn ... ."

The "Daily Nursing Assessment 7p- 7a" found in MR2, dated 6/10/24, states, "...2230 [11:30 PM] While staff was cleaning up water spilled on the floor by the patient, [P2] became aggressive, combative, violent and punched staff on the nose and led to nose bleeding. Patient is harm to himself, to staff and to his peers. Security officer and DON (Director of Nursing) [name] were on the unit and immediately proceeded to intervene... ."

The "Daily Nursing Assessment 7p -7a" found in MR2, dated 6/12/24, states. "... 9:20 [PM]-RN [Registered Nurse] heard a commotion on the unit and came out of the medication room to see staff holding the patient. Per the MHT [mental health technician], patient attempted to force himself inside the staff working area and he/she was stopped. Patient reportedly became agitated, physically aggressive, an [sic] punched the MHT in the jaw area, staff and hospital security held the patient down. Verbal deescalation was ineffective.... ."

The "Daily Nursing Assessment 7p-7a" found in MR2, dated 6/13/24, states, "...8:20 PM- Per the MHTs, patient sneaked behind and punched another patient. Patient is aggressive and not re-directable..."

On 7/2/24 at 12:15 PM the facility's quality assessment performance improvement (QAPI) meeting minutes were requested to assess, the complaint and grievance process included in the policy referenced above, was followed.

On 7/3/24 at 4:00PM S3 provided a copy of the "Silver Lake Hospital QA/PI Committee Meeting Minutes," dated 11/15/23, 12/20/23, 1/17/24, 3/20/24, 4/17/24, and 5/15/24. The majority of these documents were crossed out, redacted.

The following information was identified:

The "Silver Lake Hospital QA/PI Committee Meeting Minutes," dated 11/15/23, included, "Topic; Discussion; Action/Recommendations" columns. The " ...Complaints & Grievances" topic, the "Discussion" and "Actions/Recommendations" columns were redacted.

The "Silver Lake Hospital QA/PI Committee Meeting Minutes," dated 12/20/23 stated, "Topic; Discussion; Action/Recommendations" the " ...Complaints & Grievances" topic, the "Discussion" and "Actions/Recommendations" columns were redacted.

The "Silver Lake Hospital QA/PI Committee Meeting Minutes," dated 1/17/24 stated, "Discussion; Action/Recommendations" for the " ...Complaints & Grievances" topic, the "Discussion" column was redacted and the "Actions/Recommendation" column was blank.

The "Silver Lake Hospital QA/PI Committee Meeting Minutes," dated 3/20/24 stated, "Discussion; Action/Recommendations" for the " ...Complaints & Grievances" topic, the "Discussion" column was redacted and the "Actions/Recommendation" column was blank.

The "Silver Lake Hospital QA/PI Committee Meeting Minutes," dated 4/17/24 stated, "Discussion; Action/Recommendations" for the " ...Complaints & Grievances" topic, the "Discussion" column was redacted and the "Actions/Recommendations" column was blank.

The "Silver Lake Hospital QA/PI Committee Meeting Minutes," dated 5/15/24 stated, "Discussion; Action/Recommendations" for the " ...Complaints & Grievances" topic, the "Discussion" column was redacted and the "Actions/Recommendations" column was blank.

It could not be determined if the facility addressed complaint and grievances filed with the facility, completed investigations, or provided the complainants with follow up letter(s) as required by facility policy. It could not be determined if the facility reviewed each complaint and grievance monthly in the QA/PI Committee, identified trends, or followed through with actions or recommendations to address issues identified during the complaint and grievance investigation process.

On 7/3/24 at 4:10 PM, S3 confirmed the above findings and confirmed that the majority of the "Silver Lake Hospital QA/PI Committee Meeting Minutes" provided to the surveyors were redacted.


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Facility policy titled "Complaint and Grievance Process (revised 6/1/24) states, " ... POLICY: Silver Lake Hospital has established a mechanism for receiving, acting upon, and responding to patients, families, and visitors expressing concern for patient treatment and all areas of care. It is the policy of the Hospital to respond to such complaints promptly. ... PROCEDURE: ...4. A failure to afford a patient their rights in accordance with the following list of issues may constitute a complaint: ...f) Patient was abused, harassed and/or neglected; ... ."


On 7/3/24 at 1:05 PM, Patient (P) 4's medical record was reviewed with S3, Board Advisor. P4 was admitted to the facilities Dual Diagnosis inpatient unit on 4/22/24. The History and Physical from 4/24/24 states, " ... Reason for Admission: detox from polysubstances. ...Past Medical History: Anxiety, Depression, Bipolar Disorder, ETOH [ethanol] abuse, Marijuana abuse, Sedative abuse. ... ."

The "Daily Nursing Assessment 7a-7p" found in MR4, dated 6/7/24 states, " ...Nursing Note: ...Patient [P2's initials] touched patient's breast, emotional support offered to patient, patient transferred to 1 East due to this incident to ensure distance between [P2] and this patient; endorsed care to 1 East RN. ... ."

This Nursing Note was electronically signed by S4, Director of Nursing. On 7/3/24 at 1:24 PM, during an interview with S4, he/she explained that this incident occurred on the 1 West unit while P2 and P4 were walking down the hallway. S4 explained that P2 brushed P4's breasts as he/she walked by and P4 complained and was upset by it. S4 explained he/she moved P4 to a different unit so he/she would not have to interact with P2. S3 explained that when incidents between patients occur, the staff would separate the patients, handle the issue, and then complete an incident report. When asked if an incident report was filled out on the incident, S3 answered yes. On 7/3/24 at 4:15 PM, S4 confirmed he/she filled out an incident report related to the incident between P2 and P4.

Incident reports were requested and S3 stated, as per the facilities legal department, they would not provide incident reports for review by the surveyors. It could not be determined if the facility implemented the facility policy referenced above.

Based on medical record review, facility document review, and staff interview, it was determined the facility failed to ensure that complaints, grievances, and incidents are addressed in accordance with facility policies, to ensure care is provided in a safe setting.

Findings include:

Facility policy titled "Patient Rights and Restrictions," dated 8/23/21, states, "... The individual served has the right to voice opinions, recommendations, and grievances related to policies and services offered on the unit... The individual served has the right to be free from mental, physical, sexual, and verbal abuse, neglect and/or exploitation..."

Facility policy titled "Patient Incident Report and Department Manager Review," dated 8/16/23, states, "Purpose: To ensure that the appropriate department manager reviews all incident reports timely and formulates an appropriate plan of action. Policy: Patient incidents are entered into the computer under Clinical Documentation Assessment Add Incident Report. The Quality Department/ Nursing Department will run a daily report to see what incidents have occurred. The appropriate Department Manager... will be notified to review the incident and enter an appropriate/effective management plan of action as soon as possible after the incident occurs..."

Facility policy titled "Incident Reporting Employee," dated 8/16/23, states, "...1. Any employee involved in an incident or observing an incident resulting in an employee injury or occurrence is responsible for completing and [sic] Employee incident Report prior to the end of shift. 2. The supervisor assures that the employee is offered medical assessment/treatment...The supervisor reviews the Employee Incident Report for completeness and investigates as necessary. The supervisor's corrective actions are recorded... within 24 hours... 7. Supervisor forwards completed incident report to the HR [human resources] Coordinator and a copy to the Quality Manager/ Risk Manager ... 11. The Director of HR records aggregate information and reports to the Safety Committee."

Facility policy titled "Complaint and Grievance Process," dated 6/14/21, states, "... A failure to afford a patient their rights in accordance with the following list of issues may constitute a complaint: ...Patient was abused, harassed and/or neglected; ...if an issue cannot be resolved at the time of the complaint by Hospital staff or it is postponed for later resolution, requires investigation, and/or it requires further action, then the complaint becomes a grievance. Staff member shall notify his/her supervisor and complete the complaint form.... A letter response will be sent within 7 calendar days. If resolution cannot be completed within 7 calendar days,,, an acknowledgment letter will be issued to inform the complainant or their representative that a final resolution letter will be completed within 30 calendar days... Complaints/Grievances will be monitored monthly for the previous month..."

On 7/2/24 at 10:45 AM during an entrance conference with S3, Board Advisor, and S4, Director of Nursing (DON), the documentation for the complaint and grievance process, including the complaint and grievance log for 6/1/24 to 7/2/24, complaint forms, facility letters, the incident log for 6/1/24 to 7/2/24, and documentation of the incident reporting process were requested. S3 stated that the facility could not provide documentation of the complaint and grievance process or the incident reporting process to the surveyors as per a recommendation from their legal department. On 7/2/24 at 12:10PM, S3 confirmed they could not provide the documents related to the facility's complaint and grievance process and incident reporting process as requested.

It was explained to S3 and S4 that failure to provide the above documentation would prevent the surveyors from assessing compliance with the Federal regulations and facility policies.

During medical record review conducted on 7/2/24 and 7/3/24, with S3 and S4, evidence of incidents occurring between patients and between patients and staff were identified. The following documentation was found:

On 7/3/24, the review of MR2 was conducted with S4. The "Nursing Admission Assessment" notes dated 6/5/24, state, "... During the intake/admission process, patient repeatedly threatened me stating, "I'll slap the [expletive] out of you." On several occasions the patient entered the nurses' station after being asked several times to stay outside of the nurse's station. ...Following this, the other patients were asked to remain in the dayroom because they did not feel safe... " The incident report for this event was requested for review on 7/3/24, and S4 confirmed incident reports could not be reviewed by the surveyors.

The "Daily Nursing Assessment 7a - 7p" found in MR2, dated 6/9/24, states, "10:20 [AM] pt [patient] hit on the upper body by another patient... 10:25 [AM] [staff name] rn [Registered Nurse] apn [Advanced Practice Nurse] made aware of incident 10:45 am patient seen by house officer [staff name] rn apn ..." The incident report for this event was requested for review 7/3/24, and S4 confirmed incident reports could not be reviewed by surveyors.

The "Daily Nursing Assessment 7p - 7a" found in MR2, dated 6/10/24, states, "...2230 [11:30 PM] While staff was cleaning up water spilled on the floor by the patient, [P2] became aggressive, combative, violent and punched staff on the nose and led to nose bleeding. Patient is harm to himself, to staff and to his peers. Security officer and DON (Director of Nursing) [name] were on the unit and immediately proceeded to intervene... " The incident report and security reports for this event were requested for review on 7/3/24, and S4 confirmed incident reports and security reports could not be reviewed by surveyors.

The "Daily Nursing Assessment 7p -7a," found in MR2, dated 6/12/24, states, "... 9:20 [PM]-RN [Registered Nurse] heard a commotion on the unit and came out of the medication room to see staff holding the patient. Per the MHT [mental health technician], patient attempted to force himself inside the staff working area and he/she was stopped. Patient reportedly became agitated, physically aggressive, an [sic] punched the MHT in the jaw area, staff and hospital security held the patient down. Verbal deescalation was ineffective...." The incident report for this event was requested for review on 7/3/24, and S4 confirmed that incident reports could not be reviewed by surveyors.

The "Daily Nursing Assessment 7p-7a," found in MR2, dated 6/13/24, states, "...8:20 PM - Per the MHTs, patient sneaked behind and punched another patient. Patient is aggressive and not re-directable..." The incident report for this event was requested for review on 7/3, and S4 confirmed incident reports could not be reviewed by surveyors.

On 7/3/24, the review of MR4 was conducted with S3. The "Daily Nursing Assessment 7a - 7p" found in MR4, dated 6/7/24 states, " ...Nursing Note: ...Patient (P) [P2's initials] touched patient's breast, emotional support offered to patient, patient transferred to 1 East due to this incident to ensure distance between [P2] and this patient; endorsed care to 1 East RN. ..." This Nursing Note was electronically signed by S4, Director of Nursing.

On 7/3/24 at 1:24 PM during an interview with S4, he/she explained that this incident occurred on the 1 West unit while P2 and P4 were walking down the hallway. S4 explained that P2 brushed P4's breasts as he/she walked by and P4 complained and was upset by it. S4 explained he/she moved P4 to a different unit so that he/she would not have to interact with P2 anymore. S4 explained that when incidents between patients occur, the staff would separate the patients, handle the issue, and then fill out an incident report. When asked if an incident report was completed, S4 confirmed he/she did fill out an incident report regarding the incident between P2 and P4. The incident report for this event was requested for review on 7/3/24, and S4 confirmed incident reports could not be reviewed by surveyors.

On 7/3/24, it could not be determined if the facility followed the incident reporting policies and procedures referenced above. It could not be determined if the incidents were reported, reviewed by facility management, investigated, or if the facility implemented changes to improve patient and staff safety.

On 7/2/24 at 12:15 PM the facility's quality assessment performance improvement (QAPI) meeting minutes were requested to assess if the complaint and grievance processes and incident reporting processes, included in the policies referenced above, were followed.

On 7/3/24 at 4:00PM S3 provided a copy of the "Silver Lake Hospital QA/PI Committee Meeting Minutes," dated 11/15/23, 12/20/23, 1/17/24, 3/20/24, 4/17/24, and 5/15/24. The majority of these documents were redacted.

The "Silver Lake Hospital QA/PI Committee Meeting Minutes" dated 11/15/23 included, "Topic; Discussion; Action/Recommendations" columns. The "Incident Report Summary", the "Discussion," and "Actions/Recommendations" were redacted. For the " ...Complaints & Grievances" the "Discussion" and "Actions/Recommendations" columns were redacted.

The "Silver Lake Hospital QA/PI Committee Meeting Minutes" dated 12/20/23 stated, "Topic; Discussion; Action/Recommendations ... Incident Report Summary." The "Discussion" and "Actions/Recommendations" were redacted; ...Complaints & Grievances. the "Discussion" and "Actions/Recommendations" were redacted.

The "Silver Lake Hospital QA/PI Committee Meeting Minutes" dated 1/17/24 stated, "Discussion; Action/Recommendations ... The Incident Report Summary." The "Discussion" and "Actions/Recommendations" were redacted; "...Complaints & Grievances." The "Discussion" was redacted and the "Actions/Recommendations" column was blank.

The "Silver Lake Hospital QA/PI Committee Meeting Minutes" dated 3/20/24 stated, "Discussion; Action/Recommendations ...The Incident Report Summary." The "Discussion: and "Actions/Recommendations" were redacted; "...Complaints & Grievances." The "Discussion" column was redacted and the "Actions/Recommendation" column was blank.

The "Silver Lake Hospital QA/PI Committee Meeting Minutes" dated 4/17/24 stated, "Discussion; Action/Recommendations ... Incident Report Summary." The "Discussion" column stated, "March had [redacted] incidents in DD [dual diagnosis]" the remaining was redacted. And the "Actions/Recommendations" column was redacted; "...Complaints & Grievances." The "Discussion" column was redacted, and the "Actions/Recommendations" column was blank.

The "Silver Lake Hospital QA/PI Committee Meeting Minutes," dated 5/15/24, stated, "Discussion; Action/Recommendations ...Incident Report Summary." "April had [redacted] incidents in DD." The "Discussion" and "Actions/Recommendations" columns were redacted; "...Complaints & Grievances." The "Discussion" column was redacted and the "Actions/Recommendations" column was blank.

On 7/3/24 at 4:10 PM, S3 confirmed the above findings and confirmed the majority of the "Silver Lake Hospital QA/PI Committee Meeting Minutes" provided, were redacted. It was determined that incidents occurred in the Dual Diagnosis Unit in March and April of 2024, however, it could not be determined if the facility reviewed incident reports, investigated events, and addressed patient safety issues in accordance with their policies referenced above.

Based on the review of 1 of 1 medical record (MR)2, that contained orders for seclusion, facility document review, and staff interviews, it was determined the facility failed to ensure that orders for seclusion are not written "PRN" (as needed).

Findings include:

Facility policy titled "Restraint and Seclusion Policy and Procedure" dated 11/1/21, states, "...Orders are never to be written as a PRN order or a standing basis..."

Review of MR2, conducted 7/3/24 at 2:00 PM, with S4, Director of Nursing, identified a provider's order for seclusion, dated 6/7/24 at 2:27 PM, which stated, "Restraint/Seclusion every 4 hours PRN [pro re nata, as needed]... Patient to be placed in seclusion Q [every] 4 hours and then released for supervised 1 hour..."

The "Daily Nursing Assessment 7a-7p," dated 6/7/24, states, "4:30 PM patient in seclusion room due to behavior... 6:30 [PM] Patient taken out of seclusion room. Calm and cooperative." MR2 lacked any additional orders for seclusion on 6/7/24.
During medical record review, S4 stated that orders for seclusion or restraint should not be written "PRN" and that he/she notified the ordering provider that that was not allowed.

This finding was confirmed by S4 on 7/3/24 at 2:05 PM.

Based on the review of one of one medical records (MR), MR2, of a patient who had an order for seclusion, facility document review, and staff interviews, it was determined the facility failed to ensure that monitoring of a patient in seclusion is documented in the medical record as required by facility policy.

Findings include:

Facility policy titled "Restraint and Seclusion Policy and Procedure," dated 11/1/21, states, "... While in restraints or seclusion the RN [Registered Nurse] will assess the patient every 15 minutes and will monitor and document for the following: a. Signs of injury; b. physical and psychological status; ..."

During medical record review on 7/3/24, between 1:50 PM and 2:35 PM, Staff (S) 4, Director of Nursing, explained that patients in the seclusion room are continuously monitored either by surveillance camera or by a staff member standing in the ante room, and that the monitoring is documented in the "Observation" column of the "Accountability Flow Sheet" every 15 minutes. S4 showed the surveyor a example of the "Accountability Flow Sheet" found in MR2 and explained that the flow sheet included the documentation of the patient's location in the facility, behavior, or any other relevant status changes. The "Accountability Flow Sheet" and the "Daily Nursing Assessment" notes for P2 were reviewed with S4 and the following was identified:

The "Nursing Assessment 7p-7a," dated 6/11/24, states, "... 5:30 [AM] Blood drawn for BMP [basic metabolic panel] and Lipid panel. 6:25 [AM] Patient showed signs of agitation, back to the seclusion room. 7:00 [AM] care endorsed to the day shift nurse." And the "Daily Nursing Assessment 7a - 7p," dated 6/12/24, stated, "7:00 [AM] Received patient sleeping in Seclusion room. Respiration easy on room air. 8:00 [AM] Patient out of seclusion..."
This documentation indicates P2 was in the seclusion room from 6:25 AM until 8:00 AM.

Review of the "Observations" column on the "Accountability Flow Sheet" found in MR2, and dated 6/12/24, states, "5:30 [AM]: Engaging Staff at the Nursing Station. 7:00 [AM]: Other. 7:15 [AM]: Other. 7:30 [AM]:Other. 7:45 [AM]: Other. 8:00 [AM]: Other. 8:15 [AM]: Other...."
The "Accountability Flow Sheet" lacked comprehensive documentation of the every 15 minute monitoring between 5:30 AM and 7:00 AM, during which time the nursing note indicates P2 was in the seclusion room. MR2 lacks documentation of the required monitoring every 15 minutes. The physical and psychological status of P2 could not be determined.

The "Nursing Assessment 7a-7p" dated 6/12/24, states, "...15:00 [3:00 PM] Patient restrained in seclusion room as ordered by the house doctor due to agitation, injurious to staff. 16:00 [4:00 PM] Closely monitored, in seclusion room. 17:00 [5:00 PM] Sleeping in seclusion room. 18:00 [6:00 PM] Patient still sleeping in seclusion room. 19:00 [7:00 PM] Patient awake, out of the seclusion room, dinner and due medications served. Redirection in progress."

The corresponding "Accountability Flow Sheet" found in MR2, dated 6/12/24, states the following under the "Observation" column, "... 6/12/24 at 14:30 [2:30 PM]; Observed to be awake in rounds. Monitored for safety, comfort, and appropriate boundaries; 6/12/24 at 14:45 [2:45 PM]; Other; 6/12/24 at 15:00 [3:00 PM]: Other..." and the remaining entries documented every 15 minutes in the "Observation" column on 6/12/24 between 3:15 PM and 7:15 PM state "Other." The monitoring conducted every 15 minutes was not documented as required by facility policy. The physical and psychological status of P2 while in seclusion could not be determined.

These findings were confirmed by S4 on 7/3/24 at 4:25 PM

Based on review of one of one medical record (MR) of a patient who was ordered seclusion, (MR2), facility document review, and staff interview, it was determined the facility failed to ensure the required face-to face medical and behavioral evaluation by a provider, required within one hour of seclusion, is documented in the medical record, in accordance with facility policy.

Findings include:

Facility policy titled, "Restraint and Seclusion Policy and Procedure," dated 11/1/21, states, "...Standard of Care... The practitioners must evaluate the patient within 1 hour of the application of restraints. The evaluation note (face to face) must be documented in the EMR (electronic medical record)."

During the review of MR2 on 7/3/24, between 1:30 PM and 4:30 PM, with Staff (S) 4, Director of Nursing, S4 stated that the provider should document, in the medical record, a face to face evaluation of the patient, within one hour of the order for seclusion.

Four of six orders for seclusion, found in MR2, and reviewed on 7/3/24, lacked documentation of the face to face evaluation by a provider within one hour. The following was identified:

The provider orders for seclusion, dated 6/5/24 at 11:00 PM, lacked documentation of the provider's face to face evaluation. This was confirmed by S4 on 7/3/24 at 1:35 PM.

The provider orders for seclusion, dated 6/7/24 at 2:27 PM, lacked documentation of the provider's face to face evaluation. This was confirmed by S4 on 7/3/24 at 1:45 PM.

The provider orders for seclusion, dated 6/11/24 at 10:00 PM, lacked documentation of the provider's face to face evaluation. This was confirmed by S4 on 7/3/24 at 1:50 PM.

The provider orders for seclusion, dated 6/12/24 at 6:00 AM, lacked documentation of the provider's face to face evaluation. This was confirmed by S4 on 7/3/24 at 2:35 PM.