HospitalInspections.org

Based on facility policy and document review, medical record review (MR), and staff interview (EMP), it was determined that the facility failed to identify a grievance for 1 (Patient #1) of 8 patients sampled, resulting in the loss of the right to have a grievance filed on behalf of the patient. Findings include:

Facility policy "Patient and Family Grievances/The Role of the Patient Experience Specialist" issued June 1999, revised June 2021 and last reviewed December 2024 revealed, "...Rockford Center will provide an effective mechanism for handling patient...grievances and complaints as an important part of providing quality care...to our patients...It is the responsibility of each staff member to respond in a timely manner to any grievances or complaints voiced by patients...no matter how trivial the complaint may appear to be...A "patient grievance" is a written or verbal complaint that is made to the hospital by a patient...If a complaint cannot be resolved promptly by staff present...it is to be considered a grievance...The Director of Clinical Services or designee is made aware of all grievances and complaints..."

Facility document "The Rockford Center Statement of Patient Rights" dated March 2024 revealed, "...You have the right to file grievances and have them heard by the facility in a fair and impartial manner..."


Review of MR1 revealed:

"Patient Observation Record" nursing progress note written by EMP12, RS (Recovery Specialist) on 1/28/25 at 3 PM stated, "... Patient struggled to stay on task most of shift. Patient share (sic) numerous complaints regarding medication an (sic) care. Needs prompting to participate in groups...discharged at 3:30 PM..."

Interview conducted with EMP6, Director of Clinical Services, on 2/6/24 between 12:20 PM-12:20 PM. Surveyor inquired if Patient #1 had voiced any complaints or grievances to the staff. EMP6 replied that Patient #1 did not have any complaints or grievances during this admission.

Based on facility policy review, medical record review (MR), and staff interview (EMP), it was determined that for 1 out of 4 patients (Patient #3) sampled that were restrained, the hospital failed to modify the patient's plan of care after a restraint episode. Findings include:

Facility policy "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" issued December 1996, revised March 2024, revealed, "...Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves or others so that restraint/seclusion were indicated, a review and modification of the treatment plan is indicated. Based upon the consultation with the attending physician...information gathered from the debriefing with the patient, and the face-to-face evaluation, the RN shall review and update the treatment plan within 8 hours. The updated treatment plan shall reflect...The identification of an assessed problem associated with the use of restraint/seclusion if problem has not been previously identified...Goals related to prevention of the further use of restraint/seclusion...Interventions which define alternative approaches to address the identified problem. Responsibility for each intervention is assigned...Review of the plan with the patient..."


Review of MR3 revealed:

Patient was physically restrained on 1/19/25 for 2 minutes. "Post Intervention Face to Face Evaluation" indicated that a treatment plan modification was indicated. No evidence noted of a modification to the treatment plan.

This finding was confirmed with EMP6 on 2/6/25 at 2:44 PM.

Based on facility policy review, medical record review (MR), and staff interview (EMP), it was determined that the use of restraint was performed without a physician's order and not in accordance with hospital policy for 3 out of 4 patients (Patient #3, #7, and #8) sampled that were restrained. Findings include:

Facility policy "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" issued December 1996 and reviewed/revised March 2024, revealed, "...to support each patient's right to be free from restraint...and therefore limit the use of these interventions...Any restraint...used...requires an order from a physician...The physician...must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated...Telephone/verbal orders for restraint/seclusion may be received and recorded by an RN...The physician shall authenticate the telephone/verbal order within 24 hours...the physician's order...will be recorded in the medical record and include...The nurse receiving the order, the physician giving the order, and the nurse transcribing the orders, with appropriate dates and times..."

Facility policy "Verbal/Telephone Orders" issued March 2017 and reviewed February 2024, revealed, ".... Verbal/telephone orders are transcribed accurately inclusive of date, time and signature...Verbal/telephone orders should be noted timely..."


Review of MR3 revealed:

Patient was physically restrained on 1/19/25 for a total of 2 minutes. No evidence of a physician's order for the restraint.

This finding was confirmed with EMP6 on 2/6/25 at 2:44 PM.


Review of MR7 revealed:

A restraint order was received via telephone by the RN on 12/21/24. No time received recorded for the verbal/telephone order.

A restraint order was received via telephone by the RN on 1/14/25. No physician name or time received recorded for the verbal/telephone order.


These findings were confirmed with EMP6 on 2/6/25 at 4:46 PM.


Review of MR8 revealed:

A restraint order was received via telephone by the RN on 12/8/24 at 8:34 PM. No evidence of physician authentication of the verbal/telephone order.

A restraint order was received via telephone by the RN on 12/16/24 at 2:00 PM. No evidence of physician authentication of the verbal/telephone order.

These findings were confirmed with EMP6 on 2/6/25 at 4:49 PM.

Based on facility policy review, medical record review (MR), and staff interview (EMP), it was determined that for 1 out of 4 patients (Patient #3) sampled that were restrained, the facility failed to follow hospital policy regarding the monitoring of a restrained patient. Findings include:

Facility policy "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" issued December 1996, revised March 2024, revealed, "...Patients in restraints/seclusion will be closely monitored and evaluated...Vital signs shall be taken upon initiation and as clinically indicated, but at least every 2 hours...Post-Restraint/Seclusion Debriefing: Debriefing following the use of restraint/seclusion is important in reducing the use of recurrent restraint/seclusion. The patient and staff participate in a debriefing session following the restraint/seclusion episode...The debriefing occurs as soon as possible, and as appropriate, but no longer than 24 hours after the episode...The debriefing is used to...Identify what led to the incident and what could have been managed differently...Ascertain that the individual's physical well-being, psychological comfort, and right to privacy were addressed...Counsel the individual involved for any trauma that may have resulted from the incident..."


Review of MR 3 revealed:

Patient had a documented restraint episode on 1/19/25 which involved a 2-minute physical hold. No evidence that vital signs were obtained before, during, or after the restraint episode.

The restraint packet included a form titled "Seclusion/Restraint/Emergency Medication Patient Debriefing". The form was blank. No evidence that a debrief was completed following this episode of restraint use.

These findings were confirmed with EMP6 on 2/6/25 at 1:34 PM.

Based on facility policy review, medical record review (MR), and staff interview (EMP), it was determined that the facility failed to ensure trained registered nurses, who completed the face-to-face evaluation after a restraint/seclusion episode, consulted with the attending physician as soon as possible for 2 out of 4 patients (Patients #2 and #7) sampled that were restrained. Findings include:

Facility policy "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" issued December 1996 and reviewed/revised March 2024, revealed, "...Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician...or trained RN...If a trained RN...conducts the evaluation, he/she must consult with the attending physician...as soon as possible (within 30 minutes) after the evaluation..."

Review of MR2 revealed:

Patient was physically restrained on 1/19/25 for a total of 2 minutes. The face-to-face evaluation was completed by the RN on 1/19/25 at 4:39 AM. No evidence that the physician was notified of the results of the evaluation.

This finding was confirmed with EMP6 on 2/6/25 at 1:34 PM.

Review of MR7 revealed:

Patient was physically restrained on 12/21/24 for a total of 6 minutes. Patient was placed in seclusion for a total of 5 minutes. The face-to-face evaluation was completed by the RN on 12/21/24 at 1:40 PM. No evidence that the physician was notified of the results of the evaluation.

Patient was physically restrained on 1/14/25 for a total of 1 minute. Patient was placed in seclusion for a total of 36 minutes. The face-to-face evaluation was completed by the RN on 1/14/25 at 5:48 AM. No time documented of when the physician was notified of the results of the evaluation.

These findings were confirmed with EMP6 on 2/6/25 at 4:46 PM.