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Based on interview and file review, the facility failed to provide written notice of its decision in the resolution of a grievance for 1 of 1 (#1) grievances reviewed. Findings include:

During record review on 07/27/10 at 1000 it was determined that the correct steps were taken to investigate the grievance; however there was no written notice to the patient ' s grievance that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion.
The Risk Manager confirmed these findings on 07/27/10 at 1400.

Based on interview and record review, the facility failed to document the least restrictive interventions used by staff to protect the patient and others from harm prior to the introduction of more restrictive measures for restraints for 1 of 4 (# 1) patients restrained. Findings include:

During record review of patient #1 ' s chart on 07/27/10 at 1200 it was determined that according to documentation the patient did not receive the least restrictive form of being restrained. The patient was put into 3 point locked leather restraints at 0150 on 06/11/10. There is no documentation that supports there were other interventions that were not successful. The patient ' s family was never notified of the patient ' s change in condition.

The Chief Nursing Officer confirmed these findings on 07/27/10 at 1600.

Based on record review and interview, the facility failed to obtain a completed order for restraints for 4 of 4 (#1, #2, #3, & #4) patients restrained. Findings include:


Record review of patient #1's closed chart revealed that there was an order for restraints dated 06/11/10 at 0600 for " lock & key wrist cuffs " . The physician did not " check all that apply " , " right " or " left " . The physician also failed to complete the " physician assessment " .

Record review of patient #2's open chart revealed that on 07/26/10 the physician did not fill out the area on the order sheet that entails " Type of Restraints Applied (check all that apply)". The physician also failed to complete the "Physician Assessment".

Record review of patient #3's open chart revealed that on 07/25/10 at 1000 the physician did not complete the restraint order form completely. The physician failed to document "Type of Restraint Applied" . Also on 07/26/10 the physician failed to complete the " Physician Assessment".

Record review of patient #4's open chart revealed that on 07/27/10 at 0100, the physician failed to order the "Type of Restraint Applied".

Interview with the Chief Nursing Officer on 07/27/10 at 1600, confirmed that the form titled " Physician Restraint Order " was incomplete for patient ' s #1, #2, #3 & #4.

Based on record review and interview, the facility failed to assess, and monitor the patient in an ongoing basis to determine whether the restraints could be discontinued at the earliest possible time for 1 of 4 (#1) patients restrained. Findings include:

Clinical record review revealed the patient # 1 was placed in 3 point leather restraints during their hospital stay. According to the nursing assessment there was no documentation that re-assessment was conducted to release the patient at the earliest possible time.

Interview with the Chief Nursing Officer on 07/27/10 at 1600, confirmed that the form titled " Physician Restraint Order" was incomplete for patient's #1, #2, #3 & #4.

Based on record review and interview, the facility failed to document in the employee personnel files that training and demonstration of competency were successful for restraint application. Findings include:

During record review and interview it was determined that Security Officer # 1 and # 2 attended restraint application by the local police department according to the Risk Manager. However the facility could not provide a sign in sheet or other documentation showing that they are competent in applying leather restraints.

Interview with the Risk Manager on 07/27/10 at 1600, confirmed the security officers # 1 & #2 ' s personnel files did not contain the documentation that they were competent in the placement of leather restraints.