HospitalInspections.org

Based on document review and interview it was determined that for 1 of 1 (Pt. #1) grievance letter received, the hospital failed to ensure the grievance was acknowledged, investigated and a response was provided as required by policy.

Findings include:

1. The complaint logs for 10/1/17-12/27/17 were reviewed on 12/27/17 at approximately 9:20 AM. The logs did not contain any complaints from Pt. #1.

2. The Director of Risk Management (E #3) was interviewed on 11/27/17 at approximately 9:20 AM. E #3 stated there were no complaints received related to Pt. #1, and there have been no grievances received in the last 3 months.

3. The Hospital Policy titled, "Patient Complaint/Grievances (rev. 3/13/17) required, "Definition: Grievance-Written and verbal complaints (that cannot be resolved at the time of the complaint by staff present)...when a complaint cannot be resolved at the time and place of the complaint, it will be considered a grievance, will be reviewed, investigated and responded to in writing within 7 days..."

4. The clinical record for Pt. #1 was reviewed on 9/27/17. Pt. #1 was a 47 year old female, who arrived in the Emergency Department (ED) by ambulance on 11/16/17, at 1:22 AM, with complaint of PTSD (posttraumatic stress disorder) and flashbacks. The clinical record indicated Pt. #1 became agitated and was ordered be placed in restraints at 8:50 PM on 11/16/17.

5. An interview with the ED Clinical Nurse Leader was conducted on 12/27/17, at approximately 1:45 PM. The Nurse Leader stated that Public Safety officers, who receive the same restraint and de-escalation training as the ED nurses, apply patient restraints in the ED.

6. On 12/27/17, public safety reports for patient assists for 11/16/17, related to Pt. #1, were requested

7. The Vice President of Nursing (E #4), interviewed on 12/27/17 at approximately 2:40 PM, stated that the hospital Public Safety Department just presented a Patient Assist Report along with and investigation of a written letter of complaint (grievance) related to Pt. #1. According to E #4, she (E #4) and the Director of Risk Management were not aware of the grievance letter from Pt. #1, and only became aware of this grievance letter "today" 12/27/17, at approximately 2:00 PM. E #4 stated the letter had a received date stamp of 11/30/17, and should have been responded to within 7 days. E #4 indicated that the security officer who followed up on the complaint with the police was not sure if there was a response sent to the grievant. E #4 stated, "We have now drafted a response to the letter We know we are late in responding because it was never reported to us."

Based on document review and interview, it was determined that for 2 of 5 (Pt. #1 and #2) records reviewed, the Hospital failed to ensure face-to-face evaluations were conducted on patients within 1 hour of initiating restraints.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 12/27/17. Pt. #1 was a 47 year old female who presented in the Emergency Department (ED) on 11/16/17 with anxiety and post-traumatic stress disorder. The clinical record included an order for restraints that were applied on 11/16/17 at 8:52 PM. The restraints were discontinued at 11:25 PM. The record lacked documentation of the face-to-face evaluation of Pt. #1, by the physician, for the restraint use.

2. The clinical record for Pt. #2 was reviewed on 12/28/17. Pt. #2 was a 27 year old male who presented in the Emergency department on 11/2/17 with alcohol intoxication. The clinical record included Pt. #2 was restrained at 5:20 PM on 11/2/17 and the restraint order obtained at 5:28 PM. The restraints continued and the order was renewed at 9:42 PM. The record included a face-to-face evaluation of Pt. #2 at 9:45 PM for the renewed restraint order. However, the record lacked documentation of the face-to-face evaluation, by the physician, for the initial restraint application at 5:20 PM on 11/02/17.

3. The Hospital policy titled, "Restraint Policy" (rev. 5/15/17) required, " ...Within one hour of initiating restraint application, a physician is to perform and document a face-to-face assessment of the patient...this evaluation will be a comprehensive physical and behavioral assessment of the patient, including:...evaluation of patients reaction to the restraints...review of system...behavioral assessment...Need to continue or terminate restraints..."

4. The ED Clinical Nurse Leader (E #10) was interviewed on 12/28/17 at approximately 10:00 AM. E #10 stated that a one hour face-to face evaluation and documentation by a physician are expected for all patients ordered and placed in restraints, including renewed restraint orders.