HospitalInspections.org

Based on an onsite survey including review of the hospital policy for Patient Complaint Grievance Protocol (PCGP) (effective 2/9/2010), it is revealed that while the policy defines time frames, it fails to adhere to an average 7 day response time for patient grievances.

Hospital policy PCGP states in part, " The Patient Representative will attempt to resolve each grievance within 7 calendar days, " and " The Patient Representative will inform the patient and/or their representative that the hospital is working to resolve the grievance and that the hospital will follow-up with a written response within thirty (30) days from the receipt of the grievance ... "

While the hospital may require 30 days to investigate some complaints, the hospital is required to investigate complaints on average within seven days . Therefore, the hospital fails to specify times frames which are in compliance with this regulation.

Based on a onsite survey including review of ten (10) grievance files, it is revealed that 10 of 10 files had no resolution documentation or letters to complainants.


Review of 10 grievance files revealed no resolution, and no letters to complainants between grievance initiation dates from February 19 through March 10th 2014. The hospital stated that the individual who usually manages the grievance files has been out intermittently with an illness. The hospital also states that they have arranged to fill the position, and that a staff is currently in orientation for this purpose. However, the hospital failed to respond in writing to 10 grievances.

Based on an onsite survey inclusive of the hospital's "Quiet Room Patient Care Guidelines for Behavioral Health " (QRPCGBH) policy and 10 patient records, it is determined that 1) the Quiet Room policy demonstrates elements of a seclusion process, 2) patients #2 and #4 were placed in Quiet Room without the appropriate processes in place to ensure that quiet room was a voluntary process, and 3) patient #4 was secluded without documented justification.

Hospital policy QRPCGBH states in part under "Implementation," that Quiet room may be initiated by patient request, a physician order or after RN assessment of behavior. However, a physician order may not be used to initiate a voluntary process such a Quiet Room.

Documented under "Education" reveals that the RN is to explain to patient/family the necessity, purpose, duration and criteria for termination of the use of the quiet room. This statement does not reflect the voluntary nature of the Quiet Room which requires discussion with, and agreement from the patient regarding the purpose, agreed duration, and expectations when the patient leaves the Quiet Room. Further, under "Documentation," in the policy is the statement, "Explanation of release criteria and debriefing, if needed." which are elements used for seclusion and restraint, but not for Quiet Room.

Patient #2 is an adolescent female admitted to the hospital in March 2014. Documentation reveals in part, "Pt (Patient) sitting out in adult day area which is not allowed, pt was asked to go to the adolescent room, pt refused to move and walk herself to adolescent room, pt was then given the choice to go to QR (quiet room) or adol. Room. Pt wouldn't go to Adol. Room so she was put in QR." Other documentation reveals in part, " ...refused to comply with staff verbal directions to return to the OT room, states, "I'm not going to, I want to go home." Pt was escorted to the QR via 2 man forward take."


An approximate hour later, patient #2 was again taken by force to the Quiet Room, this time by backward take because she was "Uncooperative and disruptive in school." The forward and backward takes described in documentation are restraint processes. Therefore, staff forced patient #2 to go to Quiet Room, which is only a voluntary process. Staff failed to inform patient #2 of the voluntary nature of Quiet Room, so patient #2 did not know of her right to leave the quiet room. Even though the door to the quiet room was open, patient #2 was essentially secluded. The hospital failed to promote patient #2's rights when it failed to inform her of her right to exit Quiet Room which is tantamount to seclusion.

Patient #4 is an adolescent girl admitted in early March 2014. During her admission, patient #4 made multiple statements of doing harm to others, and on day two of admission, had struck an RN and pulled the RN's hair. It is unclear why patient #4 who had demonstrated imminent harm to others was not secluded at that time, but patient #4 was taken to the Quiet Room. No documentation is found which reveals that staff informed patient #4 of her right to leave the Quiet Room.

On the 4th day of admission, RN documentation states "Oppositional all day, not following directions, refusing to attend group or stay in the activity room. Cursing at staff, went to bedroom against staff direction. Code Green called. Pt (patient) escorted to LDS (locked door seclusion) and given IM medication."

Seclusion justification is listed as "Code Green called, Non-compliant with redirection, less restrictive measures not effective, Risk or actual danger to others." The first two listed regarding the code green and non-compliance with redirection are not of themselves, nor collectively, justification for seclusion. The third justification did not identify that patient #4 going to her room was a less restrictive measure. Lastly, the risk or actual danger to others is not supported by documentation.

Behavior exhibited towards staff is documented as "Severe agitation, and threatening." No actual threats or behaviors other than those which were oppositional are found in the record. The fact that patient #4 was attempting to go to her room demonstrated a measure of control on her part. Additionally, while it is most desirable to participate in treatment, oppositional behaviors without actual demonstration of imminent harm to self or other do not qualify as criterion for seclusion or restraint.

Based on an onsite survey inclusive of 10 patient records, it is revealed that 1) patient #2 and who was secluded, had no physician order to do so, and 2) patient #3 had an initial order for restraint, with had no rationale, no type of restraint, and no number of restraint points noted in the order, and 3) Patient #3 was taken out of restraint, but then re-restrained without an order to do so.

Patient #2 is an adolescent female admitted to the hospital in March 2014. On day five of her inpatient stay, a group note states "Inappropriate attire, disruptive with group, laying on chairs, not responding to verbal redirection, refusing to stay in quiet room, banging on doors," and "Pulling away from staff, holding onto chairs when attempting to direct to quiet room."

Staff proceeded to seclude patient #2 for 45 minutes. No physician order is found. Therefore, the hospital failed to seclude patient #2 in accordance with the order of a physician.

Patient #3 is a middle-aged male who presented via an acquaintance while intoxicated to the emergency department (ED). An approximate ? hour after presentation, patient #3 became threatening to staff and attempted to throw himself off the bed and remove his IV. Patient #3 was restrained in 4-point restraints. After some time, patient #1 stated that he could control his behavior, and he was removed from restraint. When he later pulled out his IV, patient #3 was again restrained, but no accompanying physician order is found.

The hospital failed to obtain orders for patient #2 and patient #3 who required seclusion and restraint respectively.