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Based on document review and interview, it was determined that for 1 of 1 (Pt #22), patient grievances reviewed, the Hospital failed to ensure that a grievance review was initiated within the required time frame, upon being notified of the grievance from the patient.

Findings include:

1. The Hospital's policy titled, "Patient Grievance" dated 8/2022, was reviewed on 10/5/2022, and required, "It is the responsibility of each staff member to respond in a timely manner to any concern or complaint voiced by patients and their families no matter how trivial the complaint may appear to be...The Patient Advocate or in his/her absence, the Shift Supervisor shall investigate and address the grievance within 24 hours of the time the grievance is received if possible..."

2. The clinical record for Pt #22 was reviewed on 10/3/2022. Pt #22 was admitted on 9/28/2022 to the Hospital's 3rd Floor Adult Behavioral Health Unit (3 West), with a diagnosis of major depressive disorder. Pt #22 was still inpatient at the Hospital on dates of survey.

3. On 10/5/2022 at 11:40 AM, the Associate Director of Social Services (E #6), presented a grievance, dated 10/4/2022, (3 days after being reported), regarding Pt #22. The grievance included, "Date and Time of Initial Contact (w/in 24 hours): 10/4/2022 [at] 1:45 pm...Patient advocate met with [Pt #22] to gather information regarding grievance. Patient stated that on October 1, 2022, he went to the nurse's station to take his melatonin around 8pm and was told that he was going to have to change rooms and move to the East side. Patient asked for an explanation and staff told him that they did not know why he had to move. Patient stated that a code green [staff response to de-escalate or intervene with behaviors] was called when he stated that he did not want to move...Patient stated that he felt his feelings were ignored...Patient stated that as soon as he started to walk away, staff grabbed his legs and started to drag him. Patient stated that he was pinned down on a table in the quiet room and was begging to be let up so he could calm himself down...Patient stated that 'staff are extremely disrespectful and do not treat patients as though they are human and do not take into account what patients have been through and why they are here...Patient named nurse [E #4]. Patient stated that she lies to patients all the time and he gave her his written grievance and she threw it away..."

4. On 10/5/2022 at 11:45 AM, an interview was conducted with the Associate Director of Social Services (E #6). E #6 stated that she was not aware and did not receive Pt #22's grievance until yesterday (10/4/2022). E #6 stated that when she spoke to Pt #22, he stated that he handed the nurse (E #4), a written grievance on Saturday (10/1/2022).

5. On 10/5/2022 at approximately 12:30 PM, an interview was conducted with the 3 East/West Registered Nurse (E #4). E #4 stated that Pt #22 did give her a written statement on Saturday (10/1/2022) and she placed it in the supervisor's outgoing tray.

6. On 10/5/2022 at 1:35 PM, an interview was conducted with the Director of Performance Improvement and Risk (E #1). E #1 stated that they were unable to locate Pt #22's grievance. E #1 stated that grievances should be initiated with 24 hours and that Pt #22's written statement should have been transferred to a formal grievance form.

Based on document review, observation, and interview, it was determined that for 1 of 2 (Pt #22) clinical records reviewed for restraints, the Hospital failed to ensure that the use of restraint was implemented in accordance with safe and appropriate restraint techniques by failing to ensure an emergency safety interview/crisis prevention (CPI) hold was correctly and safely performed.

Findings include:

1. The Hospital's policy titled, "Restraint/Seclusion" (dated 12/2000), was reviewed on 10/4/2022, and required, "Physical restraints: The application of any manual method that immobilizes or reduces the ability of the patient to move his or her arms, legs, body or head freely (also named therapeutic hold, protective hold, or manual restraint...Physical restraints (holds) may only be done using techniques trained through aggression management program. In no case may a patient be taken to the floor or held in a prone position..."

2. The Hospital's policy titled "Code Green" (dated 1/2022), was reviewed on 10/5/2022, and required, "[Hospital] staff will conduct a therapeutic intervention for the patient who is unable to control their behavior and becomes a threat to self, others, or the environment. Staff will page a "Code Green" over the intercom system when additional staff is required for a crisis or the potential of a crisis which may consist...Staff will follow CPI [crisis prevention institute/nonvioleent intervention] in the Code Green procedure...Staff will only use established CPI techniques to avoid harming themselves or others..."

3.The clinical record for Pt #22 was reviewed on 10/3/2022. Pt #22 was admitted on 9/28/2022 to the Hospital's 3rd Floor Adult Behavioral Health Unit (3 West), with a diagnosis of major depressive disorder.

4. The Hospital's Restraint log (dated 8/9/2022-10/1/2022), included a physical restraint placed on Pt #22 on 10/1/2022 at 9:07 PM.

5. On 10/4/2022 at 9:35 AM, the Hospital's video surveillance of the 3rd floor's Adult Behavioral Health Unit (3 East/3 West), from the 10/1/2022 event, was reviewed with the Director of Performance Improvement & Risk (E #1) and the Senior Verbal De-Escalation Specialist (E #_). The video recording included the following events at:

3W Mid Hallway 2:
- 9:03 PM: Pt #22 was in the hallway standing against the wall having a verbal exchange with 5 staff members (E #3/RN, E #7/Program Therapist, E #15/BHT, E #16/RN, E #18/BHT, E #4/RN).
- 9:04:25 PM: The Behavioral Health Technician (BHT/E #15), lunged towards Pt #22 grabbing him by the waist to restrain him.
- 9:04:32 PM: A Registered Nurse (E # 16), placed his hands around Pt #22 neck and then proceeded to push down on Pt #22's neck as he was attempting to restrain the patient. E # 16 then jumped up and came back down with body weight as his hand remained around Pt #22's neck.

3W Mid Hallway 1:
-9:04:52 PM: Pt #22 was carried/escorted to the adjacent unit (3 East), with a BHT (E #15) holding him from behind and underneath Pt #22's arms while his were hands were on the back of his neck as they were transporting him. Pt #22 was then placed in the Quiet Room (seclusion room). As Pt #22 was placed in the Quiet Room, Pt #22 was placed in a prone position (face-down) as E #15 laid on top of him attempting to maintain a physical hold.

6. The Hospital's self reported incident email communication (dated 10/4/2022 at 12:36 PM), from the Facility Risk Manager (E #13) to the Department, included, "Upon doing a camera review for a physical hold which occurred in our hospital on 10/1/2022, staff was observed pushing on a patient's neck."

7. On 10/5/2022 at 9:55 AM, an interview was conducted with the Registered Nurse (E #4/assigned to Pt #22). E #4 stated that on 10/1/2022, Pt #22 was encouraging his peers to be defiant and was told that he had to be moved to the other unit. E #4 stated that Pt #22 refused and was threatening to staff. E #4 stated that a "Code Green"(emergency response for behavior intervention) was called, and Pt #22 was placed in a hold. E #4 stated that when a patient is restrained, CPI techniques should be used and the patient should not be restrained by the neck because this could cut off the patient's circulation.

8. On 10/5/2022 a 10:13 AM, an interview was conducted with the Charge Nurse/Nursing Supervisor (E #3). E #3 stated that he was at the "Code Green" involving Pt #22. E #3 stated that Pt #22 was escalated when he arrived to the unit, because he was told that he had to change rooms and that he was refusing medication until he received information about the medication. E #3 stated that when a patient is escalated, the staff should attempt to verbally de-escalate and hands-on should be the last approach. E #3 stated that interaction became physical as the staff was attempting to transfer the patient to the other unit. E #3 stated that while restraining a patient, the patient's neck or prone position, should be avoided as it can cause harm, including pulling a muscle or choking the person.