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Based on document review and interview, it was determined that for 2 of 3 patients' (Pt. #8 and Pt. #9) complaints/grievances reviewed, the hospital failed to provide an initial acknowledgement letter within 7 days following receipt of the grievances.

Findings include:

1. On 8/30/2023, the hospital's policy titled, "Patient Complaint Grievance Process" (1/2021) was reviewed and included, "... Definitions: 1. A 'patient grievance' is defined as a written or verbal complaint (when the verbal complaint is not resolved at the time of the complaint by staff present) by a patient or the patient's representative regarding patient care... Procedure... The response letter shall be forwarded to the patient or patient representative no later than 7 days after receipt of the grievance even though the hospital's resolution need not be (completed) within the seven day limit..."

2. On 8/30/2023, the hospital's complaint/grievance log from June 1, 2023 through 8/29/2023 was reviewed. The complaint included the following:

- On 7/10/2023, the hospital received a complaint from Pt. #8's representative regarding long wait time in the ED (emergency department). The complaint was not resolved at the time of the complaint. The hospital sent a letter to Pt. #8's representative on 7/26/2023 (16 days following recieipt of the complaint/grievance).

- On 7/24/2023, the hospital received a complaint from Pt. #9 regarding an unwitnessed fall in the ED (emergency department). The complaint was not resolved at the time of the complaint. The hospital sent a letter to Pt. #9 on 8/11/2023 (18 days following receipt of the complaint/grievance).

3. On 8/30/2023 at approximately 10:30 AM, findings were discussed with E #14 (Chief Quality Officer). E #14 stated that an acknowledgement letter should be sent within 7 days following receipt of the grievance.

Based on document review and interview, it was determined that for 3 of 7 hospital employees' (E #1/Registered Nurse, E #13/APN/Advanced Practice Nurse, and MD #1/ED Attending Physician) personnel files reviewed, the hospital failed to ensure employees received training regarding prevention, identification, protection, and reporting allegations of abuse, as required.

Findings include:

1. On 8/30/2023, the Hospital's 2022 Annual Education Reference Guide (10/2022) for hospital employees was reviewed and included, "Interventions for Abuse... 8. Free from All Forms of Abuse and Harassment. Components of effective protections. Prevent... Identify... Protect... Report..."

2. On 8/30/2023, the personnel files for two registered nurses, two medical providers, two patient safety officers, and one patient sitter were reviewed. The files for E #1, E #13 and MD #1's lacked documentation regarding orientation/periodic training on prevention, identification, protection, and reporting allegations of abuse.

3. On 8/30/2023 at approximately 9:50 AM and at 11:22 AM, interviews were conducted with E #9 (Manager, Quality), E #10 (Medical Staff Coordinator), and E #16 (Human Resource Generalist). E #16 stated that training on abuse is required for all employees upon hire and annually. E #9 and E #10 stated that there was no documentation to indicate that an orientation or annual training regarding abuse was provided to E #13 and MD #1. E #16 confirmed that E #1 did not receive annual training on abuse in 2022.

Based on document review and interview, it was determined that for 1 of 3 patients (Pt. #1) clinical records reviewed regarding use of restraints, the hospital failed to ensure that a physician's order for the application of violent restraints was obtained.

Findings include:

1. On 8/29/2023, the hospital's policy titled, "Restraints Policy" (2/2021) was reviewed and included, "... Procedure... B. Obtain order from provider according to type of restraint required... C... Violent Restraints are used to manage violent or self-destructive behavior..."

2. On 8/29/2023, the clinical record for Pt. #1 was reviewed. On 6/20/2023, Pt. #1 was brought to the hospital's ED (emergency department) for psychiatric evaluation. On 6/21/2023, the clinical record indicated that Pt. #1 was placed in violent restraints (four-point restraints) from 1:50 AM through 4:58 AM (three hours and eight minutes). The clinical record lacked a physician's order regarding the use of restraints.

3. On 8/29/2023 at approximately 11:30 AM, findings were discussed with E #9 (Manager, Quality). E #9 confirmed that there was no order regarding use of violent restraints for Pt. #1.

Based on document review and interview, it was determined that for 1 of 3 patients (Pt. #4) clinical records reviewed regarding use of restraints, the hospital failed to ensure that the patient was observed while in restraints, as required.

Findings include:

1. On 8/29/2023, the hospital's policy titled, "Restraints Policy" (2/2021) was reviewed and included, "... Procedure... C... b. Violent restraints are used to manage violent or self-destructive behavior... iv. 1:1 (one to one) Observation is required for all patients in violent restraints... viii. Document observation of patient every 15 minutes..."

2. On 8/29/2023, the clinical record for Pt. #4 was reviewed. On 8/25/2023, Pt. #4 was brought to the ED (emergency department) for taking an unknown drug. On 8/25/2023 at 10:15 PM, the advanced practice provider placed a violent restraints (nylon limb) order on Pt. #4 due to violent/aggressive behavior. On 8/25/2023 at 10:20 PM, the advanced practice provider's notes indicated that Pt. #3 was placed in restraints. The clinical record did not include 1:1 observation, including documentation of the observation every 15 minutes.

3. On 8/29/2023 at approximately 2:30 PM, findings were discussed with E #9 (Manager, Quality). E #9 stated that the required every 15-minute monitoring could not be found. E #9 stated that there should be a documentation of patient's observation every 15 minutes while the patient is in restraints.

Based on document review and interview, it was determined that for 2 of 3 patients' (Pt. #1 and Pt. #5) clinical records reviewed regarding use of violent restraints, the hospital failed to assess the patient's response and the need to continue or terminate the restraints within one hour after the initiation of the restraints.

Findings include:

1. On 8/29/2023, the hospital's policy titled, "Restraints Policy" (2/2021) was reviewed and included, "... Procedure... C... b. Violent Restraints... iii. Face-to-Face provider assessment is required within one (1) hour of placing Violent Restraints... 2. This assessment must include the following... b. Patient's response to the intervention... d. Need to continue or terminate the restraints..."

2. On 8/29/2023, the clinical record for Pt. #1 was reviewed. On 6/20/2023, Pt. #1 was brought to the hospital's ED for psychiatric evaluation. On 6/21/2023, the clinical record indicated that Pt. #1 was placed in violent restraints (four-point restraints) from 1:50 AM through 4:58 AM (three hours and eight minutes). The clinical record lacked an assessment regarding Pt. #1's response to the intervention, including the need to continue or terminate the restraints.

3. On 8/29/2023, the clinical record for Pt. #5 was reviewed. On 8/26/2023, Pt. #5 was brought to the ED for suicidal ideation. On 8/26/2023 from 5:10 PM through 5:54 PM, violent restraints were applied on Pt. #5. The clinical record lacked assessment of Pt. #5's response to the intervention including the need to continue or terminate the restraints.

4. On 8/29/2023 at approximately 11:30 AM and 2:30 PM, findings were discussed with E #9 (Manager, Quality). E #9 confirmed that Pt #1 and Pt. #5's clinical record lacked the required one hour face-to-face assessments.