HospitalInspections.org

Based on review of the facility's Complaint Resolution Policy and Procedure, review of September, October and November Complaint Resolution Forms and interview with staff, the facility failed to follow their policy that a Manager would call a complainant back within 24 hours of the time the complaint had made to the facility for 2 (#11 and #12) of 2 (#11 - #12) complaints received on the weekend. This failed practice had the potential to affect all complaints received on the weekends. The findings included:

A. The December 8, 2011, 1010 review of the facilities Complaint Resolution Policy (#AD-1.57 6a) stated "Managers are to call back the Complainant within 24 hours of receiving notification of a complaint."

B. A review of Complaint Resolution Form #11 revealed a complaint had been received on Saturday October 15, 2011 (no time documented). The form documented " Date/Time Spoke with Complainant: 10/17/2011 12:00 AM " .

C. A review at 1020 of Complaint Resolution Form #12 revealed on Saturday September 3, 2011 (no time documented) a Complainant contacted the facility with a complaint. The form documented "Date/Time Spoke with Complainant: 9/5/2011 1200 AM".

D. The Quality Risk Manger (QRM) verified at 1055 on December 8, 2011 the Complainant had not received a call back within 24 hours because the complaint was made on the weekend (Saturday). She explained there were no Managers who work the weekend to make the policy required 24 hours return call.

E. The QRM verified at 11:00 on December 8, 2011, the Complainant had not received a call back within 24 hours because the complaint was made on the weekend (Saturday). She explained there were no Managers who worked the weekend to return the 24 hour required call.

The December 8, 2011, interviews and medical record reviews 4 (#1, #2, #3, & #5) of 5 (#1 - #5) revealed the facility had used soft wrist restraints or a veil bed without a physician's order. This failed practice had the potential to affect all patients placed in restraints or a veil bed. The findings included:

A. The Quality Risk Manager provided the facilities Policy and Procedure for Restraint and Seclusion (no policy # but was documented replaces policy #R-1) was reviewed. Policy statement E stated, "All restraints require verbal or written order by the attending physician or designee".

B. Review of Medical Record #1 revealed physician orders written 11/15/11 at 1850 were for "Soft Restraints for Right Wrist; Left Wrist; Right Leg; and Left Leg". The review of medical record #1 revealed the patient had been placed in an enclosed (veil bed) without a physician's order from 11/15/11 at 2135 until 11/16/11 at 1930.

C. The QRM verified at 1410 the review of medical record #1's revealed he had been placed in an enclosed bed (veil bed) without a physician's order from 11/15/11 at 2135 until 11/16/11 at 1930.

D. The review of medical record #2 verified soft wrist restrains were used from 11/4/11 from 0700 to 11/5/11 at 0900 for 26 hours and 11/13/11 from 0900 - 2100 for 12 hours without a restraint order from a physician.
E. The QRM verified at 1420 the medical record review had revealed the lack of physician orders for soft wrist restraints for 26 hours from 11/4/11 - 11/5 and 12 hours on 11/13/11.
F. Medical record #3 was reviewed for physician ordered restraints. The review revealed a 24 hour physician order for soft restraints (right and left wrist) from 9/30/11 at 1540 till 10/1/11 at 1540. The Nurses Notes Daily Shift documented at 1640 patient in right upper restraint. Patient #3 was in a right upper extremity restraint for one hour (1540 - 1640) without a physician's order.

G. This was verified at 1430 by the QRM during the record review.

H. Medical record #5 was reviewed. The medical record contained a physician signed Restraint/Seclusion Order sheet dated 10/25. The order sheet did not identify what restraint/restraints were to be used. The Nurse's Notes Daily Shift Assessment dated 10/25/11 documented the patient was in an enclosed or veil bed at 1110, 1900 and 1930.

H. The QRM verified at 1445 patient #5 was in an enclosed/veil bed without a physician's order on 10/25/11.