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Based on review of the hospital policy number G004 Complaint and/or Grievance: Patient; the governing body has not delegated in writing the responsibility to review and resolve grievances to a grievance committee. The hospital refers all grievances to the Office of Patient Relations who inputs the information in an electronic system and assigns to the unit/department to manage the grievance documentation and risk management as needed. The unit/department provides a written response to the patient/patient representative. The hospital has not met the regulatory guidelines when it failed to delegate the responsibility for the complaint/grievance process in writing to a grievance committee and the Patient Relations Representative.

Based on review of 1 out of 12 open medical records, it was determined physician failed to document the required restraint orders for 3 days during his May 2013 admission.

Patient #1 was admitted to the hospital on 4/28/13. The patient ' s medical condition required the use of restraint during his admission. Review of the medical record revealed that on 5/1/13, 5/6/13, and 5/13/13 no orders were written for restraint although the corresponding documentation revealed the patient was in bilateral wrist and ankle restraints, mittens and four side-rails. The every two hour RN assessments, nursing and physician notes reveal the patient remained in restraints to prevent removal of necessary medical equipment, self-injurious behavior and injury to others. The hospital failed to meet regulatory guidelines when they did not obtain orders for use of restraint.

Based on review of 1 out of 12 open medical records, it was determined the Registered Nurse failed to consistently document her every two hour assessments for from April 29, 2013 to May 15, 2013.

Patient #1 was admitted to the hospital on 4/28/13. The patient's medical condition required use of restraints to prevent removal of necessary medical equipment, self-injurious behavior and injury to others. The hospital policy and procedure number R001 Restraints: Non-Violent/Non-Self-Destructive Behavior determined the patient will be monitored every two hours by the Registered Nurse for continued need for restraints. Although the corresponding nursing and physician documentation revealed the continued need for restraints the medical record review revealed that on a daily basis while the patient was in restraint the every two hour assessments were not documented or documented late. For example on 4/29/13 there was no RN assessment for 12 midnight and 2:00 AM. On 4/30/13 no assessments for 8:43 PM and 10:43 PM. Example of lateness on 5/3/13 the assessment at 6:37 PM was late by 37 minutes. A detailed list of late assessments and assessment not performed will be supplied to the hospital.

Based on observation, review of closed patient medical records and interview of the Risk Management staff, it was determined that patient discharge summaries were not completed by the physician within the required 30 days after patients discharge. This was evident for 1 out of 5 closed patient medical record reviews.

Patient #16 was admitted to the hospital on 02/08/13 and discharged on 02/20/13. A review of the patient's electronic medical record revealed that the Discharge Summary (Draft) was blank. There was no indication that the Discharge Summary had been started or attempted. The Risk Management Staff were to check further for patient discharge information elsewhere in the system after 05/17/13 and to send that information if available. As of 05/29/13 no information was found or received related to the patient's discharge summary. Failure by the staff to do a Discharge Summary renders the patient medical record incomplete.