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Based on the review of 6 grievance files, interviews with grievance staff, review of pertinent documents and policies and procedures, it was determine that he hospital failed to inform the patient that he/she may file a grievance with the State agency (SA) or the hospital's accreditation organization (AO) directly.

Grievance # 3 was filed by a patient related to questions and concerns about a patient emergency department visit. The patient's grievance was reviewed by the grievance staff, the involved department's staff, leadership, and multidisciplinary review committee. The patient remained unsatisfied with the investigation resolution. A second grievance was filed with the hospital that was also investigated. The patient was not provided with information needed to file a complaint with the SA and/or AO.

Grievance staff were interviewed during the survey on 3/19/19 related to the process for notifying complainants of their ability to file grievances with State and the AO. Staff response is summarized as they usually will let the patient's know of their option when the hospital has made multiple attempts to resolve and the patient continues to verbalize dissatisfaction. This patient did persistently express dissatisfaction to the hospital, but was not provided with the information regarding the right to contact these oversight agency.

Based on the review of 6 grievance files, interviews with grievance staff, review of pertinent documents and policies and procedures it was determine that he hospital failed to investigate 2 of 6 grievances submitted in written form.

Grievance #1 was a three page written letter submitted on behalf of a 90+ year old patient by the daughter of the patient containing multiple specific care concerns. Upon receipt of the grievance the hospital sent a letter to the daughter indicating that due to Health Insurance Portability and Accountability Act (HIPAA) they were not able to investigate. The hospital simultaneously sent a letter to the patient making the patient aware that a complaint had been filed on her behalf and that if she had concerns related to care that she could contact the hospital to relay those concerns. Neither the patient nor the daughter responded to the letters sent by the hospital. The hospital failed to investigate the written concerns in the letter and closed out the case with no review or investigation of the concerns that were submitted to them in the letter written.

Grievance #2 was filed by a patient via email in addition to leaving a message on the grievance department messaging service. The patient's email was vague and brief and provided limited information regarding a patient visit to the Emergency department. A grievance associate sent a letter to the patient indicating that the patient would have to contact and speak to an associate to proceed with the grievance process. Apparently, unsuccessful attempts were made via phone to contact the patient to gain additional information. Grievance #2 was closed without investigation or notification to involved departments.

Grievance staff were interviewed during the survey on 3/19/19 and indicated that grievances were not investigated unless they could speak with the patient. The hospital's grievance policy is silent on this process. Making investigation of a grievance contingent on speaking with, or getting permission from, a patient eliminated opportunities to investigate and resolve potentially serious care issues. This process also eliminated opportunities to address dissatisfactions with care from family members of deceased or otherwise uncommunicative patients.

Based on review of 6 open and 5 closed medical records, including two restraint records, it was determined that the hospital included inappropriate criterion for the cessation of restraints for patient #1 and failed to justify continuation of violent restraints for patient #9.

Patient #9 was a 45+ year old patient who presented to the hospital's emergency department (ED) via police on an emergency petition for suicidal ideation. Patient 9 was involuntarily admitted to the hospital's inpatient psychiatric unit. During patient #9's admission, patient had an episode of self-threatening and violent behavior that appropriately required the use of violent 4-point (limb) restraints.

Per the provider order, the criteria for removal included: "De-escalation of behavior, demonstrating cooperation, and willingness to cooperate." Neither of the mentioned criterion were appropriate for continued restraint as the use of restraints must be based on actual and imminently dangerous behaviors not contingent on patients' awareness or cooperation. While de-escalation was a goal, it was subjective, and failed to describe a cessation of imminently dangerous behaviors.

Patient #1 was a teenage patient who was taken to the hospital's emergency department for "bizarre behavior" by his/her parents. At 08:23 that same day, patient #1 was appropriately restrained for violent and combative behavior towards staff. While the ED staff used a flow sheet titled "24 hour Restraint Flowsheet," to document behavioral observations every 15 minutes, review of documentation revealed one acronym "VB" for "violent behavior" spanning one full hour of restraint. The use of "VB" was subjective, nondescript, and failed to reflect ongoing behavioral justification for the patient to remain in violent restraints.

Further review identified contemporaneous nursing notes which contained additional documentation of behaviors during that hour such as "Patient continues to move body around" and "Pt continues to sit up and trying to get out of restraints." While these behaviors may have demonstrated the patient's desire for release, they revealed no definitive demonstration of imminently dangerous behaviors to justify ongoing 4-point restraint. Therefore, patient #1 was not released at the earliest possible time due to a failure to further assess patient #1 for justification of ongoing restraint, and/or recognize when behaviors did not necessarily represent imminent dangerousness.