HospitalInspections.org

Based on record review and interview, the facility failed to ensure that grievance resolution written notices contained contact name, investigative steps, grievance results and completion date, in 3 of 7 patient (Patient #'s 1 and 2, and Complainant A) grievances reviewed.

Findings include:

The 9/23/14 at 9 AM review of "Policy 99, revised 1/2010" states Level 2 complaint /grievances are written or verbal complaints that cannot be resolved at the time of the complaint by the staff present, is postponed for later resolution, is referred to other staff for resolution, requires investigation, and /or requires further actions for resolution. It continues that "all level 2 complaints will result in a written response to the complainant, unless the complainant does not want a written response sent. The decision-making body, individual, or designee, will write the complainant and include the Level 2 complaint's resolution decision, including the name of the decision-making body, individual or designee, any steps taken on behalf of the complainant, patient or patient representative to investigate or review the complaint, outcomes of the investigation, and the date of completion."

1) The 9/23/14 at 10:30 AM review of "Case Information-PR Event #050740" documents Complainant #A's verbal complaint on 3/22/14 about "rude staff behavior". Review of the written grievance notice failed to document investigation completion date.

2) The 9/23/14 at 10:35 AM review of "Case Information-PR Event #046685" documents Patient #1's verbal complaint on 11/29/13 about medical information confidentiality. Review of the written grievance notice failed to document investigation completion date.

3)The 9/23/14 at 10:40 AM review of "Case Information-PR Event #044260" documents Patient #2's verbal complaint on 9/25/13 about "discourteous staff behavior". Review of the written grievance notice failed to document investigative steps, grievance results and investigation completion date.

In interview with Clinical Risk Manager B on 9/23/14 at 10:45 AM, B stated that there would be a review of grievance letters to ensure that all components were present.

Based on record review and interview, the facility failed to ensure that all staff physicians had restraint competency training, in 2 of 2 staff physicians reviewed (C and D).

Findings include:

1) The 9/23/14 at 12:40 PM review of Patient #3 medical record documents that Physician C ordered restraints for physical violence on 2/2/14.

In interview with Hospital President E on 9/23/14 at 12:50 PM, E stated that restraint training records could not be found for Physician C.

2) The 9/23/14 at 12:40 PM review of Patient #4 medical record documents that restraints for physical violence were applied on 3/26/14 by nursing staff when Physician D was assigned to this patient's medical care.

In interview with Hospital President E on 9/23/14 at 12:50 PM, E stated that restraint training records could not be found for Physician D.

In interview with Vice President of Medical Staff F states "not to my knowledge" when asked if hospital medical staff have required restraint training on 9/23/14 at 12:55 PM.