HospitalInspections.org

INTAKE #TN00029055

Based on facility policy, medical record review and interview, it was determine the facility failed to follow its policy for investigation of complaints/grievances for 4 of 4 (Complaint/Grievance #1, 2, 3, and 4) random complaint/grievances reviewed.

The findings included:

1. Review of facility policy, "Patient/Resident Complaint/Grievance" revealed, "... Patient have a right to express concerns and expect resolution in a timely manner...The Hospital Quality Improvement [QI] Committee ensures the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance...The QI subcommittee makes recommendations for further actions and provides a summary report..."

2. Review of the facility's Complaint/Grievance investigations dated 11/21/11 - 1/11/12 revealed for Random Grievance #1, 2, 3, and 4 the completion report section was blank. For #3 and 4 the conclusions/recommendations/actions section was blank.

3. During an interview in the conference room on 1/31/12 at 1:20 PM, the Risk Manager verified the Complaint/Grievance reports for Random Grievance #1, 2, 3, and 4 were incomplete. She stated further, "The system is broken."

Based on facility policy review, medical record review, and interview, it was determined the facility failed to follow its restraint policy for 1 of 5 (Patient #5) sampled patients.

The findings included:

1. Review of the facility's policy "Restraint and Seclusion" revealed, "... Prevent, reduce, and elimate the use of restraints by basing use on the patient's assessed needs... Use of restraints shall be added to the patient's plan of care... All verbal or telephone orders must be countersigned within 24 hours... Staff is expected to continually assess and monitor the patient to ensure the patient is released from restraint or seclusion at the earliest possible time... Care is provided at least every 2 hours to include :offer of fluids/nourishment, hygiene care as required, tolieting as required, release of extremities and range of motion exercises provided... Each episode of restraint is documented in the patient's medical record,consistent with policies and procedures...

2. Medical record review for Patient #5 revealed an admission on 12/02/11 for Left hip fracture and Renal failure. The nursing "Patient Notes" dated 12/04/11 at 1400 documented the patient returned from PACU awake, alert but confused and combative, reorientation was attempted without success, the patient was swinging with fists at staff and trying to get out of bed. Documentation on the nursing restraint assessment was marked for Non-Violent Behavior on 12/04/11 at 1400. At 1410 the RN received an order from a physician to place the patient in restraints. Further review of the medical record revealed physicians orders for restraints [every 24 hours] for 12/5/11 - 12/11/11. The patient continued in restraints for 12/5/11 ,12/6/11, 12/7/11, 12/9/11, 12/10/11, 12/11/12 without documentation the restraints were being checked and released every 2 hours per the facility's policy. Documentation of a physician's restraint order for 12/5/11 revealed the order was not signed by a physician until 12/7/11 at 9:00 AM. No documentation was on the patients Plan Of Care for restraints after 12/3/11.

3. During an interview in the Administration Conference Room on 1/31/12 at 2:43 PM, the Quality Coordinator(QC) stated, The assessment for restraints for this patient was wrong."The QC stated further,"The only reference I see in the plan of care is the statement on 12/3/11 that documents restraints as ordered, I don't see anything else."