HospitalInspections.org

Based on review of policies and procedures, review of grievance documents and staff interview, the hospital failed to follow the time frames in their policy for providing a response to the complainant for 4 of 9 grievances reviewed. The facility reported a total of 10 grievances from both hospital campuses from 11/1/11 to 3/16/12. On the first day of survey census at the main campus was 203 and at the women's campus was 77 for a total of 280. Findings are:

A. Review of the policy and procedure titled Patient Grievance/Complaint Procedure with a Reviewed/Revised date of 5/10 revealed the following concerning the response to the patient:
- "The response to the patient will, whenever reasonably possible, be provided within seven (7) days after receipt of the complaint" and
- "If the grievance is not resolved or if the investigation is not or will not be completed within seven (7) days, inform the patient or the patient's representative that the hospital is still working to resolve the grievance and will follow-up as soon as possible".

B. Review of hospital grievance documentation revealed the following 4 grievances lacked documentation of any kind of response by the hospital to the patient:
1. Grievance 45286 was submitted on 12/29/11 and a letter of response was sent on 1/27/12 - 29 days after receipt of the grievance.
2. Grievance 47018 was submitted on 3/5/12 and as of 3/21/12 there had been no response to the patient - 16 days after receipt of the grievance.
3. Grievance 47073 was submitted on 3/7/12 and as of 3/21/12 there had been no response to the patient - 14 days after receipt of the grievance.
4. Grievance 44438 was received in a call placed to the patient to check on the medical status after a surgical procedure the day before - 11/23/11. During this telephone call on 11/23/11, the patient indicated they did not want a return call concerning the complaints; however, staff started investigating the complaint, entered the complaint in the computer system with a submission date of 11/23/11 even though the patient did not want a call back. Then, a letter dated 12/2/11 was received in the Business Office reiterating some of the same issues. The Business Office sent an e-mail to Risk Management on 12/14/11. On 12/16/11 a phone call was placed to patient; however, patient did not answer so a message was left for patient to return call. Patient did not return call. A letter was sent on 1/27/12 with a response. This letter was 44 days after the e-mail was sent to Risk Management and 65 days after the submission date listed on the grievance.

C. Interview with the Risk Manager on 3/21/12 confirmed the hospital was late in responding to the patient in the 4 grievances listed above.

Based on review of policies and procedures, review of new physician orientation material and staff interview, the hospital failed to provide evidence that 249 of 249 MD/DOs (Doctor of Medicine/Doctor of Osteopathic Medicine) and 73 of 73 APRN/PAs (Advanced Practice Registered Nurse/Physician Assistant) had a working knowledge of the hospital's restraint policies and procedures. On the first day of survey, census at the campus was 203 and at the women's campus was 77 for a total of 280. Findings are:

A. Review of the policy and procedure titled Restraint: Acute Medical/Surgical Standards with a reviewed/revised date of 5/10 and Restraint: Violent/Self-Destructive Behavior with a reviewed/revised date of 6/11 revealed the following regarding training for hospital staff that write restraint orders:
"Physicians and other Licensed Independent Practitioners authorized to write orders for restraint use will be oriented to the hospital policy for restraints. During initial orientation, new Physicians and Licensed Independent Practitioners will review the hospital policy on restraints. Specific aspects of the policy relevant to Physicians and Licensed Independent Practitioners will include:
a) Definition of restraint
b) Restraint order: Orientation will include the requirements of including the reason for restraint and type of restraint, and the prohibition of any PRN [pro re nata or as needed] order
c) Time Limits and Renewal requirements

B. Review of the Orientation Booklet for MD/DOs and APRN/PAs revealed a one-page document titled New Physician/Licensed Independent Practitioner [APRN/PA] Restraint Policy Orientation. This one-page document gave the definition of restraint, what needed to be included in the order and the time limits for the use of restraint for both medical/surgical and for violent/self-destructive behavior.

C. Interview with the Administrative Director of Physician Services on 3/19/12 from 2:50 PM to 3:00 PM and again on 3/20/13 from 11:35 AM to 11:40 AM revealed the following:
- Orientation for new physicians, APRNs and PAs is half a day;
- Give them the orientation booklet when they come in for their half day orientation;
- Either the Administrative Director of Physician Services or other staff in the Physician Services offices goes through the packet page by page and asks them if there are any questions;
- Have nothing the MD, DO, APRN or PA sign that says they received the restraint policy or attended the orientation;
- The staff person going over the booklet signing a page in the booklet that says they went over the information; and
- Confirmed that they could provide no evidence that the MDs, DOs, APRNs or PAs had a working knowledge of the restraint policies.

Review of the document that a staff member for the Physician Services office signs revealed a document that says Orientation Process with 6 items listed and then has a signature line and date. The items in the list say nothing about the restraint policies and has no area for signature of the physician.