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UNIVERSITY OF MARYLAND MEDICAL CENTER
PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES
Tag No.: A0122
Based on review of the hospital policy and procedure, it was determined that the hospital policy does not meet the expected length of time for resolution of grievances nor provision of a written response.
A review of the hospital's Complaint and Grievance Resolution policy, PROE-002 under III Procedure #5 all grievances are processed as follows: a written acknowledgement and the expected date of investigation completion are sent within 2 business days of receiving the grievance. The policy defines what happens to the grievance once it is received in the Executive Office. Under d), if the grievance is not resolved in 30 days, the complainant receives weekly written updates thereafter until resolution. Written notice to the patient includes the steps taken to investigate the grievance, the results and dates of completion. The policy addresses if the grievance cannot be resolved within 30 days but does not address the 7 day time frame for resolution of grievances or written response on average within 7 days. The policy and procedure as written does not meet the regulatory standards.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0168
Based on review of the hospital policy number COP-026 on restraint and seclusion the hospital policy failed to address the timely acquisition of the order for restraint or seclusion prior to its application or in emergency application situations.
The policy review revealed under III. Procedure, L-4 Orders for Seclusion and/or Restraints Controlled, Violent and/or Aggressive Behavior, a RN can initiate seclusion or restraint for violent and/or aggressive behavior in emergency situation within one hour of the initiation the prescriber must:
(1) Give a written or verbal order for the seclusion or restraint
(2) Complete a face-to-face evaluation of the patient
(3) Document results in the progress notes section of the patient's chart.
The hospital policy as written does not meet the regulatory requirements since it does not address the process for timely acquisition of an order restraint and seclusion which must be immediately.