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Based on record review and interview, the hospital failed to ensure patient notification of grievance resolution to include the investigation and results of grievances for 2 of 24 complaints/grievances reviewed.

Findings:

A review of administrative records showed no investigation or resolution of the entire complaint for 2 of 24 complaints/grievances reviewed.

Complaint #1, dated 10/18/18, showed expressed patient concerns about rudeness of emergency department staff, billing and failure to diagnosis correctly. Documentation showed a resolution to "send an apology letter for perceived rudeness," with no follow-up or efforts to address patient's billing concerns secondary to claims of being misdiagnosed.

Complaint #3, dated 10/31/18, showed expressed patient concerns about the lack of care she received related to a bleeding/infected wound. Documentation showed resolution was to "send an apology letter for perceived rudeness." Documentation showed no efforts to address patients concerns of wound management or care provided by the hospital.

On 11/07/18 at 12:55 pm, Staff A and D stated the documented resolution for complaints #1 and 3 did not show all complaint concerns were addressed.

Based on record review and interview, the hospital failed to follow their "Reporting of Death" policy for one (Pt #3) of 1 patient who died after use of a chemical restraint (Haldol).

Findings

A review of a policy titled, "Reporting of Death" showed requirements for deaths to be reported to the Joint Commission if it was an unexpected death considered to be a sentinel event.

A review of clinical records showed one (Pt #3) of 20 patients died unexpectedly during a sentinel event (unexpected death). A review of administrative records showed no report of the event to the Joint Commission.

On 11/07/18 at 12:45 pm, Staff A and D stated the death of Pt #3 was a sentinel event which was not reported to the Joint Commission and by their own policy, should have been. Staff A and D gave no reason for the hospital's failure to report the event to the Joint Commission.

Based on record review and interview, the hospital failed to ensure:
1) the registered nurse completed required charting during the administration of a chemical restraint (Haldol) for one (Pt #3) of one patient;
2) the registered nurse documented the interruption and/or completion of blood administration for one (Pt #3) of one patient who received a blood transfusion;
3) medication for a chemical restraint was not ordered as a PRN medication per hospital policy;

These failed practices had the potential to place restrained and transfused patients at risk for poor quality care, thereby affecting patient outcomes.

Findings:

A review of a hospital policy titled "Restraint and Seclusion" identified:
1) a chemical restraint as a drug or medication used as a restriction to manage the patient's behavior.
2) no use of PRN orders for chemical restraints would be accepted.

Patient # 3

CHEMICAL RESTRAINT
A review of the clinical record showed a hospital admission on 10/28/18 and discharge (due to death) on 10/30/18.

Documentation showed RN administration of:
- 2mg Ativan injection on 10/30/18 at 1:00 am
- 5mg Haldol injection on 10/30/18 at 1:02 am

A review of medications showed orders for 5mg Haldol injection as follows:
1) PRN received on 10/30/18 at 12:50 am. The order was subsequently discontinued without being given.
2) one time dose given once on 10/30/18 at 1:00 am
3) one time dose given once on 10/29/18 at 10:00 pm
NOTE: Documentation showed no orders for Haldol prior to patients episodes of agitation/confusion/anxiety on 10/29/18

BLOOD ADMINISTRATION
A review of the clinical record showed patient to be awake, confused, impulsive, unable to follow commands, agitated and irritable on 10/29/18 at 6:45 pm with no changes in assessment at 10:56 am. Documentation showed the patient with even and unlabored respirations with no apparent distress.

Documentation showed IV status/access as follows:
10/28/18 at 7:08 am, peripheral IV (left forearm) placed
10/29/18 at 7:45 pm, peripheral IV (left forearm) removed by patient
10/29/18 at 8:00 pm, peripheral IV (left lower arm) placed
10/29/18 at 10:00 pm, peripheral IV (left lower arm) removed by patient
10/29/18 at 10:40 pm, peripheral IV (left lower arm) placed
10/30/18 at 2:30 am, peripheral IV (left lower arm) discontinued

A review of the clinical record showed blood administration began on 10/29/18 at 10:56 pm with VS documented at 10:56 am, 11:00 pm, 11:05 pm, 11:10 pm, 11:15 pm. and an elevated pulse ranging from 90 (at the onset of administration) to "abnormal" (elevated) at 105, 127, 110 and 115, respectively, during blood administration. Documentation also showed the B/P flagged as "abnormal" (149/95) at the onset of administration and then 152/63, 130/86 (the only B/P reading not flagged as abnormal) and then 149/78 and 144/89 respective to timed pulse readings. Clinical documentation showed no ending time of blood administration and no VS documented at the end of the transfusion.

On 11/07/18 at 12:30 pm, Staff F stated:
1) All VS were continually being monitored for Pt #3;
2) 5 mg of Haldol was given prior to blood administration due to patient's agitation;
3) The Haldol was a chemical restraint;
4) There was no documented ending time for the second unit of PRBC because Pt #3 DC'd her IV for the second time and the transfusion didn't complete;
5) Documentation failed to show how much blood the patient received and at what time the administration of blood ended due to lack of IV access;
6) Restraint documentation failed to show administration of a chemical restraint and follow-up on client's behavior while restrained;
7) The nurse and/or House Supervisor remained at client's side while and after Haldol was administered, a nurse was always at the patient's side, they just didn't document it per restraint protocol requirements because they were so busy trying to calm the patient;
8) The patient's son was also at patient's bedside;
9) The patient remained restless, agitated and attempting to climb out of bed until she suddenly stopped moving at which time they saw she was no longer breathing and called a code.