HospitalInspections.org

Based on document reviews and interviews, the hospital failed to provide a written notice of its determination regarding a grievance for four (4) of five (5) sampled patients who filed grievances (Patient #1, #11, #12, and #13).

Findings:

The "Patient Concerns and Complaints" policy and procedure, last revised 11/2019, defines complaints as, "Concerns that can't be addressed/resolved in real time; Requests by a patient or family member for a formal review; Any written, emailed, faxed, verbal or survey complaint concerning clinical quality, service delivery or financial processing". The procedure for responding is defined, in part, "Manage the complaint response by responding within one week. If investigation requires more time, a response will be provided within 30 days".

1. On 9/8/2021, the hospital received a complaint from Patient #1. The "2021 Concern Report" indicated that the facility provided the patient with a verbal response on 9/8/2021 and 9/15/2021. As of 11/18/2021, there is no evidence of written notice of its determination regarding this complaint.

2. On 9/27/2021, the hospital received a complaint from Patient #11. The "2021 Concern Report" indicated that the facility provided the patient with a verbal response on 9/27/2021. As of 11/18/2021, there is no evidence of written notice of its determination regarding this complaint.

3. On 6/1/2021, the hospital received a complaint from Patient #12. The "2021 Concern Report" indicated that the facility left a phone message on 6/1/2021, with no evidence of a return call from the patient. As of 11/18/2021, there is no evidence of written notice of its determination regarding this complaint.

4. On 8/24/2021, the hospital received a complaint from Patient #13. The "2021 Concern Report" indicated that the facility provided the patient with a verbal response on 8/24/2021. As of 11/18/2021, there is no evidence of written notice of its determination regarding this complaint.

On 11/18/2021 at 8:50 AM, the Executive Assistant to the Chief Nursing Officer ("CNO"), The Chief Human Resource Officer ("CHRO"), the Chief Medical Officer ("CMO"), and the Chief Executive Officer ("CEO") was in interviewed regarding the complaint process. She stated that she is the person responsible for tracking the complaints. She stated that the complaints come to her, she creates a chart of the concerns, and then forwards the concern(s) to the appropriate department director. That director is supposed to handle the complaint/concern and then the response depends on the patient - if they don't want a letter or return call, they don't get one.

On 11/18/2021 at 9:41 AM, the CMO and CEO were interviewed regarding the complaint process. The CEO stated, "We do a great follow up with complaints and grievances, but we do not do a great job with letters ...".

On 11/18/2021 at approximately 10:30 AM, the above findings were confirmed with the Director of Quality.

Based on record reviews and interviews, it was determined that the hospital failed to obtain consent to treat for one (1) of ten (10) patients reviewed (Patient #3).

Finding:

The "Informed Consents" policy, last approved 12/2020, states, in part, "The consent of every adult patient should be obtained prior to treatment".

On 11/18/202 at 6:37 PM, Patient #3 drove himself/herself to the Emergency Department ("ED"). Documentation in the medical record stated that the patient was alert and oriented. There was no documented evidence of a verbal or written consent in the medical record.

On 11/18/2021 at approximately 11:45 AM, this finding was confirmed with the Executive Director.

Based on document reviews and interviews, the hospital failed to ensure staff completed restraint training in accordance with hospital policy and the documentation was contained in a staff member's personnel record for three (3) of sixteen (16) Licensed Independent Provider's ("LIP") and thirty (30) of one hundred and twenty (120) Registered Nurses ("RN") staff reviewed (LIP #1 through LIP #3 and RN #1 through RN #30).

Findings:

The hospital's "Use of Restraints for Non-Violent/Non Self-Destructive Behaviors" and the "Use of Restraints for Violent/Self-Destructive Behaviors" policy and procedure, last approved in 2/2020, states in part, "Initial staff education is provided during new-staff orientation. On-going training and evaluation for competency of the assessment/reassessment, safe use, application and release occurs annually for all staff who apply restraints...Providers ordering the restraints will receive restraint education and the current policy during Medical Staff Orientation with the Quality and Risk Department. Annual restraint training will be provided through Healthstream, or face to face with the Education Department to any caregiver responsible for applying restraints".

On 11/18/2021, surveyors were provided the entire list of restraint training for RNs and LIPs by the Director of Quality. This revealed the following information:
- LIP #1, LIP #2, and LIP #3 had documented evidence of past due restraint training since 7/31/2020;
- RN #1 had documented evidence of past due restraint training since 4/30/2020;
- RN #2 and #9 had documented evidence of past due restraint training since 7/9/2021;
- RN #3 and #30 had documented evidence of past due restraint training since 10/1/2021;
- RN #4 had documented evidence of past due restraint training since 1/31/2021;
- RN #5, #6 , #7, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28 had documented evidence of past due restraint training since 4/30/2021;
- RN #8 had documented evidence of past due restraint training since 11/6/2021;
- RN #13 had documented evidence of past due restraint training since 8/20/2021; and
- RN #29 had documented evidence of past due restraint training since 10/29/2021.

On 11/18/2021 at 3:48 PM, the above findings were confirmed with the Chief Nursing Officer.