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Based on interview and record review, the hospital failed to ensure Patient 26's entire grievance was resolved when the cardiologist included in Patient 26's grievance letter was not addressed.
This failure had the potential to result in unresolved grievances.

Findings:
During a review of Patient 26's Emergency Department record dated 2/1/24 indicated Patient 26 was admitted from the emergency Department (ED) to the hospital for Atrial Fibrillation with rapid ventricular response (fast, irregular heart rate). Patient 26's Physician Summary dated 2/2/24 indicated Patient 26 left against medical advice on 2/2/24.

During a review of Patient 26's documents dated 2/15/24 the documents indicated a grievance was sent to Santa Clara Valley Medical Center (SCVMC) Customer Relations on 2/14/24 that indicated concerns related to care, including the cardiologist assigned to Patient 26's plan of care. A response letter was sent to Patient 26 on 2/15/24 indicating the concerns are being reviewed and a response will be sent in 30 days. On 3/28/24 a letter was sent to Patient 26 indicating an investigation by the emergency department management was completed.

During an interview on 9/12/24 at 10:13 a.m. the program manager (PM) stated Patient 26's grievance was only sent to the emergency department via an email communication.

During an interview on 9/12/24 at 11:00 a.m. with the Emergency Department Medical Director (EDMD), the EDMD stated there were no ED physician issues, Cardiology was identified in the patients grievance.

During a review of the facility's policy and procedure titles, "Grievance Process for Concerns regarding Patient Care and Services" dated 2/27/24, the policy indicated, " The purpose of the policy is to establish a process to resolve complaints...". "Customer Relations Department sends resolution letter to the patient including ... steps taken to investigate the grievance....the results of the grievance.'

Based on interview and record review, the hospital failed to implement the facility policy and procedure (P&P) for restraints (a "mechanical restraint" or "physical restraint" is used as an intervention when a person's behavior presents as an immediate danger to themselves or to others) when nursing staff failed to assess one of two sampled patients (Patient 30) for the use of behavioral restraints every 15 minutes.

This failure had the potential to result in Patient 30 not being accurately assessed for change of condition and safety while in restraints.

During a review of Patient 30's Emergency Department (ED) physician notes dated 9/5/24, the ED notes indicated Patient 30 was admitted for dementia (decline in mental functioning, such as thinking, remembering, and reasoning, that interferes with daily life) with behavioral disturbance (drastic changes in behavior).

During a review of Patient 30's restraint flow sheet documentation dated 9/5/24, the restraint flow sheet indicated Patient 30's documentation started 9/5/24 at 4:27 p.m. indicated Restraint type nonviolent soft restraints with assessments and monitoring every two hours thru 10:00 p.m.

During a review of Patient 30's physician orders dated 9/5/24, the orders dated 9/5/24 at 3:53 p.m. indicated restraints behavioral or violent, right, and left arm soft.

During a concurrent interview and record review on 9/11/24 at 4:08 p.m. with Emergency Department Director (EDD) the EDD stated the monitoring should be every 15 minutes for violent/behavioral restraints, the order should be followed.

During a review of the facility's policy and procedure titled "Restraint and Seclusion of Patients in non-mental health acute care settings" dated 12/8/22, indicated, "Application of restraints requires documentation on the nursing flow sheet of the type of restraint and time of application". Violent, self-destructive behavioral restraints are used only when necessary and require close monitoring and treatment". "Violent, self-destructive behavior restraints are considered an emergency. The patient must be reassessed by a registered nurse every 15 minutes for the continued need for the restraint".

Based on observation, interview and record review, the facility failed to notify the responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action) of a conserved (patient with a court appointed conservator who has authority over the patient's needs and their finances) patient's discharge against medical advice (AMA -when a patient leaves a hospital before their medical care team recommends it) for one (Patient 3) of eight sampled patients.

This deficient practice resulted in the facility's inability to provide effective discharge planning process that focuses on the patient goals and treatments preferences, potentially placing patients at risk for ineffective post-discharge care and leading to negative patient outcomes.

Findings:

Review of Patient 3's face sheet encounter date 4/2/2022, indicated the emergency contact was a family member (FM) and conservator with phone numbers.

Patient 3's medical records was reviewed. Patient 3 was admitted to the emergency department (ED) on 4/2/22 with admission diagnoses including slurred speech.

Review of Patient 3's ED progress note dated for 4/2/22 at 10:05 p.m., indicated Patient 3 has altered mental status and aggressive behavior.

A review of the case manager note dated 4/3/2022 at 1:21 p.m. indicated, primary emergency contact was Patient 3's FM and secondary emergency contact was Patient 3's conservator with phone numbers of both. Further review of the note indicated Patient 3 was transferred to the hospital due to some behavioral issue and the police was called to assist the patient. Patient 3 has temporary conservatorship per Patient 3's FM due to physical reasons.

A review of the physician psychiatry note dated 4/3/2022 at 3:21 p.m., indicated Per Patient 3's FM, Patient 3 has a temporary conservatorship started 4/2/22 and psychiatric history indicated history of bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making) in 2021, was hospitalized several months for psychiatric illness and has conservatorship.

A review of the resident internal medicine doctor discharge summary note dated 4/4/22 at 6:25 p.m., indicated Patient 3 signed the AMA form and was witnessed by nursing staff and Patient 3 will be provided with a front wheel walker, bus or taxi voucher and medications from the discharge pharmacy.

During a concurrent interview and record review on 9/16/24 at 9:35 a.m., with registered nurse A, RN A reviewed Patient 3's medical record and stated on 4/4/2022 at 7:57 p.m., Patient 3 refused to go to SNF, Physician was notified and came at bedside. He further stated that Patient 3 signed against medical advice (AMA) with physician and witnessed it...

An interview with Patient 3's RP/Legal Conservator on 9/16/24 at 10:08 a.m., the RP stated Patient 3 was referred to public guardian for conservatorship on 2/7/2022 and official conservatorship was on 4/1/2022. Patient 3 was admitted to SNF on 4/1/2022 and she was told by SNF staff on 4/2/2022 that the Patient 3 was sent out to hospital for refill of his psychotropic (drugs affecting the mind, emotions and behavior) medications. RP stated that she received a call from acute hospital sometime on 4/2/22 or 4/3/2022 and she told them that Patient 3 was conserved. The RP further stated sometime on 4/5/2022 she received a call from the social service staff from the shelter in Santa Cruz that Patient 3 was seen in the street. RP called the hospital, and she was told Patient 3 was discharged from the hospital on 4/4/2022 and the hospital did not call her to inform her about the AMA discharge of Patient 3 on 4/4/2022.

A review of the hospital policy and procedure, dated June 7,2023, entitled "Leaving the Hospital or clinic or Refusing Care against Medical Advice (AMA)" indicated that every competent adult patient, emancipated, and patient's legal representative has the right to make informed decisions regarding the patient's medical care and to make informed decisions to leave the hospital or clinic or refuse care against the advice of members of the medical staff. If the patient lacks the legal authority to make health care decisions (e.g., a minor or certain concervatee) or the capacity to make health care decisions, the patient has the right to have a legal representative make that decision.