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A. Based on document review and interview, it was determined for 4 of 5 (Pt #9, Pt #10, Pt #11, Pt #12) complaint and grievances reviewed, the hospital failed to ensure a written notice of the grievance determination was provided to the patient. This has the potential to affect all patients who receive care by the hospital.

Findings include:

1. The policy titled "Complaints and Grievances" (revised 6/2018) was reviewed on 5/3/23. The policy noted "Grievance - A formal or informal written or verbal complaint made by the patient or the patient's representative, which is not immediately resolved by staff..."

2. The Complaint/Compliment Forms were reviewed on 5/2/23. The following complaints met the definition of a grievance for not being immediately resolved, required an investigation, and a written notice of determination:

a) Pt #9, date of event: 2/7/23, received complaint via phone 2/7/23, "Patient would like a call... due date 3/1/2023", investigation completed on 2/22/2023, unable to reach Pt #9 via phone. No letter sent.
b) Pt #10, date of event: 1/22/23, received face to face 1/22/23 prior to patient leaving Against Medical Advice. "MD will not give Risks and/or Benefits of AMA to father... Actions taken: NONE, MD request RN contact pt father via phone and give Discharge instructions... NO ANSWER". The complaint was first reviewed on 1/23/23. No letter sent.
c) Pt #11, date of event 8/27/22, received complaint via phone 12/22/22, "Actions taken: Apologized to patient. Reassured this would be reviewed... Spoke to nurse director of ED who will review and do a follow up phone call with patient." Follow up phone call was made on 1/9/23. No letter sent.
d) Pt #12, date of event: 1/21/23, received complaint via phone: 1/24/23, "Apology given... Reaction to issue: Dissatisfied". No letter sent.

3. During an interview on 5/3/23 at approximately 1:30 PM, E#1 (Vice President of Ancillary Services and Executive Director of Foundation) reviewed Pt #9, Pt #10, Pt #11 and Pt #12's complaint forms and verbally agreed letters should have been written and sent to the complainant.

B. Based on document review and interview, it was determined the hospital failed to ensure the Complaint and Grievances policy accurately noted the process for providing the complainant with a written grievance determination as required. This has the potential to affect all patients who receive care by the hospital.

Findings include:

1. The policy titled "Complaints and Grievances" (revised 6/2018) was reviewed on 5/3/23. The policy noted "10. Grievance may be resolved via phone phone call, face to face meetings, or if needed, a letter which should include...."

2. During an interview on 5/3/23 at approximately 1:30 PM, E#1 reviewed the standard and the hospital policy and verbally agreed the policy did not accurately note the process for providing the complainant with a written grievance determination.

Based on document review and staff interview it was determined for 1 of 10 (Pt #1) medical records reviewed the Hospital failed to follow the policy for consent to treat and failed to ensure consent for treatment was signed by the patient or legal representative. This has the potential to affect all patients who receive care by the hospital.

Findings include:

1. The policy titled "Administration Policy- Authorizations and Consents (reviewed 3/2019)" was reviewed on 5/3/23. The policy noted "Policy: To the extent possible, each patient treated except in case of emergency situation, should have an authorizing for treatment signed by the patient or his legally recognized representative. When it is not possible to obtain the general treatment authorization, the patient access personnel should document the reason on the consent form, which will become a permanent part of the medical records."

2. The clinical record of Pt. #1 was reviewed on 5/2/23. Pt.#1 was admitted into the ED on 12/16/22, with chief complaint of abdominal pain. The record noted on admission Pt.#1 was oriented to person, time and place, alert, cooperative, oriented to situation and clear speech. The record lacked a consent to treat form or a reason why consent to treat form wasn't signed.

3. During an interview with the Clinical Informative (E#4) on 5/3/23 at 10:00 AM, E#4 verbally confirmed the lack of any consent to treat form or a reason why consent to treat form wasn't signed.

A. Based on document review and interview, it was determined for 2 of 2 (MD#1, MD#2) physician files reviewed, the hospital failed to ensure restraint training was completed. This has the potential to affect all staff and patients who receive care by the hospital.

Findings include:

1. The policy titled "Safety Devices/Restraints/Seclusion" (last reviewed by hospital on 3/2020) was reviewed on 5/3/23. The policy noted "9. Staff Education: a. Staff education will occur... prior to participating in the care of a patient in restraints... c. Training and competence is documented in staff records."

2. The following physician files were reviewed on 5/3/23. MD#1 and MD#2's files lacked documentation of restraint training:

3. During an interview on on 05/03/23 at approximately 2:00 PM, E#4 (Clinical Informatics) reviewed MD#1 and MD#2's files and verbally agreed the physicians had not been assigned or completed the restraint training.

B. Based on document review and interview, it was determined the hospital failed to ensure physicians and licensed independent practitioners training requirements were specified per hospital policy. This has the potential to affect all staff and patients who receive care by the hospital.

Findings include:

1. The "Safety Devices/Restraints/Seclusion" policy was reviewed on 5/3/23. The policy lacked documentation of physician and licensed independent practitioners of restraint training requirements.

2. During an interview on 5/3/23 at approximately 2:25 PM, E#6 (Director of Nursing) reviewed the restraint policy and stated "I don't think our policy has ever stated physician restraint training requirements."