HospitalInspections.org

Based on document reviews and interviews, the hospital failed to provide a written receipt of the grievance and a notice of its determination regarding a grievance in accordance with their policy for seven (7) of ten (10) sampled patients who filed grievances (Patient 1G, 2G, 3G, and 6G - 9G).

Findings:

The hospitals "Patient Complaints and Grievances" policy and procedure, last revised 01/2022, states in part, "To establish procedures to respond, review and resolve patient grievances and complaints as required by the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. CMS defines a grievance as a written or verbal complaint, not resolved at the time of the complaint by the staff present, regarding the patient's care, abuse or neglect, issues related to compliance with the CMS Conditions...The procedure for responding is defined, in part, "A written (email/mail) acknowledgement to the patient or patient's representative within 7 business days of receipt of the written grievance and/or conversation with patient or representative...and a written (email/mail) response will be given to the patient or representative within 30 business days from date of receipt".

1. On 2/23/2022, the hospital received a grievance from Patient 1G. As of 07/19/2022, there is no evidence of written notice of determination within thirty (30) days of receipt of the grievance.

2. On 3/9/2022, the hospital received a grievance from Patient 2G. As of 07/19/2022, there is no evidence of written notice of determination within thirty (30) days of receipt of the grievance.

3. On 5/13/2022, the hospital received a grievance from Patient 3G. As of 07/19/2022, there is no evidence of written notice of determination within thirty (30) days of receipt of the grievance.

4. On 7/1/2022, the hospital received a grievance from Patient 6G. As of 7/20/2022, there is no evidence of written acknowledgement within seven (7) days and of written notice of determination within thirty (30) days of receipt of the grievance.

5. On 7/7/2022, the hospital received a grievance from Patient 7G. As of 7/20/2022, there is no evidence of written acknowledgement within seven (7) days and of written notice of determination within thirty (30) days of receipt of the grievance.

6. On 7/8/2022, the hospital received a grievance from Patient 8G. As of 7/20/2022, there is no evidence of written acknowledgement within seven (7) days and of written notice of determination within thirty (30) days of receipt of the grievance.

7. On 7/13/2022, the hospital received a grievance from Patient 9G. As of 7/20/2022, there is no evidence of written acknowledgement within seven (7) days of receipt of the grievance.

On 7/18/2022 at 2:30 PM, the Executive Assistant to the Chief Executive Officer ("CEO") was interviewed regarding the grievance process. She stated that she is the person responsible for receiving, tracking, and forwarding grievances to the CEO and completes a weekly review.

On 7/19/2022 at 11:35 AM, the CEO was interviewed regarding the grievance process. The CEO stated, "I make the decision on what becomes a grievance...anything that is related to the care [a patient] received would be a grievance...we still may look at other complaints but if it is a grievance, we try to adhere to the formal process we have in place".

On 7/20/2022 at approximately 9:15 AM, the above findings were confirmed with the CEO.

Based on document reviews and interviews, the hospital failed to ensure the hospital's policy for restraints, related to the documenting of less restrictive measures tried before applying restraints, was implemented for one (1) of five (5) restrained patients (Patient #1R).

Finding:

The hospitals "Use of Restraints for Non-Violent/Non Self-Destructive Behaviors" policy, last revised 1/2022, states in part,"2. Restraints are implemented when alternatives have been tried and failed and the patient continues to exhibit behavior that is harmful to the provision of the patient's well-being; 3. An order for restraint must be obtained from a provider who is responsible for the care of the patient prior to the application of restraint. If anyone other than the attending provider orders restraints (such as a consulting provider) the attending provider must be notified as soon as possible that a restraint order was initiated (not to exceed 12 hours); 4. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used; 5. In an emergency situation when the attending provider is not available to issue an order, restraint may be initiated by a RN based on an appropriate assessment of the patient. In that case, the provider is notified during the application of restraint or immediately thereafter and an appropriate medical order is obtained..."

The hospital requires a Provider to complete the Non-Violent/Non Self-Destructive Restraint order form when thy initiate the use of restraints for patients. This form is ready made so the Provider can check the boxes for different criteria in regard to the restraint. The first part asks them to check a box regarding the reason for the restraint. The second part is where they would check off what least restrictive measures have been attempted prior to the restraint. The third part is where the Provider would check off the type of restraint they want for their patient. The fourth part describes the criteria for discontinuing a restraint. The fifth part describes the education that is offered to the patient/patient's representative regarding the restraint. The final part is a check box that would show that the Provider described the above to the patient/patient's representative and that they verbalized understanding or that the patient was unable to understand / no patient representative available. At the bottom of the form, it has space for the Providers signature, printed name, date of the order and time of the order.

Documentation in Patient #1R's record indicated the following:

- Nursing staff documented that Patient #1 was restrained from 3/21/2022 at 11:00 AM through 3/22/2022 at 11:00 AM; and
- There was no documented evidence on these two (2) order forms that Medical Doctor ("MD") #1 checked any boxes that would show that less restrictive measures were attempted; and
- MD #1 signed and dated the form but provided no further information.

On 7/19/2022 at 10:00 AM, the Executive Director confirmed that these orders were not in compliance with their policy.

Based on document reviews and interviews, the hospital failed to ensure the hospital's policy for restraints, related to the documenting of the type of restraint(s) ordered, was implemented for one (1) of five (5) restrained patients (Patient #1R).

Findings:

The hospitals "Use of Restraints for Non-Violent/Non Self-Destructive Behaviors" policy, last revised 1/2022, states in part,"2. Restraints are implemented when alternatives have been tried and failed and the patient continues to exhibit behavior that is harmful to the provision of the patient's well-being; 3. An order for restraint must be obtained from a provider who is responsible for the care of the patient prior to the application of restraint. If anyone other than the attending provider orders restraints (such as a consulting provider) the attending provider must be notified as soon as possible that a restraint order was initiated (not to exceed 12 hours); 4. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used; 5. In an emergency situation when the attending provider is not available to issue an order, restraint may be initiated by a RN based on an appropriate assessment of the patient. In that case, the provider is notified during the application of restraint or immediately thereafter and an appropriate medical order is obtained..."

The hospital requires a Provider to complete the Non-Violent/Non Self-Destructive Restraint order form when thy initiate the use of restraints for patients. This form is ready made so the Provider can check the boxes for different criteria in regard to the restraint. The first part asks them to check a box regarding the reason for the restraint. The second part is where they would check off what least restrictive measures have been attempted prior to the restraint. The third part is where the Provider would check off the type of restraint they want for their patient. The fourth part describes the criteria for discontinuing a restraint. The fifth part descibes the education that is offered to the patient/patient's representative regarding the restraint. The final part is a check box that would show that the Provider described the above to the patient/patient's representative and that they verbalized understanding or that the patient was unable to understand / no patient representative available. At the bottom of the form, it has space for the Providers signature, printed name, date of the order and time of the order.

Documentation in Patient #1R's record indicated the following:

- Nursing staff documented that Patient #1 was restrained from 3/21/2022 at 11:00 AM through 3/22/2022 at 11:00 AM; and
- There was no documented evidence on these two (2) order forms that Medical Doctor ("MD") #1 checked any boxes that would show the type of restraint that was chosen and used for Patient #1; and
- MD #1 signed and dated the form but provided no further information.

On 7/19/2022 at 10:00 AM, the Executive Director confirmed that these orders were not in compliance with hospital policy.

Based on document reviews and interviews, the hospital failed to ensure the hospital's policy for restraints, related to the reason for the restraint, was implemented for one (1) of five (5) restrained patients (Patient #1R).

Findings:

The hospitals "Use of Restraints for Non-Violent/Non Self-Destructive Behaviors" policy, last revised 1/2022, states in part,"2. Restraints are implemented when alternatives have been tried and failed and the patient continues to exhibit behavior that is harmful to the provision of the patient's well-being; 3. An order for restraint must be obtained from a provider who is responsible for the care of the patient prior to the application of restraint. If anyone other than the attending provider orders restraints (such as a consulting provider) the attending provider must be notified as soon as possible that a restraint order was initiated (not to exceed 12 hours); 4. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used; 5. In an emergency situation when the attending provider is not available to issue an order, restraint may be initiated by a RN based on an appropriate assessment of the patient. In that case, the provider is notified during the application of restraint or immediately thereafter and an appropriate medical order is obtained..."

The hospital requires a Provider to complete the Non-Violent/Non Self-Destructive Restraint order form when thy initiate the use of restraints for patients. This form is ready made so the Provider can check the boxes for different criteria in regard to the restraint. The first part asks them to check a box regarding the reason for the restraint. The second part is where they would check off what least restrictive measures have been attempted prior to the restraint. The third part is where the Provider would check off the type of restraint they want for their patient. The fourth part describes the criteria for discontinuing a restraint. The fifth part descibes the education that is offered to the patient/patient's representative regarding the restraint. The final part is a check box that would show that the Provider described the above to the patient/patient's representative and that they verbalized understanding or that the patient was unable to understand / no patient representative available. At the bottom of the form, it has space for the Providers signature, printed name, date of the order and time of the order.

Documentation in Patient #1R's record indicated the following:

- Nursing staff documented that Patient #1 was restrained from 3/21/2022 at 11:00 AM through 3/22/2022 at 11:00 AM; and
- There was no documented evidence on these two (2) order forms that Medical Doctor ("MD") #1 checked any boxes that would show the clinical justification for the restraint; and
- MD #1 signed and dated the form but provided no further information.

On 7/19/2022 at 10:00 AM, the Executive Director confirmed that these orders were not in compliance with hospital policy.

Based on document reviews and interviews, the hospital failed to ensure staff completed annual restraint training and the documentation was contained in a staff member's personnel record for four (4) of seven (7) staff reviewed who had been involved in a patient restraint (Registered Nurse #1 - #4).

Findings:

The hospitals "Use of Restraints for Non-Violent/Non Self-Destructive Behaviors" policy, last revised 1/2022, states in part, "On-going training and evaluation for competency of the assessment/reassessment, safe use, application and release occurs annually for all staff who applies restraints".

1. Registered Nurse ("RN") #1 was involved in the care of the following patients who were restrained:

- Patient 1R was in restraints from 3/21/2022 to 3/22/2022; and
- Patient 4R was in restraints from 4/20/2022 to 4/22/2022.

The surveyor requested to review RN #1's training records.

As of 7/20/2022, there was no evidence provided to the surveyor that indicated RN #1 had completed any training on restraints.

2. RN #2 was involved in the care of the following patient who was restrained:

- Patient 1R was in restraints from 3/21/2022 to 3/22/2022.

The surveyor requested to review RN #2's training records.

As of 7/20/2022, there was no evidence provided to the surveyor that indicated RN #2 had completed any training on restraints.

3. RN #3 was involved in the care of the following patients who were restrained:

- Patient 3R was in restraints from 3/10/2022 to 3/12/2022; and
- Patient 4R was in restraints from 4/20/2022 to 4/22/2022.

As of 7/20/2022, there was no evidence provided to the surveyor that indicated RN #3 had completed any training on restraints.

4. RN #4 was involved in the care of the following patient who was restrained:

- Patient 5R was in restraints from 6/23/2022 to 6/24/2022.

As of 7/20/2022, there was no evidence provided to the surveyor that indicated RN #4 had completed any training on restraints since 7/15/2020.

On 7/20/2022 at 9:35 AM, the Executive Director confirmed that the RN's #1- #4, who participated in restraints for patients at the hospital, were not in compliance with their policy.