HospitalInspections.org

Based on grievance review, policy review and staff interview it was determined the staff failed to respond to patient grievances in the timeframe defined by facility policy for two (#1, #13) of two patients submitting grievances from the 13 patient sample.

Findings include:

The facility's policy "Patient Grievance Policy", no number, revised 12/11 requires that written response notifying the complainant of the results of the investigation of the grievance be sent within 7 days.

1. Review of the follow up to a grievance from patient #1 submitted on 3/6/13 revealed the complaints were investigated by the Risk Manager. There was no evidence of written notification of the results of the investigation being sent to the patient as of 5/30/13.

2. Review of the follow up to a grievance from a family member of patient #13 revealed the complaint had been received on 3/14/13. The complaint was investigated by the Risk Manager. The written response with findings of the investigation was not sent until 5/8/13.

The Risk Manger was interviewed on 5/29/13 at approximately 4:20 p.m. and confirmed she had not complied with the policy

Based on policy review, record review and staff interview it was determined the facility failed to follow facility policy regarding physician orders for use of physical restraints for 2 (#7, #11) of 4 patients whose records were reviewed for use of restraints form the 13 patient sample.

Findings include:

The facility's policy"Restraints", no number, revised 5/12, requires that a physician order is obtained for the initiation of restraint and that the physician will assess the need for continued restraint every 24 hours and write a new order.

1. Patient #7's physician orders revealed the initial order for restraints was written on 5/23/13. The physician evaluated the patient on 5/24/13 and wrote a new order. On 5/25/13, a verbal order for the restraint was written as a verbal order by a nurse. The order was not authenticated by the physician ordering the restraint. Orders were written and signed by the physician on 5/26. 5/27 and 5/28/13. On 5/29/13 the nurse documented a verbal order for the restraint. There was no authentication of the order by the physician.

2. Patient #11's physician orders revealed the initial order for restraint was written on 5/9/13 as a verbal order from the physician. The order had not been authenticated by the physician as of 5/30/13.

The Risk Manger confirmed the policy was not followed during interview on 5/30/13 at the time of the record reviews.