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Based on policy and procedure review, hospital grievance file review, and staff interviews, the hospital failed to close a grievance and send a resolution letter that included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the evaluation and investigation into the grievance and the date of completion for 1 of 3 grievance files reviewed. (# 9).

The findings include:

Review of hospital policy "Patient Grievance Procedure", date approved January 2015, revealed "...Patient Grievance - A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care....In the case of a grievance, most situations will be resolved and the patient notified of the resolution by letter within seven (7) days. The letter will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the evaluation and the investigation into the grievance, and the date of completion (indicated by the date of the letter to the patient)....In a situation requiring more extensive evaluation and investigation, written notice will be provided to the patient within seven (7) business days stating that the situation is being investigated or corrective action is being evaluated, and that another written response will be sent within a stated number of days... ."

Grievance file review, on 02/03/2016, on Patient # 9 revealed the grievance start date was recorded as 11/28/2015. File review revealed the concerns were recorded as a grievance, "Grievance - Yes". Further file review revealed the patient's wife met with the Chief Nursing Officer (CNO) on 12/03/2015 to discuss the concerns. Review revealed the CNO stated the hospital would follow-up and respond back, and "...she stated that was unnecessary as all she wanted was for us to focus on the care issues so the quality would improve. ..." Further file review revealed the status was documented as "not resolved" and the space to indicate the date the grievance was closed was not filled in, the space was left blank.

Staff interview, on 02/03/2016 at 1100, with Manager (Mgr) # 1 and Mgr # 2 revealed a final letter was not sent because the family said they did not want one. Interview revealed policy was not followed.

Based on policy and procedure review, medical record review, and staff interview, hospital staff failed to make an entry into the medical record within 7 days of the date and time the death was recorded on the internal log for 1 of 1 deaths occurring within 24 hours of restraint. (Patient # 1)

The findings include:

Review of hospital policy "Safety - Restraint", date approved May, 2015, revealed "...When no seclusion has been used and when the only restraints used on the patient are wrist restraints composed solely of soft, non-ridgid (sic) cloth-like material, the hospital does the following:....ii) Records in a log any death that occurs within 24 hours after a patient has been removed from such restraints. The information is recorded within seven days of the date of death of the patient. iii) Documents in the patient record the date and time that the death was recorded in the log. ..."

Closed medical record review for Patient (Pt) # 1, on 02/03/2016, revealed the patient was brought to the Emergency Department on 01/05/2016 after a fall from standing and sustained a hip fracture. Review revealed Pt # 1 became unresponsive, and was emergently intubated (a tube inserted into the windpipe as a way to provide air/oxygen to a patient who cannot breathe or is breathing insufficiently). Further review revealed Pt # 1 was placed in wrist restraints on 01/05/2016 at 2015, was released from restraints on 01/06/2016 at 1955, and expired on 01/06/2016 at 2150 (1 hour 55 minutes after restraint removal). Record review (28 days after Pt # 1's death) did not reveal documentation of the date and time the death was recorded on the internal log.

Staff interview, on 02/04/2016 at 0920, with Administrative Staff (AS) # 1 revealed hospital staff have not been documenting in the medical record the date and time the death was recorded on the internal log. Interview revealed AS # 1 recorded the death in the log book, but did not realize they had to record in the medical record as well. Interview revealed requirements were not met.

NC00113864