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Based on review of hospital policy, medical records, grievance log, and staff interview, it was determined the hospital failed to ensure patients were informed of the time frame for review and response to grievances for 1 of 2 patients (Patient #1) whose grievances were reviewed. This had the potential to interfere with patients' understanding of the grievance process and delay grievance resolutions. Findings include:

A hospital policy "Patient Grievance Policy," effective 8/22/17, stated, "When a grievance will not be resolved or the investigation is not or will not be completed within 7 days, the patient or patient's representative will be informed within those 7 that follow up [sic] will be provided in the form of a written response with an expected resolution date." This policy was not followed. An example includes:

Patient #1 was a 56 year old female who was admitted 10/11/18, with a diagnosis of post-operative pain and lactic acidosis. She was discharged to home on 10/13/18.

The hospital's grievance log included a grievance for Patient #1, received date 12/12/18. The identified grievance had an initial hospital response letter, dated 12/12/18, which stated, "This letter is in response to your written complaint related to your visits at Kootenai Health in October and November 2018" and "As you are aware, Patient Advocacy has communicated your experience and concerns with our Risk manager, [name], who will be communicating with you from this point forward." The initial response letter did not include an expected resolution date to Patient #1's grievance.

The Patient Advocacy Specialist was interviewed on 6/26/19, beginning at 1:21 PM, and Patient #1's grievance was reviewed in her presence. She stated Patient #1's issue was treated as a "risk management issue" and was not treated as a grievance. The Patient Advocacy Specialist confirmed Patient #1's issue should have been treated as a formal grievance with an expected resolution date included on the 12/12/18 response letter. She stated the hospital's grievance policy was not followed.

Patient #1 was not given a time frame for the response to her grievance.

Based on review of medical records, grievance log, policies, patient interview, and staff interview, it was determined the hospital failed to ensure visitation rights were not restricted for 1 of 1 inpatient (Patient #1) whose record was reviewed. This resulted in denied visitation which was not in accordance with the patient's preferences. Findings include:

Patient #1 was admitted to the hospital on 6/22/19, with a diagnosis of overdose. Prior to admission, she had been evaluated, intubated, stabilized, and transferred to the hospital from a nearby CAH. She was an inpatient at the time of survey.

The hospital's grievance log included a grievance submitted by Patient #1's spouse on 6/26/19, which stated:

- "Spoke with patient's husband, [name] about his frustration with Hospital Supervisor, [name] and DE from State of Idaho. Hospital Supervisor 'kicked me out of my wife's room stating that patient's [sic] on an involuntary hold are not allowed visitors.'"

- "Violated patient rights"

- "Ordered husband to be escorted out by security"

- "Patient and her husband were notified by Dr. [name] that patient was not placed on a hold prior to her being transferred to KBH."

Patient #1 was interviewed while an inpatient on the BHC on 6/27/19, beginning at 10:38 AM. She stated she agreed to go to the BHC voluntarily. Patient #1 stated hospital staff had security escort her husband off hospital grounds due to the fact they believed she was on a "hold." She stated she was not placed on a medical or psychological hold by a physician or court. Patient #1 stated the House Supervisor told her that her husband could not visit her if she was on a hold.

A hospital policy "Visitation," effective 5/18/19, was reviewed. The policy did not include visitation limits based upon a patient's psychological or medical hold status.

A second hospital policy "Involuntary Detention (Holds)," effective 10/30/18, was reviewed. The policy did not include visitation limits based upon a patient's psychological or medical hold status.

Patient #1's medical record was reviewed and did not include a physician or court ordered medical or psychological hold.

The Director of Quality was interviewed on 6/27/19, beginning at 11:21 AM, and Patient #1's 6/26/19 grievance was reviewed in her presence. She stated a ward clerk had mistakenly overheard Patient #1's ICU physician say Patient #1 would be placed on a hold. The Director of Quality stated the ward clerk independently made a DE request to come evaluate Patient #1 without a physician or court order. She stated the ward clerk had been reprimanded for doing this. The Director of Quality confirmed Patient #1 was not placed on a medical or psychological hold. She confirmed Patient #1's spouse was asked to leave and escorted off the hospital's grounds by security. The Director of Quality stated nursing staff reported Patient #1's spouse was asked to leave because he harassed and was aggressive towards staff. When asked if there was nursing documentation, security documentation, or an incident report which described the situation, the Director of Quality stated, "no." She confirmed a patient's hold status did not prohibit visitation.

The hospital failed to ensure Patient #1 enjoyed full visitation rights.

Based on medical record review and staff interview, it was determined the hospital failed to ensure a pre-anesthesia evaluation was completed and documented prior to surgery for 1 of 2 surgical patients (Patient #1) whose records were reviewed. This had the potential to interfere with patient safety. Findings include:

Patient #1 was a 56 year old female who was admitted 10/11/18, with a diagnosis of post-operative pain and lactic acidosis. She was discharged to home on 10/13/18. Patient #1 was readmitted on 11/30/18, for an outpatient ERCP stent removal under general anesthesia. She was discharged to home on 11/30/18.

Patient #1's medical record included an "ANESTHESIA EVALUATION NOTE," which included a section for the date and time the evaluation was completed by qualified anesthesia personnel. The date was documented by Patient #1's anesthesiologist as "11/30/18," however, he did not document a time. It could not be determined if the anesthesia evaluation was performed before, during, or after Patient #1's procedure.

The Director of Quality was interviewed on 6/27/19, beginning at 9:08 AM, and Patient #1's medical record was reviewed in her presence. She confirmed the time of Patient #1's pre-anesthesia evaluation was not documented by her anesthesiologist.

The hospital failed to ensure Patient #1's pre-anesthesia evaluation was performed prior to her procedure.