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Based upon a review of facility documents, and interview (EMP) it was determined that the facility failed to identify a patient grievance in one of four complaint files reviewed, (OTH1).
Findings include:
On November 15, 2022, a review of the policy, " Complaint and Grievance Management, F-9 " (Last Revised: 5/2022; Last Approved 5/2022), defines a complaint as, " ... 2. Post hospital verbal communications regarding patient care that would routinely have been resolved by staff present if the communication had occurred during the patient 's stay/visit. " The policy further defines the elements of a grievance, as follows, " ... 1. A verbal complaint about patient care that is not resolved at the time of the complaint..."
On November 15, 2022, the complaint and grievance log for the facility was reviewed from August 1, 2022, through November 14, 2022.
Review of OTH1, revealed that the patient presented to the Emergency Department on 07/28/2022 with " leg/foot pain, numbness and tingling without acute injury. " OTH1 was informed that OTH1 had a torn ligament and was provided a boot. Patient continued with pain and sought further treatment at another provider. X-ray revealed, " ... subtle subacute transverse fracture through the distal fibular diaphysis ... "
Further review, revealed that the facility did not identify OTH1 as a grievance because it was reported after the patient was discharged.
On 11/15/2022, at 1:30pm, EMP3 stated that the issue was not considered a grievance because " the patient indicated that OTH1wanted the hospital to be aware so it wouldn 't happen to anyone else. " EMP3 also indicated that the patient was satisfied with the conversation; thus, EMP3 did not consider the call a grievance.

Based upon a review of facility documents, and interview (EMP) it was determined that the facility failed to address a patient grievance in a timely manner in one of three grievance files reviewed.
Findings include:
On November 15, 2022, a review of the facility policy: Complaint and Grievance Management, F-9 (Last Revised: 05/2022; Last Approved: 05/2022) Section: Oversight reveals, " ... The Patient Services Representative provides a monthly report to the Patient Safety Committee regarding the number of complaints and grievances, the percentage compliance with the 7 and 45-day letter and any case involving a patient safety issue. "
A review of OTH2 revealed that the patient contacted the facility, post discharge on 07/15/2022 with a number of issues including noise on night shift, unprofessional behavior, environmental services issues, and a medication reconciliation error.
Initial patient contact, by the facility, following the patient call of 7/15/2022 was made on 08/04/2022; 19 days after the initial contact; thus, exceeding the 7 day requirement outlined in the policy.
On November 15, 2022 at 1:30pm , EMP1 stated that this " fell through the cracks " during a period of staff vacancy.

Based upon a review of facility policy and procedure, medical records (MR), and staff interview (EMP), it was determined that the facility did not adhere to facility policy regarding the use of medication to manage a patient 's behavior.
Findings include:
1. On October 21, 2022, and November 15, 2022, a review of the facility policy, Commitments for Psychiatric Care (Last Revised: 01/2022; Last Approved: 01/2022), I. 202: Application for Voluntary Inpatient Treatment as per Mental Health Procedure Act of 1976 Sections 202-207: " A. To be used when any person age 14 and over requests voluntary inpatient treatment. C. Explanation must be provided to the patient prior to his/her signature on the 201 form in regard to the type of treatment anticipated and potential restraints or restrictions. " II. 302: Application for Involuntary Emergency Examination and Treatment- not to exceed 5 days ...: B. Any person who believes the patient is in need of treatment can be the applicant. If this person is not a physician, police officer, the County Administrator or his Delegate, he must request a warrant through the County Administrator. "
2. On October 21, 2022 and November 15, 2022, a review of the policy: Management of the Violent of Potentially Violent Patient (Last Revised:03/2022; Last Approved: 03/2022) reveals: " Policy: ... The use of verbal and non-verbal techniques is preferred. Physical interventions are utilized only as a last resort and when the patient is at risk for harming themselves or others and after non-physical interventions have failed. A. De-escalation Strategies 1. Interpersonal interactions (e.g. 1:1 interaction, comfort measures, involving family/caregiver, etc.) 2. Distraction or diversion activities 3. Use of coping strategies including relaxation techniques 4. Reorientation B. Psychopharmacologic interventions ... "
3. A review of MR1on October 21, 2022, revealed that the patient presented to the ED on 10/13/2022 at 6:36pm by EMS. ED Mental Health Nurse (MHN) documented on 10/14/2022 at 12:20am, that a 302 [State of Pennsylvania- Involuntary Psychiatric Commitment] had been attempted and denied by the county. In the same note, the MHN documents that local police do not have grounds to initiate a 302.
4. MHN documents on 10/14/2022 at 12:20am, " I do not feel comfortable having the pt [patient] discharged or signing a 201[State of Pennsylvania-Voluntary Psychiatric Commitment] at this time." MHN failed to document patient assessment leading to her conclusion of discomfort with allowing the patient to be discharged or to sign a voluntary commitment as per standards of nursing practice.
5. Per MHN note, MR1 was to be " held " in the ED overnight, per the staff psychiatrist, until a 2nd petitioner arrived at 8:00am. On 10/14/2022, at 1:10am, the emergency department physician documented the following, " ...became angry and belligerent with the staff. ... slamming doors, stopping (sic) in the room in the hallway in insulting the staff (sic). ...was given 2mg of IV [intravenous] Ativan and if not able to be re-directed after Ativan will be placed in restraints. ...Her dad did come in and petition a 302 which was overturned by the county because of the information not being 1st hand. The person who had other (sic) supposedly made suicidal statements is unable to come to the emergency department tonight but is coming in the morning. She will petition a 302 at that time. The mental health nurse did speak with Dr. who recommended that she be kept in the emergency department overnight pending the petitioning of the 302 in the morning. "
6. A note by the MHN on 10/14/2022 at 1:16am states the following, " ...Police did not want to 302 the patient ... pt became more agitated and was trying to leave. Dr. ordered Ativan 2mg IV and pt received it. She was moved to room 44 from room 37. pt was cooperative with moving and getting her medication. "
7. A nurse 's note on October 14, 2022, at 1:27am, reveals a description of the patients behavior and, " Per MHRN, initial 302 petition has been overturned by the county delegate, but that another petitioner would be here at 0800 to file another 302 petition and that the ED staff were to keep patient there overnight. Pt moved to ER44 and placed under CO [constant observation]. "
8. On 10/14/2022 at 9:52am, the patient was seen by the staff psychiatrist. " Chief Complaint: unable to provide as she was lethargic. " " HPI [History of Present Illness] ... Patient became agitated and demanded to leave while in the emergency department. She required restraint. " " physical exam: groggy, inattentive, mumbled, not able to answer questions or follow commands "
9. Second petition for 302 successful at 4:33pm per MHN notes, 16 hours after the initial petition.
10. On November 15, 2022, a second review of MR1 revealed that there was not documentation of techniques and strategies used to de-escalate the patient per policy. In addition, indication for administration of IV Ativan as documented by the MD are noted as, " known mental health issue and anxiety disorder. " However, the ordering physician, on 10/14/2022 at 1:10am documented, " ...became angry and belligerent with the staff. ... slamming doors, stopping (sic) in the room in the hallway in insulting the staff (sic). ...was given 2mg of IV [intravenous] Ativan and if not able to be re-directed after Ativan will be placed in restraints. " On 10/14/2022 at 9:52am, the staff psychiatrist documented the following, " ... Patient became agitated and demanded to leave while in the emergency department. She required restraint." These finding were confirmed by EMP2 at 2:30pm on November 16, 2022.
11. On October 21, 2022, at 10:00am, EMP5 stated if, " the provider doesn ' t feel the patient is a mental health risk, we cannot hold them. "
12. On October 21, 2022, at 12:44pm, EMP8 revealed that the patient did stipulate " on the 302 call " that MR1 was willing to work with the doctors to get the help she needed.
13. On October 21, 2022, at 3:00pm, EMP10 "wished that the documentation" of the case "was better." EMP10 also stated that, " without a doubt, it was best to keep her " despite the fact that a 302 had been denied by the County Administrator.

Based on review of facility documents, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that restraints were only used on the complete order of a physician or other licensed practitioner for one of two restraint medical records reviewed (MR3).
Findings include:
On November 16, 2022, review of facility policy titled " Restraints/Seclusion, E-13 " last revised March 2022, revealed " ...3. BEHAVIORAL RESTRAINTS (FOR THE VIOLENT/SELF-DESTRUCTIVE PATIENT) ...b. Physician Order 1. The physician ' s order includes: ... d. Duration (time limit) for Restraint ... " .
On November 16, 2022, review of MR3, date of admission September 20, 2022, revealed a four point restraint order on September 20, 2022, at 11:15am that did not have a length of time chosen on the restraint order form. On September 20, 2022, at 5:15pm, restraint assessment sheet read " ...Plan of Care Reevaluation: Modifications: RUE [right upper extremity] and LLE [left lower extremity] restraint removed per MD order ... " . Unable to locate order.
On November 16, 2022, at 11:30am, EMP2 confirmed the above findings.

Based on review of facility documents, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that the condition of the patient who is restrained was monitored by trained staff for one of two restraint medical records reviewed (MR3).
Findings include:
On November 16, 2022, review of facility policy titled " Restraints/Seclusion, E-13 " last revised March 2022, revealed " ...3. BEHAVIORAL RESTRAINTS (FOR THE VIOLENT/SELF-DESTRUCTIVE PATIENT) ...b. Assessment and Monitoring 1. An RN reassesses patients who are restrained at least every 2 hours ...3. Patients in restraint/seclusion are placed on Special Constant Observation ...a. A staff member maintains continuous observation of the patient and documents the patient ' s behavior and cognitive status every 15 minutes ... " .
On November 16, 2022, review of MR3, date of admission September 20, 2022, revealed a four point restraint order on September 20, 2022, at 11:15am. On September 20, 2022, at 1:15pm and 5:15pm reassessments were completed by RN, per the two hour requirement. At 5:15pm right upper extremity and left lower extremity released from restraints. No assessments by RN completed after this. Unknown, per RN, when patient was released fully from restraints.
On November 16, 2022, at 11:30am, EMP2 confirmed the above findings.