HospitalInspections.org

Based on document reviews and interviews, the hospital failed to provide written communications regarding a grievance for one (1) of five (5) sampled patients who filed grievances (Patient #3G).

Findings:

The "Patient Complaints and Grievances" policy and procedure, last revised 1/29/2019, states in part, "The grievance will be dated using the date of receipt...The patient and or patient's representative will receive written communication from the organization within 7 days of the receipt of the grievance. If the investigation is completed within 7 days of receipt of the grievance, this written communication shall outline the results and actions taken therein. If the investigation is NOT completed within 7 days of receipt of the grievance, a written communication will be sent acknowledging the receipt of the grievance and notifying the patient and or patient's representative that more time is needed to resolve the grievance. Once the grievance is resolved, a written communication shall be sent outlining the results and actions taken during the investigation".

On 12/17/2021, the hospital received a grievance from Patient #3G. The investigation was finalized on 12/29/2021, twelve (12) days after receipt. On 1/3/2022, seventeen (17) days after the receipt of the grievance, written communication was sent that outlined the results of the investigation and actions taken during the investigation.

There was no evidence the hospital sent written communication to the patient and or patient's representative to explain that more time was needed to resolve the grievance as outlined in their policy.

On 1/5/2022 at 3:11 PM, the Patient and Guest Relations Representative/Abuse Mitigation Navigator confirmed the above finding.

Repeat Deficiency

Based on document reviews and interviews, the hospital failed to ensure orders were obtained for restraints for two (2) of five (5) sampled patients who were restrained (Patient #2R and #3R). In addition, the hospital failed to ensure that the type of restraint that was ordered was the type of restraint used for 1 (one) of 5 (five) patients reviewed (Patient #3R).

Findings:

1. Documentation in Patient #2R's medical record indicated the patient was restrained on 11/12/2021 at 12:00 AM. There was no evidence in the medical record of a physician's order for this restraint.

2. Documentation in Patient #3R's medical record indicated the patient was restrained on 10/25/2021 at 1:00 AM and on 10/28/2021 at 1:56 AM. There was no evidence in the medical record of a physician's order for either of these restraints.

3. During a complaint survey, which was completed on 7/16/2021, it was determined that the hospital failed to ensure the type of restraint that was ordered was the type of restraint was used for 2 (two) of 5 (five) patients reviewed. During this survey, it was determined that the hospital again restrained a patient with a different type of restraint than what was ordered. This determination is based on the following evidence:

On 10/28/2021 at 5:31 AM, a four (4) point violent restraint was ordered to be applied to Patient #3R.

Documentation in the patient's record indicated soft wrist restraints were applied to the patient's right wrist and left wrist from 10/28/2021 at 12:00 AM through 10/29/2021 at 12:00 AM.

Based on the above, the patient was not restrained with the type of restraint that was ordered by the physician as four (4) point restraints were ordered and soft wrist restraints were used.

On 1/5/2022 at approximately 3:00 PM, the above findings were reviewed with the Director of Accreditation and Regulatory Affairs.