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Based on policy and procedure review, grievance file review, and staff interview the facility failed to describe the steps taken on behalf of the patient to investigate the grievance or the outcome of the investigation for 2 of 3 grievance files reviewed (Files # 1, # 2).

The findings include:

Review of Hospital Policy, "Complaint and Grievance Resolution for Patients...", revised 04/2015, revealed "...Patient Grievance: a written, e-mailed, faxed, telephoned, or verbal complaint by a patient or the patient's representative which cannot be resolved at the time of the complaint....Examples of a grievance:....Any customer service issue regardless of origin....Telephone calls received from a patient or patient representative describing patient care issues....The Grievance Committee will review the grievance for appropriate follow-up and any needed action to resolve the grievance and will provide a written response to the patient and/or their representative upon receipt of grievance to include the following: a. The name of the hospital contact person b. The steps taken on behalf of the patient to investigate the grievance c. The results of the grievance process and d. The date of completion. ..."

1. Review of Grievance File # 1 revealed the grievance was received on 03/04/2016. Review revealed the patient "...Questioned Technical Skill of Health Professional". File review revealed a letter, dated 03/17/2016, that stated "...We are writing to you regarding the concerns you had surrounding your care....We understand that you have spoken with (Name of Administrator [Admin] # 1)....and she has addressed your concerns. We appreciated you informing us of your concerns as this allows us to investigate and determine how to prevent this from occurring in the future by educating our staff. ..." Letter review did not reveal a description of the steps taken on behalf of the patient to investigate the grievance nor the outcome of the investigation.

Staff Interview on 04/14/2016 at 1600 with Administrator (Admin) # 2 revealed the grievance response letter did not include all requirements. Admin # 2 stated "we know we have problems with the grievance letter. ..." Further interview revealed policy was not followed.
2. Review of Grievance File # 2 revealed the grievance was received on 03/07/2016. Review revealed concerns related to coordination of care and poor communication between staff. File review revealed a letter, dated 03/17/2016, that stated "We are writing to you regarding your care....We understand that you have spoken with Dr. (First and Last Name).....and he has addressed your concerns. We appreciated you informing us of your concerns as this allows us to investigate and determine how to prevent this from occurring to other families in the future by educating our staff. ..." Letter review did not reveal a description of the steps taken on behalf of the patient to investigate the grievance nor the outcome of the investigation.

Staff Interview on 04/14/2016 at 1600 with Admin # 2 revealed the grievance response letter did not include all requirements. Admin # 2 stated "...we know we have problems with the grievance letter. ..." Further interview revealed policy was not followed.

Based on policy and procedure review, medical record review, and staff interviews, the physician/LIP (Licensed Independent Practitioner) failed to renew a violent restraint order for a patient per facility policy for 2 of 4 patients (Pt #4, Pt #3).
The findings include:
Review of the facility's policy titled "Restraint of Patients, PC (Patient Care) 17", last revised 3/2015 revealed, "...DEFINITIONS ...Physical Restraints - any manual method or physical/mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...Restraints for Violent or Self-Destructive Behavior: refers to the use of restraints in those patients who require management of violent or self-destructive behavior towards themselves or others (including caregivers or other patients) or, who require physical restraint to manage suicidal or homicidal behaviors in ANY setting...When initiating the use of a restraint, the appropriate restraint physician's order...(Nonviolent or Violent/Self Destructive) must be completed and placed on the chart within 30 minutes. This original order is time-limited based on type of restraint and age of the patient..." The policy revealed the time limit for renewal of violent/self-destructive restraint orders is 4 hours for adults (18 years of age or older).
1. Review of the closed medical record on 04/12/2016 of the patient #4 revealed, a 48 year old male who was brought to the facility's ED (Emergency Department) by law enforcement on 12/29/2015 at 2141 for IVC (Involuntary Commitment) and crisis referral evaluation. The medical record revealed, dated 12/29/2015 at 2230 that RN #1 applied 4 point restraints and on 12/30/2015 at 0930 LPN #1 removed restraints. The medical record revealed the initial restraint order for patient #4 was dated 12/29/2015 at 2230 and a renewal order was obtained 12/30/2015 at 0618. The medical record revealed there was not a physician order for renewal of violent restraints at the four hour renewal time of 12/30/2016 at 0330 as required per facility policy.
Staff interview with Nursing Admin #1 was conducted 04/13/2016 at 1415. Nursing Admin #1 reviewed physician orders for initiating and renewal of violent restraints in the medical record for patient #4 which revealed that a renewal order for continued violent restraints was not completed by the physician/LIP on this patient and this does not meet the facility's policy for renewal of violent restraint orders.



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2. Closed Medical Record review, on 04/13/2016, revealed Pt # 3 arrived at the ED on 04/01/2016 at 1736. Review revealed Pt # 3 was "...agitated, yelling and hitting people". Review of Physician Orders revealed an initial order for restraints on 04/01/2016 at 1856. Review of Nurses Notes, on 04/01/2016 at 1920, revealed "...Pt yelling and combative. Pt has been restrained. ..." Further review of Physician Orders revealed a renewal order dated and timed 04/02/2016 at 0504 "...Apply restraint device of soft limb holders - Bilateral Wrists....catch up order for 2300. ..." Review revealed another Physician Order, also timed at 0504, that stated "...Apply restraint device of soft limb holders - Bilateral Wrists....catch up order for 0300. ..."

Staff Interview with Nursing Admin # 1 on 04/14/2016 at 1530 revealed the orders documented as "catch up orders" were not acceptable and did not meet the requirement for 4 hour restraint renewals. Interview revealed policy was not followed.

Based on policy and procedure review, medical record reviews, and staff interviews, the hospital failed to reassess and monitor a restrained patient according to hospital policy for 1 of 4 restraints reviewed. (Pt #8)

The findings include:

Review of Hospital Policy, "Restraint of Patients...", last revised March 2015, revealed "...It is the policy of (Hospital Name) to: ...Monitor and meet the patient's needs while in restraints....Once restraint is initiated, the patient should be monitored for the continued need of the intervention and the continued appropriateness of the type of intervention....The frequency of monitoring the patient must be made on an individual basis, which includes a rationale that reflects consideration of the individual patient's medical needs and health status. The assessment includes, as appropriate to the type of restraint used:....signs of injury associated with restraints....nutrition/hydration....circulation and range of motion in the extremities....hygiene and elimination....physical and psychological status and comfort....readiness for release from restraints....For non-violent restraints, reassessment and documentation is required at least every 2 hours... ."

Closed medical record review for Pt # 8, on 04/13/2016, revealed a non-violent restraint order on 02/06/2016 at 0303. Record review revealed monitoring and reassessment at least every two hours from restraint initiation until 2100. After 2100, review did not reveal evidence of ongoing monitoring and reassessment until 02/07/2016 at 0730 (9 and 1/2 hours later).

Interview with Nursing Administrator #3, on 04/14/2016 at 1005, revealed there was nothing in the record to indicate monitoring and reassessment occurred every two hours between 02/06/2016 at 2100 and 02/07/2016 at 0730. Interview revealed policy was not followed.

Based on policy and procedure review, medical record review, and staff interviews, nursing staff failed to reassess vital signs according to facility policy on 2 of 10 patients (#4, #7).
Findings include:
Review of the nursing policy titled "Assessment, Planning, and Evaluating Patients Nursing Care Policy", last revised 12/2011 revealed, "...At a minimum, vital signs (T (Temperature), P (Pulse), R (Respirations),) blood pressure and pain assessment are measured on a regular basis...Initial Assessment Triage assessment prior to registration. Within 30 minutes of arrival to (named facility)...Re-assessment Q (every) 2 hours...Vital Signs Temp (Temperature) on entry. P, R, B/P (Blood Pressure) q (every) 4 hrs. (hours)..." Review of the named facility's Emergency Department (ED) policy titled "Assessments and Reassessments", last revised 12/2011 revealed, "...B. REASSESSMENTS: 1. The frequency of reassessments is based on the patient's acuity, condition, history and complaint, or as directed by the Physician or Physician Extender; minimally every four (4) hours...5. All patients should be reassessed and have a complete set of vital signs, including temperature, when clinically indicated, within one hour of patient's discharge."
1. Review of the closed medical record on 04/12/2016 of patient #4 revealed, a 48 year old male who was brought to the facility's ED (Emergency Department) by law enforcement on 12/29/2015 at 2141 for IVC (Involuntary Commitment) and crisis referral evaluation. The medical record revealed patient #4 was triaged at 2141 and was assigned an acuity level of 2. Physician order dated 12/29/2015 at 1257 revealed "VS (Vital Signs) Per Policy". The "EMERGENCY PROVIDER RECORD", dated 12/29/2015 at 2200 stated the patient was having a schizophrenic (Schizophrenia is a serious disorder which affects how a person thinks, feels and acts. Someone with schizophrenia may have difficulty distinguishing between what is real and what is imaginary.) exacerbation (worsening or flare up) and was "agitated/hostile" and without trauma. The "Emergency Department Triage Report", dated 12/29/2015 at 0128 revealed patient #4's vital signs were B/P 130/80, temperature 97.8 F (Fahrenheit (unit of measure)), pulse 80, respirations 18 and pulse oximetry 96% (percent). Further medical record review revealed no evidence of vital signs or reassessment throughout patient #4's stay or at discharge on 12/31/2015 at 0605 (52 hours and 37 minutes).
Staff interview was conducted on 04/13/2016 at 0916 with RN #2 and revealed the facility policy for taking vital signs in the ED on arrival at triage, subsequent reassessment of vital signs based on acuity level assigned, and then one hour prior to discharge.
Staff interview was conducted on 04/13/2016 at 1415 with Nursing Administrator #1. Interview revealed the only evidence of vital signs being taken on patient # 4 was on 12/29/2015 at 0128 and this did not meet the facility's policy for vital sign reassessment.




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2. Closed medical record review on 04/12/2016 for patient #7 revealed, a 56 year old male presented the ED (Emergency Department) on 03/18/2016 at 1958 with the CC (Chief Compliant) of flu like symptoms with an onset of three days. Review of an "Emergency Department Triage Report" dated 03/18/2016 at 2012 revealed, patient #7 was triaged at 2008 and assigned an acuity of 5 (1 most severe, 5 least severe). Review revealed the documented vital signs were, pain assessment of 10/10 (0 pain free, 10 worst pain), B/P (Blood Pressure) 129/79, Temperature 99.0 F (Fahrenheit (unit measure)), Pulse bpm (beats per minute) 85, Respirations 18 and Pulse Oximetry 95% (percent). Review revealed at 0030 (four hours and twenty-two minutes after triage) by RN #5 documented, "nasal/ head congestion for 3-4 days, Mucinex/ Benadryl (without) relief- Flonase (without) relief (some but returns) mid abd pain starting today N (nausea) @ times 0 (no) V (vomiting) 0 diarrhea ..." Further review revealed no documented VS at 0030. Review revealed at 0130 RN #5 documented "Going to check on pt and get VS. Pt state he's going to leave doesn't want to wait any longer." Further review revealed patient #7 left the ED at 0130 "LWBS (left without being seen)" after waiting 5 hours and twenty-two minutes. Review revealed patient #7 was not reassessed with VS within four hours.
3. Closed medical record review revealed patient #7 presented for a second visit to the ED on 03/22/2016 at 1548 with the CC of "Other: sinus pressure." Review of an "Emergency Provider MSE (Medical Screening Exam) Record" dated 03/22/2016 at 1550 revealed, patient #7 had sinus pressure for three to four weeks, coughing up mucous and abdominal pain for five days without improvement. Review revealed the treatment plan was "labs pending". Review of the "Emergency Department Triage Report" dated 03/22/2016 at 1553 revealed, patient #7 was triaged at 1552 and assigned an acuity of 3. Review revealed the documented vital signs were pain assessment 8/10, BP 143/69, Temperature 98.8 F, Pulse 90 bpm, Respirations 20, and Pulse Oximetry 99%. Review revealed labs were placed into the computer at 1610, were collected at 1626 and released at 1703. Review revealed patient #7 was waiting in "ED waiting room 3" while labs were being processed. Review revealed on 03/22/2016 at 2210 RN #3 documented "0 answer when called" Further review revealed RN #3 documented "...LWBS...." Review revealed no documented reassessment and or VS during the 6 hours and 18 minutes time frame after triage (1552-2210). Review revealed patient #7 was not reassessed with VS within four hours.

Interview on 04/14/2016 at 1044 with RN #2 (initial triage nurse) revealed while reviewing closed medical record, she did not remember caring for patient #7 on his second ED visit. Interview revealed triage nurse is responsible for patients that are sent back into the waiting room after triage and reassessment is done every four hours. Interview revealed RN #2 shift ended at prior to the four hour reassessment time frame.

Interview on 04/14/2016 at 0935 with RN #3 revealed he assumed care from RN #2 during patient #7 second visit. Interview revealed, patient #7 returned to the waiting room, after triage, because there was not a room available. Continued interview revealed reevaluations should have been performed every four hours. Interview revealed no four hour reassessment with VS was done for this visit.

Telephone interview on 04/14/2016 at 1123 with RN #4 (triage nurse, first visit) revealed, she did not remember patient #7. Interview revealed depending on the patient's acuity, patients are to be reassessed every two hours. RN #4 stated the two hour reassessment is what she has been told since working in the ED.

Interview on 04/13/2016 at 1444 with Nursing Administrator #1 revealed facility staff failed to reassess patient #7 per facility's policy. Interview confirmed the review findings.

RN #5 was unavailable for interview during the investigation.

NC00113816, NC00115972