HospitalInspections.org

Based on review of 3 sampled patient grievances files, interview of 2 risk managers and Patient Safety Officer and review of patient grievance policy, the facility does not respond to patient grievances with a written notice of the decision. This practice does not ensure written notification of an investigation completed by the facility to the patient.
Findings include:
1. On 1/13/11, a review of 3 patient grievance files was conducted. Grievance#2 (G2) of the three grievance files contained a decision letter to the patient. A request was made to the Patient Safety Officer, for any additional information, for patient grievance files Grievance 1 (G#1), and Grievance 3 (G#3). Risk Manager #1, returned and stated that there is no letter documented for (G#1). Patient , (G#1), had called and spoke to risk management regarding care concerns on 10/4/10. The file contained notes from the risk manager of discussion with the patient and closure of the case on 10/7/10. The surveyor asked if there was any written letter or correspondence to the patient to close the case. The Risk Manager stated that all of the contacts with patient , (G#1), were verbal.
2. Interview was conducted with Risk Manager, #2, regarding patient (G#3). The Risk Manager retrieved the notice of decision letter and brought to the surveyor to review. Further interview with the Risk Manager, stated that a letter was developed because the patient ' s physicians office called with complaint. The surveyor asked Risk Manager, #2, if patients are sent a written notice of the results of their grievance. The Risk Manager stated , " no, unless, they sent us a letter, not usually. "
3. Review of policy #1.81.010.3, Title: Reporting of Patient Care Concerns, last reviewed on 9/25/09, states, a formal grievance requires a written response to the complaining party containing the results of any investigation, the hospital ' s findings, name of a contact person, and the completion date of the response.

Based on observation and staff interview, it was determined that the facility failed to ensure personal privacy for patients being bathed in the clean utility/tub room on the Memory Disturbance Unit (MDU).

Findings include:

During a tour of the MDU on 1/12/11 at approximately 12:30 p.m. the clean utility room was entered and observed. A blue tub was noted in the room, by a window. A drain from the tub was noted to drain into a hole in the floor. The staff nurse in attendance stated that patients are bathed in the tub if they do not wish to shower. It was noted that the door leading into the room has a class window, which provides visual access into the room. The staff nurse confirmed that there is no covering for the window and no screen available to shield the patient. The Director of the unit was interview on 1/12/11 at approximately 12:45 p.m. and confirmed that patient personal privacy is not maintained when the patient is being bathed.

Based on record review and staff interview, it was determined that the facility failed include the use of physical restraint in the patient's plan of care for 1 (#8) of 9 sampled patients. This practice does not ensure continuity in the patient's care.

Findings include:

Review of the medical record of patient #8 on 1/12/11 revealed that he was placed in wrist restraints on 1/11/11 at 9:30 p.m. Review of the Daily Assessment and Plan of Care for 1/12/11 revealed the use of restraint had not been incorporated into the patient's plan of care. During interview on 1/12/11 at approximately 2:00 p.m., the Director of Nursing confirmed the nurse had failed to add the restraint usage to the plan of care.

Based on record review, policy review, patient observation and staff interview, it was determined that the nursing staff failed to ensure documentation of an appropriate order for physical restraint for 1 (#8) of 9 sampled patients. This practice does not ensure safe use of restraints.

Findings include:

Review of the physician orders for patient #1 revealed a form entitled "Physician Order for Restraint to Manage Safety Needs". The form contained a physician's signature, but the date and time was not indicated. The form noted that the restraint order was the initial order and the restraints were initiated at 9:30 p.m. on 1/11/11. A yellow flag was on the form, near the physician's signature, requesting a signature. During interview on 1/12/11, the Director of Nursing stated that it appeared that the nurse had taken a verbal order for the restraint and completed all the information, but neglected to write the verbal order on the form. The facility's policy "Restraint Usage, Implementation, and Monitoring" #2.00.012.4 last reviewed 3/9/09, requires that an "an order must be obtained from MD immediately after applying the restraint". There was not sufficient documentation to conclude the order was obtained immediately after the restraint was applied. Observation of patient #8 on 1/12/11 at approximately 2:15 p.m. confirmed the patient remained in soft wrist restraints.