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Based on records reviewed and interviews, the hospital failed to ensure a written response was sent to one patient (Patient #7), of three patient complaint records, from a total sample of ten patient records.

The Hospital's Complaint/Grievance Policy and Procedure, dated 8/11/14, indicated a letter will be provided upon the completion and resolution of the grievance.

The Hospital's Complaint Log, dated September 2016-January 31, 2017, indicated a grievance was filed regarding Patient #7's care.

The grievance file for Patient #7 indicated that, on 12/28/16, the complaint was received and on 1/18/17 the complaint was closed. However, at the time of survey, no letter of resolution was in the file indicating a written response was sent.

The Associate Vice President for Regulatory Affairs was interviewed at 1:00 P.M. on 2/11/17. The Associate Vice President said the Hospital had not yet sent a letter, but will be sending a letter with the outcome of the investigation.

Based on records reviewed and interviews, the hospital failed to ensure that an order was written prior to the application of soft limb restraints for one patient (Patient #5), of three patient restraint records, from a total of ten records reviewed.

The Hospital's Restraint Policy and Procedure, dated 10/15/15, indicated an order was required for all restraints.

Patient #5's medical record dated, 11/08/16, indicated at 1:05 P.M. limb restraints were applied to Patient #5; however, the order was not documented until 3:00 P.M., approximately two hours after the restraints were applied.

The Regulatory Compliance Manager was interviewed at 11:45 A.M. on 1/31/17. The Regulatory Compliance Manager acknowledged the restraint was applied before the order was documented.