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Based on record review and interview, the hospital failed to ensure patient's rights to receive a timely resolution of patient complaints, in that, the hospital failed to send a timely written grievance resolution to 1 of 1 grievance (Patient #3) submitted during 2015.

Findings Included

The 03/01/2015 through 10/18/2015 grievance log was reviewed. The log documented a 03/14/2015 grievance for Patient #3, "...Closed 05/21/15..."

The 05/12/2015 hospital letter to Patient #3 acknowledged the 03/14/2015 complaint and stated, "delayed response to your initial complaint..."

The 07/09/2015 hospital letter to the complainant stated, "...Her wishes were respected with her end of life decisions..."

During an interview on 10/19/2015 at 1:45 PM, Personnel #2 was asked if Patient #3 received a letter within 7 days per their policy. Personnel #2 stated, "I met with her personally, but did not get the letter out."

During an interview on 10/20/2015 ending at 3:30 PM, Personnel #1 was asked if Patient #3 recieved a letter within 7 days and an update letter every seven days per the policy. Personnel #1 acknowledged that the letters were not sent timely.

The 06/27/2014, last reviewed, "Complaint/Grievance Resolution process" policy required, "Grievances require written notice...to the patient within seven (7) days...The written notice of the hospital's determination regarding the grievance must be communicated to the patient...If the grievance is not resolved within seven (7) days and if investigation is not complete or if corrective action is still being evaluated, the hospital's response should address that the hospital is still working to resolve the complaint and that the hospital will follow-up with another written response within 7 business days."

Based on record review and interview, the hospital failed to use restraints with an order from the physician responsible for the care of the patient, in that, there was no order for restraints for 1 of 3 restrained patients (Patient #2) on 09/18/2015 and there was no order for restraints for Patient #2 on 09/17/2015 until 8:57 AM.

Findings Included

The 09/17/2015 "Restraint Flow Sheet" documented every two hour checks on Patient #2 from 12:00 AM to 10:00 PM.

The 09/18/2015 "Restraint Flow Sheet" documented every two hour checks on Patient #2 from 12:00 AM to 6:00 PM.

The 09/17/2015 "Non-Behavioral Restraints" physician order for Patient #2 was signed at 08:57 AM.

There was no physician order in the chart for Patient #2 for the use of restraints from 09/17/2015 from 12:00 AM up to when the physician placed an order at 8:57 AM.

There was no physician order in the chart for Patient #2 for 09/18/2015 restraint use.

During an interview and records review of the electronic medical record for Patient #2, Personnel #8 navigated the records and was asked to see the restraint documentation and the restraint orders for 09/17/2015 and 09/18/2015. Personnel #8 presented the above information and confirmed the 09/17/2015 order was at 8:57 AM and there was no order for 09/18/2015 in the record.

The 03/12/2015, last reviewed "Restraint/Seclusion" policy required, "Orders for Restraints...Orders should: a) Before each use of the restraints and related to a specific episode of the patient's behavior and not for an unspecified future time or episode. b) All verbal or telephone orders must be countersigned within 24 hours...emergency application...initiate the application of restraint...In this event the order must be obtained either during the emergency application of the restraint...or immediately...within a few minutes...after the restraint or seclusion has been applied..."

Based on record review and interview, the hospital failed to renew an order for behavioral restraints prior to the required 4 hour timeframe for adult restraint use, in that, the hospital did not have a renewed restraint order for 1 of 1 "Behavioral Restraint" patients (Patient #3) on 02/13/2015 and continued to document the patient was restrained.

Findings Included

The 02/13/2015 1:00 PM "Behavioral Restraints order for Patient #3 reflected, "Time limits...4 hours...adults...Device...Limb...Clinical Justification...Aggressive or destructive behavior placing patient or others in danger..."

On 02/13/2015 after the 1:00 PM order, there was no order for the continued use of behavioral and/or non-behavioral restraints on Patient #3. The next order for restraints was signed by the nurse on 02/14/2015 and timed at 11:00 AM.

The two (one from emergency and one from the floor) 02/13/2015 "Restraint Flow Sheet(s)" for Patient #3 documented every two (2) hours after being placed that the soft wrist restraints were in place and the patient was agitated.

The 02/14/2015 Restraint Flow Sheet(s)" for Patient #3 documented every two (2) hours that the soft wrist restraints were in place and the patient was agitated.

During an interview on 10/20/2015 at 1:30 PM, Personnel #2 was informed that after the 02/13/2015 four hour Behavioral restraint order there was no order to continue restraints. Personnel #2 was asked to confirm the information. Personnel #2 reviewed the chart, stated we don't use behavioral restraints here and confirmed there was not an order.

The 03/12/2014, last reviewed "Restraint/Seclusion" policy required, "As the time frame is about to expire the RN must contact the LIP (Licensed Independent Practitioners) as soon as possible, report the results of the latest assessment and request that the order be renewed, not to exceed the required time frame limits..."