HospitalInspections.org

Based on interview and record review, the facility failed to provide written notice of grievance investigation and closure for 1 (P-13) of 3 patients reviewed for complaints and grievances resulting in the loss of the patient's right to the grievance process. Findings include:

On 7/28/2025 at 1330, review of the Complaint and Grievance Log for the past six months revealed an entry for P-13 regarding his care.

On 7/29/2025 at 1049, the complaint regarding P-13 was reviewed with Patient Relations Staff CC who stated the patient's daughter had emailed the complaint to the chief nursing officer regarding provision of care, call light availability, and concerns regarding a potential bedsore being "dismissed."

On 7/29/2025 at 1049, Staff CC was asked to provide letters of acknowledgement and closure. Staff CC stated the facility had identified this as a complaint, so no letters had been sent. When queried as to the difference between a complaint and grievance, she stated a complaint was if the patient was an inpatient and it was resolved before discharge. A grievance was anything needing follow-up or in writing.

Facility policy titled "Patient Complaint and Grievance Policy" last revised 10/28/2024 states, "DEFINITIONS Complaint: 1. A verbal expression of dissatisfaction with patient care or service made by a patient or patient's representative during the time of service that can be resolved at the time by staff present. 2. A verbal communication received after the time of service that could have been handled by staff present if communication had occurred at that time or is resolved to the patient's satisfaction at the time of initial contact. *Becomes a grievance if patient is requesting follow up or if not resolved to their satisfaction. Grievance: A complaint is considered a grievance when it meets one of the following criteria: 1. A verbal complaint that is not resolvable by staff present at the time the complaint is made because it requires further investigation, and/or actions for resolution. 2. A verbal complaint made after the time of service when patient requests follow up. 3. Any written expression of dissatisfaction by a patient or patient's representative, directed to this organization. This may include a written letter, email, fax, letter attached to a satisfaction survey or a survey comment requesting a resolution..."

Based on interview and record review, the facility failed to renew orders for violent/behavioral restraint for 1 (P-7) of 4 patients reviewed for violent restraint resulting in the loss of patient rights. Findings include:

Review of the medical record for P-7 revealed he was a 34-year-old male who presented to the Emergency Department (ED) on 7/10/2025 with altered mental status and polysubstance abuse. Review of physician orders revealed orders on 7/10/2025 at 0313 for 4-point locking restraints continuously for 4 hours due to P-7 being a danger to himself and others. P-7 was placed in restraint at 0321. Restraints were released one limb at a time until the release of the left wrist at 0918.

On 7/29/2025 at 1451, Staff A confirmed there were no renewal orders present for P-7.

Facility policy titled "Restraint (Non-violent and Violent)" last revised 2/2025 states, "A physician/LIP (Licensed Independent Practitioner) restraint order to manage a patient's violent or self-destructive behavior must be renewed on the following scheduled (sic): i. Adults 18 and older: every four (4) hours..."

Based on interview and record review, the facility failed to renew orders for non-violent/non-destructive behavior restraint for 1 (P-5) of 2 patients reviewed for non-violent restraint resulting in the loss of patient rights. Findings include:

Review of the medical record for P-5 revealed she was a 70-year-old female who was admitted for acute on chronic exacerbation of severe COPD (chronic obstructive pulmonary disease) on 7/16/2025. Review of restraints revealed orders were placed on 7/17/2025 at 0319 for bilateral soft wrist restraints. The order was updated 7/17/2025 at 1330 for 4-point soft restraints. No order for renewal was present on 7/18/2025 until 2018.

On 7/29/2025 at 1405, Staff A confirmed there was no renewal order for restraints on 7/18/2025 until 2018 and that it should have been ordered earlier.

Facility policy titled "Restraint (Non-violent and Violent)" last revised 2/2025 states, "Non-violent, non-destructive restraint orders will need to be renewed every 24 hours after an evaluation of the patient by a physician/LIP (Licensed Independent Practitioner)."