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Based on clinical record review, policy review and staff interviews it was determined the facility failed to provide a resolution to a grievance for 1 (#1) of 10 sample patients. This practice does not ensure patient rights are maintained.

Findings include:

A review of the grievance log for January 2013 revealed a grievance was filed on behalf of patient #1 on 1/9/13. Further review of the grievance revealed it had been investigated and reported.

An interview with the Risk Manager (RM) was conducted on 2/28/13 at approximately 2:00 p.m. The RM was questioned concerning the grievance and if a resolution had been reached. The RM stated there had been no communication with the person who filed the grievance since 1/10/13.

There was no evidence of a resolution or that the person who filed the grievance was informed of the findings.

A review of the facility's policy Patient Complaint and Grievance Policy, no policy #, revised 10/10, page 6 of 7, Grievance Resolution, paragraph (B) Written responses to Grievances, revealed "In conjunction with appropriate management staff, Risk Management will make a determination regarding the resolution of each grievance, and will provide the patient with written notice of the investigative decision that contains:
1. the name of the hospital contact person
2. the steps taken on behalf of the patient to investigate the grievance
3. the results of the grievance process and,
4. the date of completion.

Further review of the policy, page 7 of 7, section (D), Timeframe's for Grievance Resolution revealed "on average, a timeframe of (7) working days for the provision of the written response will be considered appropriate for all grievances.... paragraph (3) if the investigation cannot be completed and a written response issued within (7) working days, Risk Management will inform the patient or patient's representative the hospital is still working to resolve the grievance and the hospital will follow-up with a written response within an additional (7) working days".

Based on clinical record review, review of policies and documents and staff interview it was determined the facility failed to obtain physician orders for the use of restraints for 1 (#1) of 10 sampled patients. This practice does not ensure the patient's rights are met for being free of restraints.

Findings include:

Patient #1's nurses notes dated 1/9/13 at 1:54 a.m. revealed the patient was fighting with staff and trying to climb out bed. The staff attempted to apply wrist restraints but the patient pulled them off.

A review of the facility's security log dated 1/8/13 3rd shift revealed at 11:44 p.m. security received a STAT page about a patient fighting the nurses. The patient was physically aggressive with staff and was restrained with two-point restraint.

Further review of patient #1's physician orders did not reveal any orders to apply wrist restraints to the patient on 1/8/13 or 1/9/13.

A interview with the Director of Nursing (DON) was conducted on 2/27/13 at 2:00 p.m. The DON was questioned concerning obtaining orders for restraints and confirmed the above findings. The DON replied a physicians order for restraints is required no matter how long the restraints are applied for.

A review of the facility's policy Restraints, no policy #, revised 2/13, page 2 of 6, revealed "restraints may be initiated by a Registered Nurse (RN) per protocol order approved by the Medical Executive Committee. For violent patient-the RN must contact the physician immediately after initiation to obtain verbal or telephone order. Orders must be renewed every 4 hours by telephone and every 24 hours written by the physician.