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Based on an interview and record review of nine grievance files from October to December 2016 performed on April 5, 2017, it was determined that the hospital failed to provide written notice of the grievance decision for two reviewed complaint files as evidenced by:

The surveyor reviewed one complaint which was opened on 10/12/2016. There was no resolution letter with the complaint. A second complaint was also reviewed which had been opened on 11/15/16. There was no resolution letter with that complaint. The findings were reviewed with the patient representative in charge of complaints and grievances who also confirmed that there were no resolution letters.

Based on staff interview and record review of two patients chosen from the restraint log, it was determined that one patient was restrained in 4-point (all limb) restraints based partially on a request from the patient's family. The findings are:

Patient #1 was admitted in February 2017 with fluctuating mental status, confusion, and delirium thought to be from polysubstance abuse. The patient was described in the nursing notes on the first day of admission as very confused, agitated, and occasionally uncontrollable. The patient had a sitter and was noted to be relatively calm when family was present. The note indicated that the patient became very agitated around the time the family had to leave and the family member requested restraints. The nurse then indicated that the physician assistant ( PA-C) was informed and an order was obtained for 4-point restraints.

The patient remained in 4-point restraints for approximately 3.5 hours.

Please also see Tag A-0175

Based on review of patient records it was determined that patient #1 was not monitored in accordance with the hospital policy while in 4 point restraints as evidenced by:

Patient #1 was admitted in February 2017 with fluctuating mental status, confusion, and delirium thought to be from polysubstance abuse. The patient was described in the nursing notes on the first day of admission as very confused, agitated, and occasionally uncontrollable. The patient had a sitter and was noted to be relatively calm when family was present. The note indicated that the patient became very agitated around the time the family had to leave and the family member requested restraints. The nurse then indicated that the physician assistant (PA-C) was informed and an order was obtained for 4-point restraints.

Patient #1 remained in 4-point restraints for approximately 3.5 hours. The medical record contained a restraint flow sheet noted to be for non-violent restraints with hourly documentation of the patient's condition. This flow sheet contained no notations about patient #1 behavior or the continuing need for restraint.

There were no flow sheets used to document close monitoring for violent restraints for the 3.5 hours that patient #1 remained in restraints on the medical records. The hospital's restraint policy (#50010-38, approved 5/7/14) calls for monitoring and documentation every 15 minutes while patients are in restraints for violent behavior.