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Based on interview and record review it was determined the facility failed to ensure patient grievances were investigated timely, thoroughly and a written response was provided for two (2) of fifteen (15) sampled patients. (Patients #1 and #9)


The findings include:


Review of facility policy for "Patient Complaint/Grievance Process" revised on 02/2013, stated "It is the supervisor's responsibility to handle unresolved complaints immediately and act immediately to resolve. If the issue is not resolved immediately by those present, it is considered a grievance. The supervisor must: 1. initiate an initial investigation, including interviews of all involved, 2. Initiate the Complaint and Grievance form. 3. Notify the Director of Quality Management by calling the risk hotline. The Director of Quality Management obligations are to coordinate, aggregate, track, trend and report. The Department Head/Management obligations are to investigate, document, act, and respond. The investigations include interviews, document review and scene re-enactment if necessary. The Chief Executive Officer obligations: assure investigation and action, respond and document. If the complainant considers the matter resolved: write or review the Chief Executive Officer letter, sign and send within seven days of the complaint."

Review of Patient #9's medical record revealed the patient was admitted to the facility on 08/14/14 with a diagnosis of respiratory failure. Upon admission the patient had a tracheostomy tube and was on a ventilator for respiratory support.

Interview with Registered Nurse #3, on 12/17/14 at 2:30 PM, revealed Patient #9's spouse notified her of a bruise on the patient's right cheek and blood in the mouth. She stated she could not remember the date of this occurrence but remembers it was early in her shift when she was notified by the spouse. She stated she filled out an incident report and notified the physician and management after concerns were made by the spouse. Registered Nurse #3 stated she did not document an assessment of the patient in the medical record. She stated the patient was unable to speak, due to the tracheostomy tube, so the spouse posed yes or no questions to the patient, and reported to her, that something had been dropped unintentionally on the patient's face by respiratory staff. RN #3 stated the spouse requested to speak with management regarding this incident, so she contacted the House Supervisor. She stated the House Supervisor came up later to speak with the spouse. She stated she did not believe the Unit Manager was in the building when the spouse reported the bruise.

Interview with Unit Manager, on 12/17/14 at 12:00 PM, revealed she was unaware of the report made by Patient #9's spouse regarding the bruise to the right cheek.

Interview with the House Supervisor, on 12/17/14 at 12:45 PM, revealed Patient #9's spouse requested to speak with her about a bruise to the cheek and bleeding in the mouth, sometime in October. The House Supervisor stated she did not see any active bleeding from the patient's mouth when she assessed the patient and there was a slight discoloration to the right cheek. She stated she asked respiratory staff to look into the patient's mouth to see if there was any trauma. She stated respiratory did not find any trauma to the mouth. She stated it was determined the patient chewed on the tongue and the spouse performed frequent suctioning. The House Supervisor stated she believed this behavior may have caused the bleeding from the mouth, however, she was not able to determine what caused the discoloration to the cheek. The House Supervisor stated she did not document or report to management her; discussion with the spouse, assessment of the patient, determination of the cause bleeding or her inability to determine the cause of the discoloration to the right cheek.

Interview with the Director of Respiratory Therapy, on 12/17/14 at 11:45am, revealed the Director of Quality Management (DQM) sent him an e-mail on 10/30/14 requesting him to investigate the cause of the bruise to Patient #9's right cheek. He stated he was not made aware of the report that the patient had experienced bleeding from the mouth. He stated because of his busy schedule, it took him two days from the request to begin his investigation. He stated his investigation included observation of the patient and interview with the spouse. He stated he did not remember if he interviewed any other respiratory therapists or staff and did not have any documentation to review to determine if he had. He stated his determination was that a piece of the ventilator tubing probably caused the bruise to the right cheek. He stated the patient exhibited involuntary movement of the head and upper body and the patient could have easily hit the right cheek on a piece of the ventilator tubing. He stated due to the patient's condition he believed the patient bruised easily and did not think it was caused by staff mistreatment. He stated he e-mail his findings to the Director of Quality Management after he completed his investigation.

Review of Patient #1's medical record revealed the patient was admitted to the facility on 09/10/14 with a diagnosis of respiratory failure.

Interview with Patient #1's Healthcare Surrogate and Power of Attorney, on 12/17/14 at 10:00 AM, revealed she had filed a grievance with the facility in October of 2014 regarding the theft of Patient #9's belongings . She stated it took the facility about a month before she heard back from them regarding their investigation and the information was provided verbally. She stated as of 12/17/14 she had not received a written response regarding the facility's investigation or their findings.

Review of the facility's grievance records on 12/18/14 revealed no evidence the facility had provided Patient #1's Healthcare Surrogate and Power of Attorney a letter regarding their findings from the filed grievance.

Interview with the Director of Quality Management (DQM), on 12/18/14 at 2:30 PM, revealed she was made aware of Patient #9's grievance on 10/19/14. She stated the patient's wife reported a bruise of unknown origin to the patient's right cheek. She stated this information was reported out in the facility's daily meeting with leadership and the Unit Manager was asked to investigate. She stated a week later during an Interdisciplinary Team Meeting the physician inquired about the bruise and it was determined the investigation had not been completed. The DQM stated the investigation was then assigned to the Director of Respiratory Therapy. She stated after the Director of Respiratory Therapy concluded his investigation a conversation was had with Patient #9's spouse and the spouse was satisfied with the details of their findings.

Continued interview with the DQM revealed the facility's grievance policy and procedure required the facility to conduct an investigation if the grievance was not immediately resolved at the time it was made. The DQM stated the person that used to handle the grievance process and complaints was no longer with the facility. She stated it was identified during the survey that the grievance policy was not followed for Patient #1 and #9. She stated it was also facility policy to send a written response to the complainant upon completion of their investigation. However, she misunderstood the policy and thought as long as a verbal response was provided to the complainant a written response was not needed. She stated as of 12/18/14 a written response had not been provided to Patient #1's Healthcare Surrogate and Power of Attorney or to Patient #9's spouse.

Interview with the Chief Operation Officer and Chief Executive Office, on 12/18/14 at 2:30 PM, revealed the facility had not followed their grievance policy and procedure regarding Patient #1 and #9. They stated it was identified, once the complaint survey began, that the facility's process was broken. They stated the facility had recently eliminated the position in which someone was responsible for the completing the grievance investigation and notification process. They stated the various parts of the policy and procedure for grievances were given to other employees within the facility. However, since the change occurred the process had not been hardwired to ensure all parts were completed thoroughly and timely, when a complaint or grievance was received.

Based on observation, interview and record review it was determined the facility failed to ensure restraints were not used on an "as needed basis". In addition, the facility failed to ensure staff did not reapply restraints after preforming unsupervised releases without obtaining a new order for one (1) of fifteen (15) sampled patients. (Patient #1)


The findings include:

Review of facility policy for "Physical Restraints and Seclusion" revised on 10/2014, stated "The caregiver must maintain direct observation during care and reapplication of the restraints. Timeframes for restraint orders and use (PRN orders). PRN used is Prohibited. The general rule prohibits the ordering of a restraint or seclusion on a PRN or "as needed" basis. Whenever a patient's restraints are removed (except to temporarily provide direct care), the restraint episode ends and a new order is required."

Review of Patient #1's medical record revealed the patient was admitted to the facility on 09/10/14 with a diagnosis of respiratory failure. Review of physician restraint orders, dated 12/12/14, revealed bilateral soft limb restraints were ordered for seven (7) days.

Observation of Patient #1, on 12/16/14 at 8:27 AM, revealed soft wrist restraints were applied to both wrists.

Observation of Patient #1, on 12/16/14 at 2:05 PM, and again at 3:15 PM, revealed the bilateral soft wrist restraints were not applied.

Interview with Registered Nurse #4, on 12/16/14 at 2:05 PM, revealed she had removed Patient #1's bilateral wrist restraints per the sister's request while she visited. The nurse stated as long as the sister was in the room with patient it was OK to remove the restraints.

Review of Patient #1's Safety Checks and Monitoring sheet for restraints, dated 12/16/14, revealed restraints were documented as on the patient from midnight till 2:00 PM and off for the rest of the evening hours.

Observation of Patient #1, on 12/17/14 at 9:25 AM, revealed the bilateral soft wrist restraints were not applied.

Review of Safety Checks and Monitoring sheet for restraints, dated 12/17/14, revealed the bilateral wrist restraints were reapplied at midnight on 12/17/14 and then removed again at 8:00 AM.

Continued interview with Registered Nurse (RN) #4, on 12/17/14 at 9:40 AM, revealed Patient #1's bilateral soft wrist restraints were reapplied during the night for safety. RN #4 stated she had removed the wrist restraints around 8:00 AM, after she came on shift. She stated a new order was not obtained and the staff was going by the original order obtained on 12/12/14 when reapplying the restraints.

Interview with RN #2, on 12/18/14 at 8:40 AM, revealed she was assigned to care for Patient #14. She stated the patient had bilateral soft wrist restraints applied. RN #2 stated a restraint order was good for seven (7) days. She stated she would conduct a trial release by removing one of the patient's wrists from the restraint. However, she would not stay in the room after removing, but would monitor frequently to see if the patient would attempt to pull at the tubes. She stated if the patient showed signs of pulling at tubes she would reapply the restraints using the same order.

Interview with the Director of Education, on 12/18/14 at 10:10 AM, revealed re-education was provided regarding the facility restraint policy in May and July of 2014. However, no testing for comprehension of the material was conducted. She stated a trial release of restraints was not allowed and that a new order must be obtained once a restraint was removed.

Interview with the Chief Operating Officer, on 12/18/14 at 1:15 PM, revealed the facility had identified issues with restraint application earlier in the year and re-education was provided. She stated audits were completed for paper documentation requirements. However, an audit for comprehension regarding the requirements surrounding the application and removal of restraints was not conducted. She stated she was not aware nursing; was conducting trial releases, removing restraints per family request and then reapplying them after the family left without obtaining a new order.