HospitalInspections.org

Based on a review of the hospital Complaint/Grievance Program (CGP) policy, and 9 grievance files, it is determined that the hospital did not send resolution letter to grievant #2, #3, #6, #7, and #9 who filed a grievances.
The CGP policy (revised July 2011) revealed that "If a grievance has been resolved, the hospital departmental administrator will prepare a letter to the patient of patient representative and forward the letter to Risk Management .....and Risk management will forward the letter of resolution to the patient or patient representative within 7 days from the date that the patient grievance was received ... "
Review of 9 grievance files revealed that files #2, 3, 6, 7, and 9 had no resolution letter. In lieu of a letter, managers of respective departments called the grievant instead. Therefore, the hospital did not provide a written response to the grievances.

Based on review of hospital policy for Patient Restraint Devices, interview, and 5 patient restraint records, it is revealed that 1) the hospital policy does not address the frequency of monitoring and care given to patients in restraints, and 2) review of patient records #7, and #9 reveals no 15-minute documentation of ongoing behaviors and care for patients in violent restraints.

Patient #7 is a young adult male who presented to the ED following arrest by police. Patient 7 was already in police handcuffs and shackles on his ankles upon presentation, as he was under arrest. At 0740, a single leg restraint was applied to patient #7's right leg due to his kicking with both feet in the shackles at staff. This continued until 0830 when patient #7 was assessed as no longer presenting the same danger. While other documentation appears appropriate, no 15-minute monitoring is noted in the record of ongoing behaviors and care. Review of patient records #9 also revealed that no 15-minute documentation was performed.

Interview with a hospital administrator revealed that nursing generally documents the care that was given following the release of the patient. However, this type of late documentation does not demonstrate real-time monitoring for behavior and care. Moreover, without real-time 15-minute behavioral documentation, which may indicate readiness for release, the patient may not be released at the earliest possible time.

Based on review of the hospital Visitor policy, and the Patient Handbook the hospital, 1) the hospital does not identify a patient support person, 2) neither the Visitor policy nor the Patient Handbook specifies that visitation privileges are not restricted, limited, or denied on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability, and 3) that patients have a right to withdraw or deny consent for visitation at any time.

The hospital visitor policy reveals the various units of the hospital and their respective visiting hours as well as a short description to qualify the rationale for the visiting hours listed. The Patient Handbook reiterates the policy for visiting hours specific to various clinical areas.

However, patient information regarding the right to choose a support person; information that visiting is not limited for other than clinical reasons, and that patients may refuse or deny visitations is not found. Therefore, the hospital failed to meet the regulatory requirements for visitation.