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Based on document reviews and interviews, the hospital failed to send a written notice of its determination regarding a grievance in accordance with their policy for three (3) of five (5) sampled patients who filed grievances (Patient 2G, 3G and 4G).

Findings:

The hospital "Complaints and Grievances - Resolution of Patient - Family" policy and procedure, last revised 08/2021, states in part, "The Quality and Patient Safety Department (or designee) will investigate and formulate an action with the assistance of the Department Director as needed. The individual will receive a written response within 7 business days; the method of the response can be a letter or email...".

On 10/6/2022 at 2:58 PM, five (5) grievance records were reviewed and revealed the following information:

1. On 2/21/2022, the hospital received a grievance from Patient 4G. As of 10/7/2022, there was no evidence that the written notice to the patient of its determination regarding this grievance was sent to the patient.

2. On 5/29/2022, the hospital received a grievance from Patient 2G. As of 10/7/2022 there was no evidence of written response being sent within the seven (7) days of receipt of the grievance.

3. On 6/8/2022, the hospital received a grievance from Patient 3G. As of 10/7/2022, there was no evidence that the written notice to the patient of its determination regarding this grievance was sent to the patient.

On 10/7/2022 at approximately 2:30 PM, the above findings were confirmed with the Senior Director of Quality and Safety.

Based on document reviews and interviews, the hospital failed to ensure the hospital's policy for restraints and seclusion, related to the documenting of less restrictive measures tried before applying restraints, was implemented for two (2) of five (5) restrained patients (Patient 1R and 2R).

Findings:

Mid Coast Hospital's "Restraint and Seclusion for Patients with Violent or Self Destructive Behavior" policy, last reviewed 09/2020 states, in part, "Least restrictive interventions are to be utilized to attempt to de-escalate the situation, including but not limited to; offering the patient medication, suggesting deep breathing, offering time away from the stimulation or other interventions that may diffuse the situation...Documentation: Each episode of use is recorded on a Restraint or Seclusion Flow sheet...".

On 10/7/2022 at 9:51 AM, Patient 1R and 2R's medical records were reviewed with the Senior Director of Quality and Safety.

1. Documentation in Patient 1R's record indicated the following:
- Nursing staff documented that Patient 1R was in seclusion on 9/16/2022 from 7:46 AM to 9:46 AM; and
- There was no documented evidence on the Restraint or Seclusion Flow sheet that would show that less restrictive measures were attempted.

2. Documentation in Patient 2R's record indicated the following:
- Nursing staff documented that Patient 2R was in Four Point restraints on 9/14/2022 from 10:32 AM to 11:47 AM; and
- There was no documented evidence on the Restraint or Seclusion Flow sheet that would show that less restrictive measures were attempted.

On 10/7/2022 at 9:51 AM, these findings were confirmed by the Senior Director of Quality and Safety at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure a physician's order was obtained for two (2) of five (5) sampled patients who had been restrained (Patient 1R and Patient 3R).

Findings:

Mid Coast Hospital's "Restraint and Seclusion for Patients with Violent or Self Destructive Behavior" policy, last reviewed 09/2020 states, in part, "An order is written indicating the type of restraint, early release criteria and the length of time of restraint or seclusion placement specified..."

On 10/7/2022 at 9:51 AM, Patient 1R and 3R's medical record were reviewed with the Senior Director of Quality and Safety.

1. Documentation in Patient 1R's record indicated the following:
- Nursing staff documented that Patient 1R was placed in a physical hold on 9/16/2022 from 8:51 PM to 8:52 PM; and
- There was no evidence in the medical record of a physician's order for the physical hold.

2. Documentation in Patient 3R's record indicated the following:
- Nursing staff documented that Patient 3R was restrained with an escort on 7/19/2022 at 4:43 PM; and
- There was no evidence in the medical record of a physician's order for the escort.

On 10/7/2022 at 9:51 AM, these findings were confirmed by the Senior Director of Quality and Safety at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure a restraint was discontinued at the earliest time possible for one (1) of five (5) patients (Patient 3R).

Findings:

Mid Coast Hospital's "Restraint and Seclusion for Patients with Violent or Self Destructive Behavior" policy, last reviewed 09/2020 states, in part, "...The use of restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order...".

On 10/7/2022 at 9:51 AM, Patient 3R's medical record was reviewed with the Senior Director of Quality and Safety.

1. Documentation in Patient 3R's record indicated the following:
- Nursing staff documented that Patient 3R received an seclusion, escort and a physical hold on 7/19/2022 at 4:43; and
- There was no documentation that the restraint order for the escort or physical hold was discontinued; and therefore,
- It could not be determined if the restraint was discontinued at the earliest possible time.

On 10/7/2022 at 9:51 AM, this finding was confirmed by the Senior Director of Quality and Safety at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure that a Registered Nurse was certified in Cardiopulmonary Resuscitation per hospital policy for one (1) of six (6) Registered Nurse's that were involved in a patient restraint and/or seclusion (RN #5).

Findings:

Mid Coast Hospital's "Restraint and Seclusion for Patients with Violent or Self Destructive Behavior" policy, last reviewed 09/2020 states, in part, "Training will include information on common risks of restraint and seclusion and an overview of first aid interventions...".

The Basic Life Support certificate for the Registered Nurse's involved in restraints and/or seclusion was reviewed.

- RN #5 was involved in the care of the following patient who was restrained; and
- Patient 4R was in restraints on 5/5/2022 from 6:25 PM through 8:35 PM.
- As of 10/7/2022, there was no evidence that RN #5 completed Cardiopulmonary Resuscitation / Basic Life Support training.

Based on document reviews and interviews, the hospital failed to ensure staff completed restraint training and the documentation was contained in the staff member's personnel record for three (3) of six (6) staff for MOAB® training and five (5) of six (6) staff for annual restraint training, who had been involved in a patient restraint (Registered Nurse #1 - #6).

Findings:

Mid Coast Hospital's "Restraint and Seclusion for Patients with Violent or Self Destructive Behavior" policy, last reviewed 09/2020 states, in part, "The staff on the Behavioral Health Unit, Emergency Department, Clinical Supervisors and Security staff will have 4 hours of restraint and seclusion training (MOAB®) during their unit orientation and every two years thereafter or when policy and/or procedure changes...Only staff who are deemed competent and have attended MOAB training are allowed to apply restraints/seclusion... All staff receive annual education at orientation and a module assigned through annual safety education (Healthstream in Rapid Regulatory Safety training)...".

1. Registered Nurse ("RN") #1 and RN #2 were involved in the care of the following patient who was restrained:

- Patient 1R was in restraints and/or seclusion on 9/16/2022 from 4:50 AM through 12:11 PM.

The surveyor requested to review RN #1 and #2's training records.

As of 10/7/2022, there was no evidence provided to the surveyor that indicated RN #1 or #2 had completed the annual training on restraints that is required per hospital policy.

2. RN #3 was involved in the care of the following patient who was restrained:

- Patient 5R was in restraints on 3/18/2022 from 4:00 PM through 5:15 PM.

The surveyor requested to review RN #3's training records.

As of 10/7/2022, there was no evidence provided to the surveyor that indicated RN #3 had completed the annual training on restraints that is required per hospital policy.

3. RN #4 was involved in the care of the following patient who was restrained:

- Patient 3R was in restraints on 7/19/2022 from 11:53 AM through 1:45 PM and 4:43 PM through 4:58 PM.

The surveyor requested to review RN #4's training records.

As of 10/7/2022, there was no evidence provided to the surveyor that indicated RN #4 had completed the MOAB® training or the annual training on restraints prior to being involved in a restraint that is required per hospital policy.

4. RN #5 was involved in the care of the following patient who was restrained:

- Patient 2R was in restraints on 9/14/2022 from 10:32 AM through 11:47 AM.

The surveyor requested to review RN #5's training records.

As of 10/7/2022, there was no evidence provided to the surveyor that indicated RN #5 had completed the MOAB® training prior to being involved in a restraint or the annual training on restraints that is required per hospital policy.

5. RN #6 was involved in the care of the following patient who was restrained:

- Patient 4R was in restraints on 5/5/2022 from 6:25 PM through 8:35 PM.

The surveyor requested to review RN #6's training records.

As of 10/7/2022, there was no evidence provided to the surveyor that indicated RN #6 had completed the MOAB® training prior to being involved in a restraint that is required per hospital policy.