HospitalInspections.org

Based on document review and interview, it was determined the Agency failed to ensure patients were given the correct State Agency complaint hotline number. This has the potential to affect all patients who receive services provided by the Hospital (average daily census of 26 patients).

Findings include:

1. The policy titled "Patient Rights and responsibilities" was reviewed on 9/29/15 at approximately 1:00 PM. The policy lacked the correct phone number for filing a complaint with the State Agency.

2. The policy "Patient Complaint and Grievance Process" was reviewed on 9/29/15 at approximately 2:00 PM. The policy lacked the correct phone number for filing a complaint with the State Agency. The policy noted "The patient/patient representative is provided with information upon admission, and upon request, of whom to contact to file a complaint/grievance.

3. During an interview on 9/29/15 at approximately 1:30 PM, E#1 (Director of Quality) verbally agreed the phone number for filing a complaint with the State Agency was incorrect.

Based on document review and staff interview, it was determined that 1 of 3 (Pt #9) patient with restraints, the Hospital failed to ensure the renewal authorization by the physician in accordance with its policy.

Findings include:

1. The Hospitals' policy titled "Restraint Use" was reviewed on 10/01/15 at approximately 9:25 AM. The policy required: ..."General Provisions: f) A physician's order is required to initiate, change, continue and discontinue restraint..."

2. The clinical record of Pt.#9 was reviewed on 09/30/15 at approximately 11:00 AM. A Restraint Order and Flow Record form dated 08/18, 08/26, 08/31 and 09/15/15 included the physician's signature, however the form lacked the date and time of the signature, therefore unable to determine date and time of the order for the restraints. A Restraint Order and Flow Record form dated 08/29/15 noted Pt #9 was restarted on restraints on 08/29/15 at 1900 (7:00 PM). The order lacked a physician's signature for the order to restart the restraints. A Restraint Order and Flow Record form dated 09/10/15 noted a RN (Registered Nurse) signature for the restraints being discontinued. The record lacked a physician's signature for the order to discontinue the restraints.

3. During an interview on 10/01/15 at approximately 9:10 AM, E#3 (Case Manager)confirmed the lack of the signatures, dates and times by the physician for the order for restraints.