HospitalInspections.org

Based on document and interview, it was determined that for 1 of 3 (Pt. #1) records reviewed regarding complaints and grievances, the Hospital failed to follow the grievance process.

Findings include:

1. On 3/29/2022, the Hospital's policy titled, "Complaint and Grievance Policy" (revised on 10/2021) was reviewed and included, " ... Definitions A. Complainant: A patient, a patient's family member ... B. Complaint: An expression of concern or discontent ... and that can be resolved promptly by the staff receiving the concern ... C. Grievance. A ... verbal complaint (when the verbal complaint about the patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care ... III. Procedure ... D ...3. Complaints and grievances will be entered into the appropriate Online Event database ... Resolution Process ... 1. Investigation and response to grievance shall be initiated as soon as possible. Grievances require a written response ..."

2. On 3/29/2022, the Hospital's complaint and grievance log from 1/1/2022 through 3/29/2022 was reviewed. There was no complaint or grievance filed for Pt. #1.

3. On 3/29/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital's acute inpatient rehabilitation unit on 2/25/2022 with a diagnosis of stroke. The clinical record indicated that an enclosed bed and self-release belt were used for Pt. #1. Pt. #1 was discharged on 3/8/2022.

4. On 3/29/2022 at approximately 2:42 PM, an interview was conducted with E #1 (Director of Nursing). E #1 stated that Pt. #1's wife left a voicemail on the weekend (2/26/2022 or 2/27/2022) concerning Pt. #1's care. E #1 said that Pt. #1's wife was concerned about Pt. #1's being belted (while in the wheelchair), not allowing the patient to walk, and using the enclosure bed. E #1 stated that she called back Pt. #1's wife and explained the use of self-releasing belt while in the wheelchair and the bed enclosure due to Pt. #1's fall and safety risks. E #1 stated that concern was not resolved right away because she (E #1) needed to speak with staff to get more information. Later in the day, E #1 called Pt. #1's wife back. After explanation surrounding the plan of care for Pt. #1, E #1 said that the concern was resolved. E #1 could not provide documentation regarding the actions she took (or the Hospital's) in response to the patient care concern.

Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) clinical records reviewed in the acute inpatient rehabilitation units, the Hospital failed to assess a fall precaution intervention, to ensure that the intervention did not prevent or reduce the patient's ability to move freely.

Findings include:

1. On 3/29/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital's acute inpatient rehabilitation unit on 2/25/2022 with a diagnosis of stroke. On 2/26/2022, the day shift nurse's assessment indicated that Pt. #1 was forgetful and confused. On 2/26/2022, a self-release belt was used as fall precaution intervention for Pt. #1 while in the wheelchair during the morning shift. There was no documentation that Pt. #1 demonstrated the ability to remember how to remove the self-release belt while in the wheelchair.

2. On 3/30/2022, the Hospital's policy titled, "Restraint Management Policy" (revised 12/2021) was reviewed and included, " ... III. Definitions A. Manual Restraint: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head and cannot be removed by the patient ..."

3. On 3/31/2022, the Hospital's job description for registered nurse (effective 5/2021) was reviewed and required, "... Responsibilities... Monitors, records... patient condition as appropriate..."

4. On 3/30/2022 at approximately 10:25 AM, an interview was conducted with MD #1 (admitting physician). MD #1 stated that Pt. #1 had a CVA/stroke with a significant functional deficit. During the first weekend of Pt. #1's admission (2/26/2022 and 2/27/2022), MD #1 stated that Pt. #1 had periods of agitation, did not have the insight, and could not be redirected.

5. On 3/30/2022 at approximately 2:00 PM, findings were discussed with E #1 (Director of Nursing). E #1 could not provide documentation that Pt. #1 demonstrated the ability to remember how to remove the self-release belt while in the wheelchair.

Based on document review and interview, it was determined that for 2 of 6 (Pt. #1 and Pt. #2) clinical records reviewed regarding use of restraints, the Hospital failed to ensure that a physician's order was obtained.

Findings include:

1. On 3/29/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital's acute inpatient rehabilitation unit on 2/25/2022 with a diagnosis of stroke. The clinical record indicated that Pt. #1 had non-violent restraints (lap-belt) on 3/1/2022 from 6:00 AM through 10:00 PM. The clinical record did not include a physician's order regarding use of non-violent restraints.

2. On 3/29/2022, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Hospital on 3/9/2022 with a diagnosis of Parkinson's Disease (progressive disease of the nervous system). The clinical record indicated that Pt. #2 had non-violent restraints (enclosed bed) from 3/24/2022 at 7:00 AM through 3/25/2022 at 5:00 PM. The clinical record did not include a physician's order regarding use of non-violent restraints.

3. On 3/30/2022, the Hospital's policy titled, "Restraint Management Policy" (revised 12/2021) was reviewed and included, "... This policy and procedure will establish process and guidelines for the safe and appropriate use of restraints in all areas... IV. Procedures. Each episode of restraint... must be ordered by a physician or an authorized licensed opractitioner responsible for the patient's ongoing care..."

4. On 3/30/2022 at approximately 2:00 PM, findings were discussed with E #1 (Director of Nursing). E #1 confirmed that there was no physician's order for the restraints. E #1 stated that an order should be obtained.

Based on document review and interview, it was determined that for 2 of 6 (Pt. #2 and Pt. #3) clinical records reviewed regarding use of restraints, the Hospital failed to ensure that the patients were monitored, as required.

Findings include:

1. On 3/29/2022, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Hospital on 3/9/2022 with a diagnosis of Parkinson's Disease (progressive disease of the nervous system). The clinical record indicated that Pt. #2 had non-violent restraints from 3/23/2022 at 7:00 PM through 3/24/2022 at 7:00 AM. The clinical record lacked the every two-hour monitoring from 3/23/2022 at 9:00 PM through 3/24/2022 at 3:00 AM (six hours).

2. On 3/29/2022, the clinical record of Pt. #3 was reviewed. Pt. #3 was admitted to the Hospital on 3/10/2022 with a diagnosis of stroke. The clinical record indicated that Pt. #3 had non-violent restraints from 3/22/2022 at 11:00 PM through 3/23/2022 at 7:00 AM. The clinical record lacked the every two-hour monitoring on 3/23/2022 from 1:00 AM through 5:00 AM (four hours).

3. On 3/30/2022, the Hospital's policy titled, "Restraint Management Policy" (revised 12/2021) was reviewed and included, "... This policy and procedure will establish process and guidelines for the safe and appropriate use of restraints in all areas... IV. Procedures... C. Non-violent... 1... b. The patient shall be monitored at regular intervals, at least every two (2) hours... and will have documented assessment to assure patient is free from adverse events and to determine if restraints shall be continued..."

4. On 3/30/2022 at approximately 2:00 PM, findings were discussed with E #1 (Director of Nursing). E #1 stated that the every two-hour monitoring and assessment were not documented.

Based on document review and interview, it was determined that for 1 of 3 (Pt. #6) clinical records reviewed regarding use of violent restraints, the Hospital failed to ensure that the patient was seen face-to-face within one hour after the initiation of restraints.

Findings include:

1. On 3/30/2022, the clinical record of Pt. #6 was reviewed. Pt. #6 was brought to the ED/emergency department on 2/11/2022 due to aggressive behavior. The clinical record indicated that restraints was applied to Pt. #6 on 2/11/2022 from 3:45 PM through 6:45 PM due to violent behaviors. The clinical record lacked documentation that Pt. #6 was seen face-to-face by the required staff within one hour after the initiation of restraints.

2. On 3/30/2022, the Hospital's policy titled, "Restraint Management Policy" (revised 12/2021) was reviewed and included, "... This policy and procedure will establish process and guidelines for the safe and appropriate use of restraints in all areas... IV. Procedures... D. Violent... 1...a. when the restraint... is used for the emergency management of violent or self-destructive behaviors... the patient must be seen face-to-face within one hour after initiation of the intervention by a physician, a authorized licensed practitioner, or a trained supervisory nurse..."

3. On 3/30/2022 at approximately 1:00 PM, findings were discussed with E #6 (ED Nursing Supervisor) and E #7 (RN Educator). E #6 and E #7 could not provide documentation that Pt. #6 was seen face-to-face within one hour after the initiation of restraints.