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Based on review of hospital policy and grievance documentation, it was determined the hospital failed to ensure written notice was provided to patients or their legal representatives that included the steps taken to investigate the grievance and the results of the grievance process for 1 of 2 patients (#4) whose grievances were reviewed. This resulted in an incomplete resolution to the grievance process. Findings include:

The hospital policy "Patient/Family Complaint and Grievance Policy," dated 8/06/15, was reviewed. It stated "In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion."

Two grievances were reviewed. Complaint documentation indicated a complaint was received on 9/15/15 by a legal guardian of Patient #4. The complainant alleged he was not included in treatment team meetings, that Patient #4's medications were being changed without his approval, and that he was not notified of Patient #4's impending transfer to another facility.

The written notice of response, dated 10/09/15, did not include the steps taken to investigate the grievance and the results of the grievance process. This was confirmed by the Patient Advocate on 11/18/15 at 2:28 PM. She stated the complaint had been investigated and the complainant had not responded to telephone calls and she expected him to contact her after receipt of the letter.

In its resolution of a grievance, the hospital did not provide Patient #4 or her legal representative with written notice that included the steps taken to investigate the grievance and the results of the grievance process.

Based on medical record review, policy review, and staff interview, it was determined the use of restraints was not implemented in accordance with current, clear, and complete orders of physicians or other LIPs for 1 of 5 patients (#12) who were physically restrained and whose medical records were reviewed. This resulted in missing or incomplete orders and restraint use that was not consistent with the orders of a physician or other LIP. This had the potential to result in unsafe care of restrained patients. Findings include:

A hospital policy titled "Patient Restraint/Seclusion," approved 7/08/14, stated "An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release." The facility failed to ensure the staff followed the policy in the following examples:

1. Patient #12 was a 25 year old male who was admitted to the Behavioral Health Unit on 10/26/15, for psychiatric services related to depression. He was discharged on 11/04/15. His record included documentation he was placed in restraints on two occasions.

a. Patient #12's record included a verbal order for "Seclusion/Restraint" on 10/29/15 at 1:02 PM. However, the order was not clear and specific as follows:

The order did not specify the type of restraints, such as leather restraints or the limbs to be restrained, such as all 4 extremities. Patient #12's record documented he was placed in leather restraints on all four extremities. A note entered by the RN caring for Patient #12 at that time read "Patient stated he was hearing voices but would not reveal what they were saying. Stated he could not remain safe. Staff offered 1:1 to help him stay safe and he began to strike himself in the head. Patient agreed to lie down for restraints. Restraints safely applied while pt was very cooperative." Patient #12's record did not include documentation he was placed in seclusion in accordance with the order.

b. Patient #12's record included a verbal order for "Seclusion/Restraint" on 10/30/15 at 7:12 PM. However, the order was not clear and specific as follows:

The order did not specify the type of restraints, such as leather restraints or the limbs to be restrained, such as all 4 extremities. Patient #12's record documented he was placed in leather restraints on all four extremities. A note entered by the RN caring for Patient #12 at 7:20 PM read "Due to prior amount of prn's no additional meds were ordered and order received for seclusion and restraints now. BERT team called and restraints were placed [4 points]. 1:1 sitter placed outside door."

During an interview on 11/20/15 beginning at 11:00 AM, an RN from the Behavioral Health Unit reviewed Patient #12's record and stated "A restraint order means 4 point hard restraints." He further demonstrated how restraint orders were entered in the EMR. The RN stated the drop down screen did not allow the user to select the type of restraint or the limbs to be restrained. The RN stated they did not seclude patients on the Behavioral Health Unit, and the room Patient #12 was placed in was used as a quiet room, it had video monitoring, and the patient had a one-to-one sitter. The RN confirmed the nursing note entered on 10/30/15 at 7:20 PM documented Patient #12 was placed in seclusion. Additionally, he confirmed the EMR orders for Patient #12 did not specify the type and amount of restraints to be used.

The hospital failed to ensure physician orders for restraint and seclusion were complete and clear.

Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure orders for restraint used to manage violent or self-destructive behavior were renewed every 4 hours for 1 of 1 patients (#12) who was restrained for more than 4 hours to manage violent or self-destructive behavior and whose record was reviewed. This resulted in lack of oversight by a physician or qualified LIP and had the potential to interfere with patient safety. Findings include:

The hospital's policy titled "Patient Restraint/Seclusion," approved 7/08/14, stated "Physician orders for restraint or seclusion must be time limited, and must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of restraint or seclusion use, the type of restraint, and behavior-based criteria for release. Orders for restraint or seclusion must not exceed 4 hours for adults." Additionally, the policy stated "To continue restraint or seclusion beyond the initial order duration, the RN determines that the patient is not ready for release and calls the ordering physician to obtain a renewal order."

1. Patient #12 was a 25 year old male who was admitted to the Behavioral Health Unit on 10/26/15, for psychiatric services related to depression. He was discharged on 11/04/15.

Patient #12's record included a verbal order on 10/30/15 at 7:12 PM, for "Seclusion/Restraint" for "Violent/Self Destructive" behavior. The order was written for 4 hours, which would have expired at 11:12 PM. However, he was released from seclusion and restraint on 10/31/15 at 1:10 AM, which was a total of 5 hours and 58 minutes. Patient #12's record did not include additional orders for further restraint and seclusion beyond 11:12 PM.

During an interview on 11/20/15 beginning at 11:00 AM, an RN from the Behavioral Health Unit reviewed Patient #12's record and confirmed he was in 4 point leather restraints and seclusion for greater than four hours.

The hospital failed to ensure orders for restraint and seclusion were renewed after four hours.