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Based on staff interview and document review, it was determined the facility failed to follow its established procedures for patient grievances in two (2) of two (2) patient grievances reviewed for Patient #5.

Findings:

The hospital's policy "IHS Patient Complaint/Grievance Process in the Hospital Policy" last revised August 7, 2023 was reviewed and reads in part, "...Patient Grievance - 1. A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by the staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, or issues related to the hospital's compliance with the Centers of Medicare and Medicaid Services (CMS) Hospital Conditions of Participation...Complaints and grievances will be recorded in the complaint module of the Safety Always database and will include documentation of actions associated with case investigation, resolution and response...All grievances are responded to in writing. a. It is expected that many grievances can be resolved within 7 days. If the grievance cannot be resolved within 7 days, the hospital will provide a written acknowledgement within that time period. In the acknowledgement, the hospital will notify the complainant of the expected period of time (in most cases, 30 days) needed in order to resolve the grievance. b. If a grievance is not immediately resolved, it is expected the grievance can be resolved and there resolution communicated in writing within 30 days."

The hospital's grievance log was reviewed from November 2024 - present. The log contained no documented grievance from Patient #5. An interview was conducted with EMP9 on April 01, 2025 at 1:30 PM who stated they received a phone call from Patient #5 regarding a complaint that the patient verbalized a penicillin allergy to staff members, the allergy was not documented in the medical record, and the patient was discharged with a penicillin antibiotic. EMP9 stated that this phone call was not recorded as a grievance despite the facility's policy that a verbal complaint regarding patient care not resolved at the time of the complaint by staff present should be considered a grievance. EMP9 acknowledged the concerns should have been recorded as a grievance, but were not. EMP9 indicated the facility has recently implemented a new job aid to help staff determine what patient concerns should be recorded as grievances.

The hospital sent Patient #5 a letter on December 17, 2024 acknowledging receipt of the patient's concerns on December 16, 2024. A resolution letter was sent to Patient #5 on February 20, 2025, over two (2) months after the hospital's receipt of the grievance despite the hospital's policy indicating that resolution to the grievance should be communicated within 30 days.

A second grievance response letter dated March 25, 2025 related to a grievance received on March 11, 2025 in which Patient #5 had concerns regarding results of a CT scan and other care performed in the ED was reviewed. The second grievance was not logged on the facility's grievance log. EMP9 confirmed neither of the grievances received from Patient #5 were logged on the facility's grievance log.

Based on medical record review and document review, it was determined the facility staff failed to ensure less restrictive interventions had been determined ineffective to protect the patient, staff, or others from harm before initiating restraints for for one (1) of six (6) patients sampled for restraint/seclusion, medical record (MR) 10.

Findings:

Review of facility policy "IHS Restraints and Restraint Alternatives Policy" indicates, in part: Under the heading "Policy Description - ... 5. Documentation in the medical record includes the following: a. The patient's condition or symptom(s) that warranted the use of the restraint or seclusion. b. All alternatives or other less restrictive interventions attempted. c. Staff concerns regarding safety risks to the patient, staff, and others that necessitated the use...". Addendum C attached to the policy and titled "Restraint and Seclusion Table", under the table titled "Non-Violent or Non-Self-Destructive Reasons, and under the section titled "Registered Nurse Assessment and Reassessment" indicates, in part "... Must document attempt to use less restrictive method at the initiation of restraints...". The policy was last revised and effective June 25, 2024.

The review of MR10 revealed on February 21, 2025 at 1:30 AM, MR10 had mittens applied to both hands. At the time of application, there was no documentation indicating a reason for the restraint or what, if any, less restrictive alternatives had been used. During the 6:00 AM timeframe, a registered nurse did document a note indicating that MR10's medical history includes dementia and that MR10 was "confused" and had attempted to pull a medical equipment/lines.

Based on medical record review, document review, and interview, it was determined the facility staff failed to ensure ongoing assessment and monitoring was documented for one (1) of six (6) patients sampled for restraint/seclusion (MR10).

Findings:

Review of facility policy "IHS Restraints and Restraint Alternatives Policy" indicates, in part: Under the heading "Policy Description - ... 5. Documentation in the medical record includes the following: ... h. Individual patient assessments and reassessments...". Addendum C (within the policy) titled "Restraint and Seclusion Table" indicates, in part: Under the table titled "Non-Violent or Non-Self-Destructive Reasons" and under the section titled "Registered Nurse Assessment and Reassessment" indicates, in part: "... Every 2 hours must document: 1. Skin, respiratory, circulatory, and neurovascular assessment to identify any signs of injury. 2. ROM and repositioning of the patient. 3, Patient's current behavior indicating continuation for restraints or readiness for restraint release. 4. Educate patient on discontinuation criteria. Every 2 hours assess the need for comfort measures including hydration, food, and hygiene...". The policy was last revised and effective June 25, 2024.

The review of MR10 revealed on February 21, 2025 at 1:30 AM, MR10 had mittens applied to both hands. The restraint flowsheet documentation revealed that a registered nurse reassessment was documented at 3:30 AM. The next registered nurse reassessment for restraints was not documented until 7:30 AM.

The state agency (SA) asked staff member (EMP) 10, who was assisting with record review navigation, for confirmation of the missing documentation. EMP10 confirmed there was no restraint reassessment documented at 5:30 AM.

Based on medical record review, document review, and interview, it was determined the facility staff failed to ensure a one hour face-to-face evaluation was documented following the initiation of seclusion for one (1) of six (6) patients sampled for restraint/seclusion (MR9).

Findings:

Review of facility policy "IHS Restraints and Restraint Alternatives Policy" includes Addendum A titled "For Behavioral Health Units" that indicates, in part: Under the title "For Behavioral Health Units: Restraint and Seclusion for Violent and/or Self-Destructive Behavior... 3. Specially trained RN: On behavioral health units only, if the LIP is not available, a specially trained nurse may perform the initial in-person evaluation within one hour after the initiation of restraint and/or seclusion. The in-person evaluation must include the following: a. An evaluation of the patient's immediate situation. b. The patient's reaction to the intervention. c. The patient's medical condition, and whether factors such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., are contributing to the patient's violent and/or self-destructive behavior. d. The need for continuing restraints and/or seclusion and identifying strategies for discontinuation. e. Any modification to the plan of care. f. The specially trained RN consults with the LIP responsible for the care of the patient as soon as possible after the evaluation to discuss his or her findings...". Addendum C to the policy titled "Restraint and Seclusion Table" indicates, in part: Under the table titled "Violent or Self-Destructive Reasons" and under the section titled "Physician/APP or Specially Trained Behavioral Health RN Face-to-Face Assessment and Reassessment" indicates, in part: "Initially, must be within 1 hour of application or patient must be released... Must evaluate to address any medical/surgical reasons that could underlie the patient's assaultive, aggressive, destructive, or self-injurious behavior. Face-to-face documentation must include: 1. An evaluation of the patient's immediate situation. 2. The patient's reaction to the intervention. 3. The patient's medical and behavioral condition. The need to continue or discontinue the restraint or seclusion...". The policy was last revised and effective June 25, 2024.

The review of MR9 revealed on February 26, 2025 at 9:00 PM, MR9 was put into seclusion because of violent, aggressive behavior and attempts made to elope from the unit. Seclusion was discontinued at 10:30 PM. There was no documentation that an in-person evaluation was completed within one hour of the seclusion initiation by a physician or specially trained RN.

The SA asked EMP10, who was assisting with record review navigation, for confirmation of the missing documentation. EMP10 confirmed (EMP10) was unable to locate documentation of an in-person evaluation within one hour of the seclusion initiation.