HospitalInspections.org

Based on a review of the hospital's grievance policy and 9 grievance files, it was determined that for 4 of 9 files reviewed, no resolution letter was sent.

The hospital "Patient Grievance Policy" (reviewed 6/2014) revealed in part, " ...Grievances are to be resolved within an average 7 days. Written response to the patient includes ..."

A review of 9 grievance files revealed that files #1, 3, 4, and 6 included no resolution letters. Therefore, the hospital failed to meet regulatory requirements for 44% of grievance files reviewed.

Based on a review of the emergency department behavioral health pod, it was revealed that behavioral health patients were not effectively notified of continuous video monitoring in the bedrooms of the pod.

Observations of care in the emergency department behavioral health pod identified a sign on the entry door which notified those entering that they were entering an area of video monitoring. However, once a patient was on the inside of the behavioral health area, the sign was no longer visible. Due to various mental health conditions, behavioral health patients entering the area might not be able to accommodate the momentary presentation of the sign while passing through the entry. Therefore, the hospital failed to ensure that all patients in the behavioral health pod understood they would be continuously monitored.

Based on interview related to a real-time restraint, it was revealed that rationales for the restraint failed to justify that restraint, and two criterion for release were not behavioral in nature.

Patient #3 presented to the emergency department on an emergency petition due to being a danger to self and other. Patient #3 had two previous and appropriate restraints due to actual aggressive behaviors and specific threats of harm.
Review of documentation revealed that on the day after presentation patient #3 approached the nursing station and insisted on seeing the physician. Attempts were made to respond to patient #3, including informing patient #3 that the physician would be made aware of the request. Patient #3 remained standing at the nursing station in the behavioral health pod despite many attempts from staff to request patient #3 return to the bedroom.

At some point security placed hands on patient #3 to take patient #3 to the bedroom. Patient #3 was noted to have "struggled" and at that time, patient #3 was placed into 4-point restraints. Interview with the RN caring for patient #3 at approximately on 7/24/18 at 0900 revealed justification for restraint respectively as patient #3's statements not to touch patient #3, stating that patient #3 would call the police, and stating patient #3 would leave. None of the statements by the nurse could be noted as threats of imminent harm requiring restraints.

Review of the record revealed criterion for release as "Absence of specific behavior." Further interview with the nurse inquired as to what criterion for release was given to patient #3. The nurse responded that patient #3 was informed to "Communicate with staff, follow staff direction, and not threaten. While the last of these criterion was appropriate had patient #3 made a threat, the first two were not based in imminently dangerous behaviors and were not requirements for release.

Based on all documentation and interview, the hospital failed to justify restraint, and once doing so, failed to utilize appropriate criterion for release.