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Based on a review of the hospital Patient information Booklet and Complaint handling policy, interview of Patient Relations, review of the complaint log and review of 8 complaint and grievances, 1) the hospital does not currently distinguish between complaints and grievances, and therefore, complaints which qualify as grievances are not handled per grievance regulatory directives, and 2) the hospital patient information booklet fails to describe the complaint/grievance process, and 3) the information intake process lacks consistency, follow-up and investigation.

Interview with Director of Patient Advocacy reveals that the hospital keeps one complaint/grievance log which does not distinguish between complaints and grievances. The patient advocate's input of information on a standardized form for managing complaints and grievances was noted to be is inconsistent when reviewed by the surveyor. There is no case identification number to help track the cases, some forms have only the patient's name, others have the name and medical record, review of the intake form revealed no information on the investigation and only a notation on the log regarding the resolution. There is no evidence of consistent implementation of the complaint grievance process and documentation of the steps taken to investigate and the results. Review of the complaint log reveals multiple complaints, some which may have been grievances, but the surveyor was unable to make that determination based on available documentation. Review of the Patient Information Handbook revealed the posting of the State agency address as required but no telephone number.

Based on review of Complaint Handling Policy, the governing body has not delegated in writing the responsibility to review and resolve grievances to a grievance committee and the Patient Advocacy Team. The hospital does not have a grievance committee. All complaints and grievances are referred to Patient Advocacy who refers the grievance to the involved hospital leadership, unit or department for review and investigation. The hospital failed to meet regulatory requirements since the complaint/grievance policy does not delegate the responsibility in writing to the Patient Advocacy Team or a grievance committee.

Based on review of the hospital policy Complaint Handling, review of 8 complaints/grievances files and interview with the Director of Patient Advocacy on 4/10/14, it was determined that the hospital does not meet the expected length of time for resolution of grievances nor provision of a written response.

A review of the hospital's Complaint Handling Policy, had conflicting information such as under procedure #11 states a patient representative will complete a written response within five working days of the receipt of the complaint but #12 states after the completion of the investigation, which must be completed within ten working days, a written response will be mailed or direct contact will be made with the patient and/or family to review the findings. In addition, the patient handbook instructs the patient to speak to the unit manager and if not satisfied they can contact the Patient Advocacy Team. It goes on to state that it is their policy to investigate all concerns and respond within five working days which would make the patient concern a grievance.

The hospital must attempt to resolve all grievances as soon as possible. The regulation requires the resolution of grievances and written response on average within 7 days. If a grievance cannot be resolved within the 7 day time frame, the hospital must inform the patient or the patient's representative that the hospital will follow-up with written response within a stated number of days in accordance with the hospital's grievance policy. The current policy "Complaint Handling" does not meet the regulatory requirements for provision of time frames for review of grievance and provision of response.

Based on review of the medical record, policy and procedure Behavioral Health Restraint/Seclusion Use and staff interviews there is no indication that the attending physicians are being notified after hours when their patients are restrained or secluded.

The patients placed in restraint or seclusion after hours are evaluated by the Hospitalist. The medical record review indicated no documentation of notification of the attending physician who may be able to provide relevant information regarding the patient's treatment and care and facilitate continuity of care. In addition, the notification is not addressed in the hospital policy and procedure.

Based on a review of 2 out of 12 patient records, inclusive of 1 open seclusion patient record and 1 closed seclusion patient record, it was determined that the physician face-to-face documentation failed to include all the listed elements of this requirement.

Patients #3 and # 6 were placed in seclusion after offering least restrictive interventions and attempts to de-escalate verbal and physical aggressive behavior.

Patient #3 was placed in seclusion on 4/8/14 at 1:00 PM. His face-to-face was performed by the physician at 1:30 PM and consisted of a one-line statement "Loud, disruptive, threatening."

Patient #6 was placed in seclusion on 4/8/14 at 9:30 AM. His face-to-face was performed by the physician at 9:45 AM and consisted of a one-line statement "Patient is agitated, paranoid, danger to self and others."

These one-line statements do not constitute a complete face to face assessment of the patients nor does it meet the regulatory guidelines for all the elements for complete face-to-face. Of note the space provider to the physician list the elements of a complete face-to-face.

Observation and review of the facility's condition of participation for Patient's Rights during a Federal Survey, it was determined that the facility lacked key points for compliance with the requirement to maintain a log or internal system that tracks patient deaths with use of soft wrist restraints.
Review of the facility's Behavioral Health Restraint/Seclusion Use policy and procedure dated 7/18/2012 revealed that the policy did not address death reporting requirements to CMS for patients in restraints and/or seclusion when reviewed by the surveyor on 4/10/14.
In addition, a log for patients in soft wrist restraints could not be located in the facility's tracking documentation. Interview of the facility's Director of Risk Management on 4/10/14 at 4 PM revealed that: 1) the facility has not had any deaths in restraints, 2) there was a lack of awareness or knowledge about the required soft wrist restraint tracking log, and 3) confirmed that there was no policy and procedure that outlined these requirements.

Based on review of the patient information handbook and the hospital visiting policy, the hospital does not clearly outline the patient's visitation rights as it relates to informing each patient (or support person, where appropriate) of their right (subject to his or her consent) to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including same-sex domestic partner), another family member, or friend, and of his or her right to withdraw or deny such consent for visitation. The policy states "the hospital allows for the presence of a support individual of the patient's choice, unless the individual's presence infringes on others' rights, safety, or is medically or therapeutically contraindicated." The policy identifies special considerations or restrictions/clinical reasons where visitation would not be permitted or limited. However, the policy fails to reflect that the patient is informed of his/her right to have or deny visitation by the persons of their choosing. The patients are currently not informed of their rights through the current patient information handbook nor does the policy include these patient rights.

Based on review of the hospital's visitation policy and guide for patient and their families under patient rights and responsibilities, it was revealed that the hospital's visitation policy and the guide for patients and their families does not inform the patient, support person or representative of their visitation rights.

Review of the visitation policy and visitation under the guide for patients and their families, revealed visitation is open 24 hours a day, seven days a week. The policy identifies special considerations or restrictions/clinical reasons where visitation would not be permitted or limited. However, the policy fails to specify that visitation will be allowed regardless of the visitor's race, color, national origin, religion, sex, gender identity, sexual orientation or disability and in accordance with the patient's expressed preferences. The hospital failed to fully provide patients and their support persons (as appropriate) with details concerning visitation rights.