HospitalInspections.org

Based on review of grievance information, hospital policies, and staff interview, it was determined the facility failed to notify patients/representatives of whom to contact, within the hospital, to file a grievance. This had the potential to impact all patients/representatives who wished to file a grievance. It also had the potential to interfere with, or prevent, patients/representatives from filing a grievance. Findings include:

1. The hospital's policy "Patient/Family Complaint and Grievance," dated 10/12/10, was reviewed. It included, but was not limited to, the following information:

"Each patient and/or the patient's representative will be informed of the grievance process, including whom to contact to file a grievance or complaint. The patient will be informed that a grievance maybe directly lodged with the Idaho Bureau of Facility Standards or the Joint Commission, regardless of whether he/she has first used the organization's grievance process." The policy did not inform each patient whom to contact, within the facility, to file a grievance. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

2. A framed document containing patients' rights information was observed in the lobby area of the facility on 7/07/15 at approximately 11:12 AM. The poster included information on how to file a written or verbal complaint with the Joint Commission, Bureau of Facility Standards and the facility's parent company, HCA. The poster did not provide the name or contact information for the individual(s), in the facility, patients or representatives could contact to file a grievance. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

3. An undated patient handout, "Your Patient Rights and Responsibilities," was reviewed. Although the handout included information about how to file a written or verbal complaint with the Joint Commission and Bureau of Facility standards, it did not provide the name or phone number of an individual(s), within the facility, patients' could contact to file a grievance. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

Patients and representatives were not informed of who to contact, within the facility, to file a grievance.

Based on staff interview, observation of patient rights posters, and review of hospital policy and patient rights information provided to patients upon admission, it was determined the hospital failed to establish a clearly explained procedure for the submission of a patients' written or verbal grievance to the hospital. This had the potential to interfere with the ability of patients to exercise their right to submit a grievance and have it promptly addressed. Findings include:

1. The hospital's policy "Patient/Family Complaint and Grievance," dated 10/12/10, was reviewed. It included, but was not limited to, the following information:

- "Each patient and/or the patient's representative will be informed of the grievance process, including whom to contact to file a grievance or complaint. The patient will be informed that a grievance maybe directly lodged with the Idaho Bureau of Facility Standards or the Joint Commission, regardless of whether he/she has first used the organization's grievance process."

- "Each patient and/or patient representative is informed of the rights and responsibilities afforded patients upon entry into the facility, and the process by which they may lodge a complaint. This information includes the name of the designee of the organization, such as the Risk Manager, and the method of access to the designee to provide immediate assistance as needed."

The policy did not state how patients would be informed of the hospital's grievance process including how to file a written and verbal grievance with the hospital. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

2. An undated patient handout, "Your Patient Rights and Responsibilities, was reviewed. Although the handout included information on how to file a written or verbal grievance with the Joint Commission and Bureau of Facility standards, it did not inform the patient how to file a verbal or written grievance with the hospital or a phone number to call. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

3. A patient rights poster, was observed in the hospital's lobby area on 7/07/15 at 11:12 AM. The poster did not include information on how to file a written and verbal grievance with the hospital. Although the handout included information on how to file a written or verbal complaint with the Joint Commission, Bureau of Facility Standards, and HCA, it did not inform the patient how to file a verbal or written grievance with the hospital or a phone number to call. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

The hospital did not establish a clearly explained procedure for the submission of a patient's written or verbal grievance to the hospital.

Based on review of grievance information and hospital policy and staff interview, it was determined the hospital failed to ensure grievances were responded to within the time frame specified in policy, or notified when a delay was anticipated to occur in accordance with policy, for 2 of 6 patients (#8 and #9) whose grievances were reviewed. This resulted in unexplained delays in communicating results of the grievance investigation. Findings include:

1. The hospital's policy "Patient/Family Complaint and Grievance," dated 10/12/10, was reviewed. The policy included, but was not limited to the following information:

- "Upon receipt of a grievance, the Risk Manager, House Supervisor, or other designee of the organization, will confer with the patient and/or patient representative within seven days of receipt of the grievance with the exception of complaints that endanger the patient (i.e., abuse or neglect). These grievances should be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient. A representative of the administrative staff will oversee and assist with the resolution process as needed. medical staff leadership may be involved as needed to resolve physician delivery of care issues.

- Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days.

The hospital's letter of response to patients/complainants was not within the time frame specified in policy. Examples include:

a. A complaint was received 4/12/15, on behalf of Patient #8 regarding physician care and behavior for an ED visit in December, 2014. Two letters of response were provided, dated 4/24/15 and 4/28/15. There was no documentation to indicate the complainant was informed of the delay beyond the seven days specified in hospital policy. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:15 AM.

b. A complaint was received on 4/18/15, on behalf of Patient #9 related to physician care in the ED the prior week. Letters of response were dated 5/21/15 and 6/02/15. There was no documentation to indicate the complainant was informed of the delay beyond the seven days specified in hospital policy. This was confirmed by the Interim Patient Advocate during an interview on 7/07/15 at 11:24 PM.

Patient #8 and Patient #9 were not sent responses to their grievances within the time frame specified in policy, nor were they notified the response would be delayed.

Based on review of letters of response to grievances, hospital policy, and staff interview, it was determined the hospital failed to ensure written notice of response included the date of completion of the investigation of complaints for 4 of 6 patients (#5, #7, #8 and #9) whose grievances were reviewed. This resulted in a lack of clarity as to whether the investigation was complete. Findings include:

1. The hospital's policy "Patient/Family Complaint and Grievance," dated 10/12/10, was reviewed. The policy 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."

The following are examples of letters of response to grievances that did not include the date the investigation was considered complete:

a. A complaint was received on 4/02/15, on behalf of Patient #5 regarding physician care during an ED visit on 4/01/15. The letter of response, dated 4/10/15 did not include the date the investigation was considered complete. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:12 AM.

b. A complaint was received 4/12/15, on behalf of Patient #8 regarding physician care and behavior for an ED visit in December, 2014. Two letters of response were provided, dated 4/24/15 and 4/28/15. Neither letter indicated the date the investigation was considered complete. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:15 AM.

c. A complaint was received on 4/10/15, by Patient #7 related to nursing care in the ED during a visit on 4/10/15. Letters of response, dated 4/15/15 and 6/10/15, did not include the date the investigation was considered complete. This was confirmed by the Interim Patient Advocate during interview on 7/07/15 at 11:15 AM.

d.. A complaint was received on 4/18/15, by Patient #9 related to physician care in the ED the prior week. Letters of response, dated 5/21/15 and 6/02/15, did not include the date the investigation was considered complete. This was confirmed by the Interim Patient Advocate during an interview on 7/07/15 at 11:24 PM.

Letters of response to grievances for Patients #5, #7, #8 and #9 were incomplete.

Based on staff interview, policy review, and medical record review, it was determined the hospital failed to ensure a process was established to ask patients if they wanted a family member/representative and/or personal physician notified of their admission to the hospital. This directly impacted 3 of 11 patients (#1, #3 and #4) whose admission documents were reviewed for this purpose. This had the potential to interfere with the ability of patients to coordinate their personal and healthcare needs. Findings include:

1. An undated patient handout, "Your Patient Rights and Responsibilities," was reviewed. The policy stated the patient could expect "prompt notification to your physician and a family member, per your request, if you are admitted to the hospital."

Documentation was not found in the following records indicating the facility had asked patients whether they wanted the hospital to notify a family member/representative and/or a personal physician of admission to the facility as follows:

- Patient #1 was a 54 year old female admitted to the Mental Health Unit of the facility on 4/01/15. Her diagnoses included bipolar 1 disorder with manic with psychotic features. There was no documentation in Patient #1's medical record indicating she had been asked if she wanted the facility to notify a personal physician of her admission.

- Patient #3 was a 32 year old female admitted to the facility on 4/17/15, for care related to a hernia repair. Documentation was not found in her medical record indicating she had been asked if she wanted the facility to notify a family member/representative or personal physician of her admission.

- Patient #4 was a 35 year old female admitted to the facility on 5/03/15, for delivery of a male infant. Documentation was not found in her medical record indicating she had been asked if she wanted the facility to notify a family member/representative or personal physician of her admission.

The Director of Advanced Clinical & Meaningful Use Coordinator was interviewed on 7/07/15, beginning at 1:05 PM. She reviewed the inpatient admission records of Patients #1, #3 and #4 and confirmed she did not see documentation of family members/patient representative notification of admission for Patients #3 and #4. She also said she did not see documentation of notification of personal physicians for Patients #1, #3 or #4.

The Director of the Mental Health Unit was interviewed on 7/07/15, beginning at 1:51 PM. She stated patients were asked if they wanted a family member or representative notified of their admission during the initial, psychiatric-social assessment. The Director of the Mental Health Unit also said she was not aware of a hospital process or document instructing staff to ask patients if they wanted their family/personal physicians notified of their admission.

The hospital did not have a uniform process in place to ensure patients were asked if they wanted family members or representatives and/or a personal physician notified of their admission.

Based on staff interview and review of hospital policy and medical records, it was determined the hospital failed to ensure restraint use was in accordance with the order of a physician or other LIP for 2 of 2 patients placed in behavioral restraints in the ED (#12 and #17) whose medical records were reviewed. This resulted in unauthorized restraint use. Findings include:

1. The "Restraint/Seclusion" policy, dated 6/03/14, was reviewed. The policy included, but was not limited to the following information:

- "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."

This policy was not followed. Examples include:

a. Patient #12 was a 52 year old male seen in the ED on 4/01/14, after being brought into the ED by police and placed on an involuntary hold due to suicidal and homicidal ideation. Nursing documentation indicated physical restraints were initiated on 4/01/15 at 5:40 PM. The time of discontinuation of restraints was not indicated in Patient #12's record. There was no order documented in the record, by a physician or other LIP, for restraints for Patient #12. This was confirmed by the Director of Advanced Clinicals and Meaningful Use Coordinator during interview on 7/08/15 at 1:20 PM.

b. Patient #17 was a 45 year old female seen in the ED on 4/15/15 and 4/16/15, for care related to a drug overdose. Nursing documentation indicated Patient #17 was placed in locking synthetic leather restraints (number or limbs not documented) at 4/15/15 at 9:50 PM, related to violent behavior. The physician's order for restraints was dated 4/16/15 at 2:38 AM, more than 4 hours after initiation of restraints.

An ED RN and the Director of Advanced Clinicals and Meaningful Use Coordinator were interviewed together at 7/08/15 at 12:45 PM. The ED RN stated there should have been a hard copy of an order written at the time of restraint initiation and scanned into Patient #17's medical record by the Medical Records Department. She confirmed the hard copy of the order was not in the record and she did not know why.

The use of restraint was not in accordance with the order of a physician or other licensed independent practitioner for Patient #12 and Patient #17 in accordance with hospital policy.

Based on staff interview and review of hospital policy and medical records, it was determined the that the hospital failed to ensure restraints used to ensure the physical safety of the non-violent or non-self-destructive patients, were renewed in accordance with hospital policy. This directly impacted 2 of 2 patients (#13 and #14) who were restrained for medical reasons. This resulted in unauthorized restraint use. Findings include:

1. The "Restraint/Seclusion" policy, dated 6/03/14, was reviewed. The policy stated an order for restraint for non-violent or non-self destructive behavior "must not exceed twenty-four hours for the initial order" and "a new order must be written each calendar day." The hospital's policy was not followed in the following examples:

a. Patient #13 was a 72 year old male admitted to the critical care unit of the hospital on 6/26/15. Nursing notes documented continuous upper extremity soft wrist restraints from 6/26/15 at 9:15 PM until 7/05/15 at 11:00 AM.

Physician orders for upper extremity bilateral wrist restraints were documented at the following dates and times for 24 hours each time:

- 6/26/15 11:16 PM
- 6/28/15 6:27 PM
- 6/29/15 4:56 PM
- 7/01/15 4:00 PM
- 7/02/15 9:34 AM
- 7/02/15 4:00 PM
- 7/03/15 4:00 PM
- 7/04/15 9:11 AM

There were no orders present for the following times when Patient #13 was in bilateral wrist restraints:

- 6/27/15 at 11:16 PM until 6/28/15 at 6:27 PM
- 6/30/15 at 4:56 PM until 7/01/15 at 4:00 PM
- 7/05/15 at 9:11 AM until 7/15/15 at 11:00 AM

Orders "per calendar day," were missing on 6/27/15, 6/30/15, and 7/05/15.

The Director of Advanced Clinical & Meaningful Use Coordinator reviewed Patient #13's record on 7/07/15 at 1:35 PM with the surveyor and confirmed there were missing orders for restraints.

b. Patient #14 was a 78 year old female, admitted to the hospital on 6/08/15, for surgery related to lumbar stenosis. The hospital's restraint log indicated Patient #14 was restrained from 6/12/15 at 12:00 PM until 6/16/15 at 11:45 AM.

Physician orders for bilateral upper extremity restraints were documented at the following dates and times for 24 hours each time:

- 6/11/15 at 12:04 PM
- 6/12/15 at 5:30 PM
- 6/13/15 at 9:00 PM
- 6/15/15 at 6:44 PM

There were no orders present for the following times when Patient #14 was restrained:

- 6/13/15 at 5:30 PM until 6/13/15 at 9:00 PM
- 6/14/15 at 9:00 PM until 6/15/15 at 6:44 PM.

An order "per calendar day," was missing on 6/14/15.

The Director of Advanced Clinical & Meaningful Use Coordinator reviewed Patient #14's record on 7/07/15 at 1:35 PM, with the surveyor and confirmed there were missing orders for restraints.

Restraints used to ensure the physical safety of the non-violent or non-self-destructive patients, were not renewed every 24 hours as authorized by hospital policy.

Based on staff interview and review of hospital policy and staff orientation documents, it was determined the hospital failed to ensure physicians and other LIPs had a working knowledge of hospital policy regarding the use of restraint or seclusion. This had the potential to interfere with patient safety and lead to inappropriate continued restraint use. Findings include:

1. The "Restraint/Seclusion" policy, dated 6/03/14, was reviewed. The policy stated "Physicians and other LIPs authorized to order restraint will have a working knowledge of this policy on the use of restraint and seclusion."

A page of physician orientation was provided for review that included information provided to physicians at orientation. There was a half a page of information related to "Restraint and seclusion" and a referral to the hospital's restraint and seclusion policy for more information.

The Medical Staff Coordinator was interviewed on 7/08/15, beginning at 9:14 AM. She said reminders of necessary education were emailed at various times throughout the year, including reminders concerning restraint training. She indicated physicians were prompted to review the restraint policy and the 1 page document previously discussed. She stated physicians were not required to provide proof of competency or attest that they have reviewed the restraint policy.

An ED physician was interviewed by telephone on 7/08/15 at 10:06 AM. When asked about his understanding of the face-to-face requirement for restraints used to manage violent or self-destructive behavior, he stated he was not sure of the specific requirements and he was not sure they applied to the ED setting since providers were in and out of the room and would likely see a patient within one hour of initiation of restraints. He stated nurses usually document "doctor in room" which would be evidence a face-to-face was conducted.

The hospital failed to ensure physicians had a working knowledge of restraint policy.

2. Refer to A184 as it relates to the failure of the hospital to ensure patients were assessed within one hour of the application of behavioral restraints.

Based on staff interview and review of hospital policies and medical records, it was determined the hospital failed to ensure a face-to-face evaluation was conducted within one hour of application of behavioral restraints to assess the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion, for 2 of 2 ED patients (#12 and #17) whose medical records were reviewed. Findings include:

The hospital's "Restraint/Seclusion" policy, dated 6/03/14, was reviewed. The policy included, but was not limited to, the following information:

"a. A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manager violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, a staff member, or others. At the time of the face-to-face assessment, the LIP/physician/RN/PA will:

1) Work with staff and patient to identify ways to help the patient regain control

2) Evaluate the patient's immediate situation

3) Evaluate the patient's reaction to the intervention

4) Evaluate the patient's medical and behavioral condition

5) Evaluate the need to continue or terminate the restraint or seclusion

6) Revise the plan of care, treatment, and services as needed

Note: A telephone call or telemedicine methodology does not constitute face-to-face assessment.

b. When the 1 hour face-to-face is performed by a RN or physician assistant with demonstrated competence, the following must occur:

1) The RN or physician assistant with demonstrated competence must consult the attending physician or LIP who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. ('As soon as possible' is to be as soon as the attending physician is able to be reached by phone or in-person.) A consultation that is not conducted prior to renewal of the order would not be consistent with the requirement "as soon as possible."

2) The consultation should include, at a minimum, a discussion of the findings of the 1 hour face-to-face evaluation, the need for other treatments, and the need to continue of discontinue the use of restraint or seclusion.

3) If a patient who is restrained or secluded for aggressiveness or violence quickly recovers and is released before the physician arrives to perform the face-to-face assessment, the physician must still see the patient face-to-face to perform the assessment within 24 hours after the initiation of restraint or seclusion."

The records of 2 ED patients who were restrained in the ED for violent or self-destructive behavior were reviewed. There was no documentation to confirm a qualified individual conducted a face-to-face evaluation within one hour of initiation of restraints to manage violent or self-destructive behavior. Examples include:

a. Patient #12 was a 52 year old male who was seen in the ED on 4/01/14 after being brought to the ED by police, and placed on an involuntary hold, due to suicidal and homicidal ideation. Nursing documentation indicated physical restraints were initiated on 4/01/15 at 5:40 PM. The time of discontinuation of restraints was not indicated in Patient #12's record. There was no documentation that Patient #12 was evaluated face-to-face for Patient his reaction to the restraints, behavioral condition, and the need to continue or terminate restraints. This was confirmed by the Director of Advanced Clinicals and Meaningful Use Coordinator and an ED RN during an interview on 7/08/15 at 12:45 PM.

b. Patient #17 was a 45 year old female who was seen in the ED on 4/15/15 and 4/16/15 for care related to a drug overdose. Nursing documentation indicated Patient #17 was placed in locking synthetic leather restraints (number or limbs not documented) at 4/15/15 at 9:50 PM related to violent behavior. There was no documentation that Patient #17 was evaluated face-to-face for her reaction to the restraints, behavioral condition, and the need to continue or terminate restraints.

An ED physician was interviewed by telephone on 7/08/15 at 10:06 AM. When asked about his understanding of the face-to-face requirement for restraints used to manage violent or self-destructive behavior, he stated he was not sure of the specific requirements and he was not sure they applied to the ED setting since providers were in and out of the room and would likely see a patient within one hour of initiation of restraints. He stated nurses usually document "doctor in room" which would be evidence a face-to-face was conducted.

The hospital failed to ensure patients restrained in the ED for behavioral reasons received a one hour face-to-face assessment related to the use of the restraints.