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Based on staff interview and review of hospital policy and grievance documentation, it was determined the hospital failed to ensure written responses to grievances included steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 4 of 8 patients whose grievances were reviewed (#13, #14, #15, and #18). This resulted in a lack of information provided to patients and/or their representatives in response to their grievances. Findings include:

1. Patient #13 was a 53 year old male whose grievance documentation was reviewed. The following summary of complaints, dated 4/02/15, related to Patient #13's inpatient admission 3/27/15 to 3/30/15:

"1. Patient not given warning about discharge time and was told he needed to find a ride

2. Patient said he had it set up with his insurance to pay for rehab, but was then told he did not qualify

3. Patient reports they did not tell him why did not qualify for rehab

4. Patient concerned that home health did not see him until 4/1

5. Patient concerned that there was no physical therapy ordered with home health

6. Patient reports his dressing did not get changed while he was in the hospital and it did not get changed until 4/1

7. Patient stated he was not bathed in the hospital until day 4

8. Patient reports his catheterization was done wrong (not sterile), and that they wanted to put one in that would stay because of their error

9. Delays in getting call light answered

10. Pain medications were late"

The hospital's letter of response to Patient #13 regarding his complaints, dated 5/01/15, was reviewed. The letter stated the concerns had been referred to the RN Director of the nursing unit Patient #13 resided on while hospitalized, the RN Director of Case Management, and the RN Director of Home Care. The letter stated these individuals "completed a thorough review" of concerns and "conducted the appropriate follow up with staff."

Upon review, the hospital's internal grievance documentation included a more detailed review of Patient #13's complaints. However, the hospital's letter of response to Patient #13 did not state the steps taken to review the concerns, the results of the investigation, and the date of completion.

During an interview on 6/16/15 between 1:20 PM - 2:35 PM, the Manager of Patient Relations confirmed details were not included in the letter of response.

The hospital's response to Patient #13's complaints was incomplete.

2. Patient #15 was a 44 year old female whose grievance documentation was reviewed. The following complaint, dated 11/17/14, was documented related to an inpatient hospitalization for surgery, dated 11/10/14 through 11/14/14:

"During the D/C [discharge] phone call on 11/17, pt was very unhappy on how she was treated, mostly on 11/12, the day after the surgery. Felt everyone was rushing for her to go home and not listening to her. She was in pain, could not urinate, could not pass gas. She said she had authorization from her insurance company, if that was the issue. It wasn't until she was in tears that she feel [sic] anyone listened to her."

The hospital's letter of response to Patient #15's complaints, dated 11/21/14, was reviewed. The letter stated the concerns were referred to the RN Manager of the nursing unit Patient #15 resided on during her hospitalization. It further stated the RN Manager had "completed a thorough review" of concerns and "conducted the appropriate follow up and education with her staff."

Upon review, the hospital's internal grievance documentation included a more detailed review of Patient #15's complaints. However, the hospital's letter of response to Patient #15 did not state the steps taken to review the concerns, the results of the investigation, and the date of completion.

During an interview on 6/16/15 between 1:20 PM - 2:35 PM, the Manager of Patient Relations confirmed details were not included in the letter of response.

The hospital's response to Patient #15's complaints was incomplete.

3. Patient #14 was a 98 year old female whose grievance documentation was reviewed. The documentation indicated a representative of the patient filed the complaint. The following complaint summary, dated 2/12/15, was related to an inpatient hospitalization from 1/17/15 to 1/29/15.

- Patient's DNR and medication list did not follow the patient from the ED to Nine East. The paperwork was lost.

- Medications that were faxed over, were not instituted until the following day.

- The patient did not receive her Mirtazapine on the first night of her stay.

- A physician stopped six of the patient's medications.

- Discharging nurse did not review the medication list with the representative at discharge.

The hospital's letter of response to Patient #14, dated 2/27/15, was reviewed. The letter stated the complaints were referred to the Director of the Boise ED and the RN Supervisor of the unit Patient #14 resided on during her hospitalization. It further indicated staff "completed a thorough review" of concerns and "conducted the appropriate follow up and education with her staff." The letter stated the concerns regarding medications being discontinued at discharge were referred to medical staff leadership for review and follow-up and the review was confidential.

Upon review, the hospital's internal grievance documentation included a more detailed review of the complaints regarding Patient #14's care. However, hospital's letter of response to Patient #14 did not address four of the five allegations. Additonally, it did not include the steps taken to review the concerns, the results of the investigation, and the date of completion.

During an interview on 6/16/15 between 1:20 PM - 2:35 PM, the Manager of Patient Relations confirmed the details were not included in the letter of response.

The hospital's response to the concerns identified by Patient #14's representative was incomplete.

4. Patient #18 was a 54 year old female whose grievance documentation was reviewed. A complaint, dated 7/31/14, documented many concerns about a male RN during a hospitalization from 7/18/14 to 7/21/14 and a desire not to have the RN provide care for her in the future.

The hospital's letter of response to Patient #18's concern, dated 8/28/14, was reviewed. The letter stated the concern was referred to the Director of the unit Patient #18 resided on during her hospitalization, who "completed a thorough review" of concerns and "conducted the appropriate follow up and education with the staff involved."

Upon review, the hospital's internal grievance documentation included a more detailed review of Patient #18's concern. However, the hospital's letter of response to Patient #18, did not state the steps taken to review the concerns, the results of the investigation, or the date of completion.

During an interview on 6/16/15 between 1:20 PM - 2:35 PM, the Manager of Patient Relations confirmed the details were not included in the letter of response. She stated the male RN had been terminated and this information was confidential.

The hospital's response to Patient #18's complaints was incomplete.

5. The hospital policy, "Patient Complaint and Grievance Process," dated 7/31/13, was reviewed. The policy stated, "After review of the complaint or grievance, the written notice of the hospital's determination regarding the grievance will be communicated to the patient or the patient's representative by Patient & Family Relations or under the direction of Patient & Family Relations in a language they understand. The written notice to the patient, family member or customer will not reveal confidential or privileged peer review or attorney-client privileged information.

The hospital's grievance policy did not address the regulatory requirement to include the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Based on staff interview and review of hospital policy and medical records, it was determined the hospital failed to ensure the least restrictive type of restraints were used to protect patients or others from harm for 2 of 8 patients (#19 and #20) who were physically restrained and whose records were reviewed. This resulted in patients being restrained in a manner that was more restrictive than warranted by their behavior. Findings include:

1. The hospital's policy, "Restraints," dated 5/05/14, was reviewed. The policy included, but was not limited to the following information:

- Restraints may only be imposed to ensure the immediate physical safety of the patient, staff member, or public and through the use of the least restrictive device for the shortest possible time when restraints are clinically appropriate and adequately justified

- Prior to the use of any restraint, the patient care provider must attempt and/or consider less restrictive measures to protect the patient, staff members, or others from harm.

- Document the implementation of less restrictive measures or the reason less restrictive measures were not an option prior to restraint application/use.

This policy was not followed. Examples include:

a. Patient #19 was a 36 year old male seen in the ED on 3/16/15. The medical record included a physician's order, dated 3/16/15 at 1:36 PM, for 4 point hard restraints for 4 hours for violent/self-destructive behavior. There was no documentation that described violent or self-destructive behavior exhibited by Patient #19.

Nursing restraint documentation indicated the hard restraints were applied by nursing staff on 3/16/15 at 1:44 PM.

The following less restrictive measures were documented as "tried" prior to the application of four point hard restraints on 3/16/15:

- Diversional activities

- Use of Patient Safety Attendant/family member to sit with the patient

- Addressed physical/medical needs

- Employed verbal de-escalation techniques

There were no less restrictive physical restraints (such as 2 point soft restraints) considered or tried prior to the application of 4 point hard restraints.

The nurse and physician who cared for Patient #19 were unavailable for interview.

An ED RN was interviewed on 6/19/15 at 11:30 AM. She reviewed restraint documentation for Patient #19. She stated she did not see documentation to explain the use of hard four point restraints.

An ED physician was interviewed on 6/19/15, at 12:00 PM. He reviewed restraint documentation for Patient #19 and confirmed documentation was lacking.

Hospital staff did not use the least restrictive type of restraint that would be effective to protect Patient #19 or others from harm.

b. Patient #20 was a 45 year old male seen in the ED on 3/27/15. A nursing "Triage" note, dated 3/27/15 at 12:33 PM, documented Patient #20 had been transported via air ambulance after Patient #20's roommate found him punching walls in the bathroom and then becoming less responsive and frothing at the mouth. Patient #20 was described, after arrival at the ED, as confused, restless, and anxious.

Physician history, dated 3/27/15 at 1:06 PM, described Patient #20 as combative and agitated. It further stated Patient #20 had been transported along with a large container of medications and a suicide note.

The medical record included a physician's order, dated 3/27/15 at 1:35 PM, for 4 point hard restraints for 4 hours for aggressive/violent behavior and an inability to consistently follow or understand directions. There was no documentation included that explained what behaviors Patient #20 was exhibiting that were considered aggressive, violent, or combative.

Nursing restraint documentation indicated the hard restraints were applied by nursing staff on 3/27/15 at 1:35 PM.

The following less restrictive measures were documented in nursing notes, dated 3/27/15 at 1:35 PM, as "tried" prior to the application of 4 point hard restraints on 3/27/15:

- Diversional activities

-Verbal de-escalation techniques

There were no less restrictive measures or physical restraints considered or tried prior to the application of four point hard restraints.

The nurse and physician who cared for Patient #20 were unavailable for interview.

An ED RN was interviewed on 6/19/15 at 11:30 AM. She reviewed restraint documentation for Patient #20. She stated she did not see documentation to explain or justify use of hard four point restraints.

An ED physician was interviewed on 6/19/15 at 12:00 PM. He reviewed the restraint documentation for Patient #20 and confirmed documentation was lacking.

Hospital staff did not use the least restrictive type of restraint that would be effective to protect Patient #20 or others from harm.

Based on staff interview and review of hospital policy and medical records, it was determined the hospital failed to ensure orders for non-violent restraints were renewed in accordance with hospital policy for 1 of 2 patients (#3) who were restrainted for medical reasons and whose records were reviewed. This resulted in unauthorized restraint use. Findings include:

The hospital's policy, "Restraints," dated 5/05/14, was reviewed. The policy included, but was not limited to the following information:

- The initial restraint order is good for 1 calendar day.

- Continued use of nonviolent/non-self destructive restraint beyond the first calendar day requires a restraint renewal order by a physician each calendar day.

Patient #3 was a 43 year old male who was admitted on 4/23/15 for care related to severe sepsis and chest pain. He died on 4/30/15.

Patient #3's medical record documented Patient #3 was restrained with bilateral soft wrist restraints from 4/27/15 until 4/30/15 at 7:00 AM. An order for initiating bilateral soft wrist restraints was dated 4/27/15 at 11:00 PM. The medical record did not include an order for restraints on 4/28/15, although nursing documentation indicated continuous restraints. This was confirmed by the Accreditation Director on 6/17/15 at 1:30 PM.

A restraint used to ensure the physical safety of the non-violent or non-self-destructive of Patient #3 was not renewed per calendar day in accordance with the hospital's policy.

Based on staff interview and review of hospital policy and medical records, it was determined the hospital failed to ensure restraints were discontinued at the earliest possible time for 2 of 8 patients who were restrained (#19 and #20) and whose records were reviewed. This resulted in patients being restrained longer than was necessary to ensure safety. Findings include:

1. The hospital's policy, "Restraints," dated 5/05/14, was reviewed. The policy included, but was not limited to, the following information:

- Restraints may only be imposed to ensure the immediate physical safety of the patient, staff member, or public and through the use of the least restrictive device for the shortest possible time when restraints are clinically appropriate and adequately justified

- Restraints must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

Restraints were not discontinued at the earliest possible time as required by this policy. Examples include:

a. Patient #19 was a 36 year old male seen in the ED on 3/16/15. There was a physician's order, dated 3/16/15 at 1:36 PM, for 4 point hard restraints for 4 hours for violent/self-destructive behavior. Nursing restraint documentation indicated 4 point restraints were applied at 1:44 PM. Nursing documentation on 3/16/15 at 2:14 PM, documented Patient #19 continued in hard restraints while "sedated and resting." There was no documentation to indicate 4 point hard restraints were required for safety at that time.

An ED RN was interviewed on 6/19/15 at 11:30 AM. She reviewed restraint documentation for Patient #19. She confirmed the medical record documented Patient #20 continued to be restrained with four-point hard restraints while "sedated and resting."

An ED physician was interviewed on 6/19/15 at 12:00 PM. He reviewed restraint documentation for Patient #19 and confirmed documentation was lacking.

Patient #19 was not released from four point restraints at the earliest possible time.

b. Patient #20 was a 45 year old male transported to the ED on 3/27/15 by air ambulance. Patient #20's medical record included a physician's order, dated 3/27/15 at 1:35 PM, for 4 point hard restraints for 4 hours for aggressive/violent behavior. Nursing restraint documentation indicated 4 point restraints were applied by nursing staff on 3/27/15 at 1:35 PM. Restraint documentation at 2:00 PM and 2:30 PM described Patient #20 as "sedated and resting" while continuing to be restrained in four point hard restraints.

The nurse and physician who cared for Patient #20 were unavailable for interview.

An ED RN was interviewed on 6/19/15 at 11:30 AM. She reviewed restraint documentation for Patient #20. She confirmed the documentation that Patient #20 continued to be restrained with 4 point hard restraints while "sedated and resting."

An ED physician was interviewed on 6/19/15 at 12:00 PM. He reviewed restraint documentation for Patient #19 and confirmed documentation was lacking.

Patient #20 was not released from restraints at the earliest possible time.

Based on staff interview and review of medical records and the hospital's restraint policy, the hospital failed to ensure a face-to-face examination was completed within 1 hour of the application of behavioral restraints in the ED setting. This directly impacted 6 of 6 patients (#19, #20, #21, #22, #23, #24) who were restrained in the ED and whose records were reviewed. This resulted in the potential for adverse patient events to go undetected and untreated by hospital staff. Findings include:

1. The hospital's policy, "Restraints," dated 5/05/14, was reviewed. The policy stated "Restraints used to manage violent/self-destructive behavior require a physician in person examination of the restrained/patient within one hour of initiation." The policy did not address documenting the 1-hour face-to-face medical and behavioral evaluation in the patient's medical record.

The face-to-face evaluation was not conducted by a physician within 1 hour after application of restraints used to manage violent or self destructive behavior, as follows:

a. Patient #19 was a 36 year old male seen in the ED on 3/16/15. The medical record included a physician's order, dated 3/16/15 at 1:36 PM, for 4 point hard restraints for 4 hours for violent/self-destructive behavior. Nursing restraint documentation indicated the restraints were applied at 1:44 PM. There was no documentation that a physician conducted a face-to-face examination within 1 hour of application of restraints.

b. Patient #20 was a 45 year old male seen in the ED on 3/27/1.5 by air ambulance. The medical record included a physician's order, dated 3/27/15 at 1:35 PM, for 4 point hard restraints for 4 hours for aggressive/violent behavior and an inability to consistently follow or understand directions. Nursing restraint documentation indicated the restraints were applied by nursing staff on 3/27/15 at 1:35 PM. There was no documentation that a physician conducted a face-to-face examination within 1 hour of application of restraints.

c. Patient #21 was a 41 year old male seen in the ED on 6/07/15, for smoking an unknown substance. He was brought in by EMS and accompanied by local police. Patient #21's medical record included a physician order, dated 6/07/15 at 10:11 PM, for 2 point hard restraints for 4 hours related to aggressive/violent behavior, destructive behavior, and inability to consistently follow or understand directions. Nursing restraint documentation indicated the restraints were applied by nursing staff on 6/07/15 at 10:12 PM. Patient #21's record did not include documentation a physician conducted a face-to-face examination within 1 hour of the application of restraints.

d. Patient #22 was a 74 year old male seen in the ED on 5/18/15, for garbled speech. He was brought in by private auto from a physician's office. Patient #22's medical record included a physician order, dated 5/18/15 at 12:19 PM, for 4 point hard restraints for 4 hours related to violent/self-destructive behavior, aggressive/violent behavior, and inability to consistently follow or understand directions. Nursing restraint documentation indicated 4 point hard restraints were applied by nursing staff on 5/18/15 at 12:30 PM. Patient #22's record did not include documentation a physician conducted a face-to-face examination within 1 hour of the application of restraints.

e. Patient #23 was a 24 year old male seen in the ED on 5/20/15, for a mental health hold. He was brought in by local police. Patient #23's medical record included a physician order, dated 5/20/15 at 6:15 PM, for 4 point hard restraints for 4 hours related to violent/self-destructive behavior and aggressive/violent behavior. Nursing restraint documentation indicated the restraints were applied by nursing staff on 5/20/15 at 6:02 PM. Patient #23's record did not include documentation a physician conducted a face-to-face examination within 1 hour of the application of restraints.

f. Patient #24 was a 40 year old female seen in the ED on 5/28/15, for a mental health hold. She was brought in by local police. Patient #24's medical record included a physician order, dated 5/28/15 at 12:15 AM, for 4 point hard restraints for 4 hours related to violent/self-destructive behavior, aggressive/violent behavior, and inability to consistently follow or understand directions. Nursing restraint documentation indicated the restraints were applied by nursing staff on 5/28/15 at 1:50 AM. Patient #24's record did not include documentation a physician conducted a face-to-face examination within 1 hour of the application of restraints.

During an interview on 6/18/15 at 4:10 PM, the Accreditation Director reviewed the records of Patients #19, #20, #21, #22, #23, and #24. She confirmed the records did not include documentation of the 1 hour face-to-face by a physician. She stated nursing staff were not qualified to perform the face-to-face according to hospital policy.

An ED physician, who was identified as the Chair of the ED, was interviewed on 6/19/15 at 12:00 PM. He stated it was his understanding that seeing the patient face-to-face prior to the initiation of restraints met the face-to-face requirement.

The hospital did not ensure a face-to-face evaluation was conducted by qualified staff within one hour after application of restraints used to manage violent or self-destructive behavior.

Based on staff interview and review of medical records and the hospital's restraint policy, it was determined the hospital failed to ensure medical records contained documentation of a description of the patient's behavior that justified the use of restraints for 1 of 8 patients (#19) who were restrained and whose records were reviewed. This resulted in a lack of clarity as to whether the patient's behavior warranted the use of restraints. Findings include:

The hospital's policy, "Restraints," dated 5/05/14, was reviewed. The policy stated "Staff will document patient behavior necessitating restraint use."

Patient #19 was a 36 year old male seen in the ED on 3/16/15. There was a physician's order, dated 3/16/15 at 1:36 PM, for 4 point hard restraints for 4 hours for violent/self-destructive behavior.

Patient # 19's ED visit, dated 3/16/15 beginning at 1:15 PM, included the following descriptions of Patient #19's behavior:

-The patient on arrival to the emergency department had a tonic-clonic seizure witnessed by the nurse.

-The patient is agitated and pacing the room.

- He appears to be paranoid checking behind the curtains and having tangential thoughts.

There was no documented description of Patient #19's behavior that demonstrated how he was at risk of hurting himself or others.

The nurse and physician who cared for Patient #19 were unavailable for interview.

An ED RN was interviewed on 6/19/15 at 11:30 AM. She reviewed restraint documentation for Patient #19 and confirmed there was no documentation present that explained the use restraints.

An ED physician was interviewed on 6/19/15 at 12:00 PM. He reviewed restraint documentation for Patient #19 and confirmed documentation was lacking.

Patient #19's medical record did not include documentation of the behavior that justified the use of hard four point restraints, or any other type of physical restraint.

Based on staff interview and review of medical records and hospital policy, it was determined the hospital failed to ensure a process was established to consistently transfer necessary medical information at discharge for follow-up or ancillary care. This affected 1 of 1 patient (#7) whose closed medical record was reviewed for evidence of transfer information. This had the potential to interfere with continuity of patient care after discharge. Findings include:

1. The hospital's policy, "Discharge Planning Process and Discharge of Patient," dated 2/28/14, was reviewed. The policy stated that on or prior to the day of discharge, forms and/or activities would be completed for the patient to be ready for discharge. This included, but was not limited to, providing the receiving agency/facility with copies of the pertinent financial and medical information and the expectation the staff nurse complete the patient transfer report related to the patient's clinical status and the interdisciplinary plan of care for purposes of hand-off communication.

The policy did not define what was considered "pertinent medical information." It did not address how or if information was sent to patients' physicians when patients were discharged home and the time frame for providing the information.

The policy did not describe any expectation to list what information was transferred. It did not describe how information would be transferred to facilities or patients' physicians who did not have access to the electronic health record.

The Director of Case Management and the Manager of Case Management were interviewed together on 6/17/15 at 9:30 AM. When asked about the process of transferring patients' medical information at discharge, they stated they thought the discharge summary was sent to the physician but it was not their role as discharge planners.

The Accreditation Director was interviewed on 6/17/15, at 11:30 PM and again at 3:05 PM. She confirmed the hospital sent a discharge summary, when completed, within 30 days. She stated primary care doctors were sent a duplicate on any dictated notes, such as H&Ps and or consultations. She stated she was not sure how the information was sent to physicians who were not part of the St Luke's health system and who did not have electronic access. Later in the survey, she provided "Patient Facility/Agency Discharge Checklist" which listed information that was to be transferred at the time of discharge. On the bottom of the form it stated "Worksheet is not a part of the permanent medical record."

The discharge planning process as it related to transfer of medical information was incomplete and lacked specificity.

2. Patient #7 was a 68 year old female who was admitted to the hospital on 4/25/15 related to respiratory problems. She was discharged on 4/27/15 to home with home health services. The medical record documented a referral via fax to the home health agency on 4/27/15. There was no documentation in Patient #7's medical record that identified what medical information was provided to the home health agency or to Patient #7's primary physician who would manage Patient #7's care after discharge. This was confirmed on 6/17/15 by the Director and Manager of Case Management.

There was no documentation the hospital transferred Patient #7's necessary medical information to the home health agency and to Patient #7's primary physician, upon discharge.