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Based upon record review, policy review, and interview, the hospital failed to ensure: 1) the Grievance Policy identified the correct complaint number for the Health Standards Section of DHH, and 2) the patient handbook given to the patient on admission contained the telephone number and address of the state agency (HSS/DHH) to lodge a complaint directly with the department. Findings:

Review of the Grievance Policy and Procedure revealed there was an 800 number listed; however, when the 800 number was dialed, it was for purchasing a medical alert button for individuals to push in case of an emergency while in the home environment.

Review of the patient handbook given to the patient on admission revealed there failed to be documented evidence the phone number and address of the state agency (DHH/HSS) were provided to the patient in order to file a complaint directly with the state agency. S3 RN/DON confirmed there was no number listed

On 5/20/14 at 10:30 p.m., S3 RN/DON was requested to dial the 800 number listed in the Grievance Policy. After S3 RN/DON dialed the 800 number and listened to the message he confirmed the number was not the complaint number for the state agency.

Based upon medical record review and interview, the hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the nursing care for 1 of 9 in-patient psychiatric patients (#9), out of a sample size of 19. This was evidenced by S9 RN's failure to notify the admitting physician of patient #9's elevated blood pressure upon admission to the hospital on 04/22/14. Findings:

Review of patient #9's medical record revealed the patient was admitted to the hospital on 4/22/14 at 1:00 a.m. According the the Nursing Assessment conducted by S9 RN. it was documented the patient's blood pressure was 166/104. On 4/22/14 on the 3 p.m. to 11:00 p.m. shift the blood pressure was recorded as 140/90. On 4/23/14 on the 11:00 p.m. to 7:00 a.m. shift the blood pressure was recorded as 146/110. Further review of the admission nursing assessment revealed S9 RN documented the patient had Hypertension and was on Clonidine 0.1 milligrams (last taken at 2:30 p.m. on 4/22/14 at the transferring hospital), Procardia 90 milligrams once a day, and HCTZ 25 milligrams. Review of the Nursing Admission Assessment and the Daily Nursing Assessment form dated 4/22/14 revealed there failed to be documented evidence the physician was notified of patient #9's high blood pressure upon admission.

Interview with S3 RN/DON on 5/20/14 at 9:30 a.m. revealed when asked about the patients medications on admission to the hospital, S3 RN/DON responded if a patient is admitted from home, the nurse reviews the medication list with the physician who makes the determination if the patient was to continue the medications. When asked the procedure for patients who were transferred to the hospital during the 11:00 p.m. to 7:00 a.m. shift, S3 RN/DON stated the nurse would review the Medication Administration Record from the referring hospital and if the patient was stable, the physician would not be notified until the morning. S3 RN/DON further stated S5 Psychiatrist did not want to be notified during the night if the patient was stable.

On 5/20/14 at 9:50 a.m., a telephone interview with S9 RN revealed she worked the 11:00 p.m. to 7:00 a.m. shifts. When asked about notifying the physician related to patient #9's hypertension, S9 RN replied the physician would only be notified during the night if the patient's systolic was greater than 180 and the patient was unstable. When asked about the diastolic level, S9 RN again stated if the patient was symptomatic she would notify the physician, if the patient was "ok" she would wait until the morning to call the physician. S9 RN further stated she followed the "Routine Orders" form that indicates to notify the physician if the systolic blood pressure is greater than 180.

Further interview with S3 RN/DON on 5/20/14 at 10:30 a.m. revealed when asked about the routine order form, S3 RN/DON produced a form titled "Routine Orders". On this form was documentation "Call MD for: Heart rate greater than 120 or less than 50; Temperature greater than 100; SBP (Systolic Blood Pressure) greater than 180 or less than 90". When S3 RN/DON was asked about the parameters for the diastolic pressure, S3 RN/DON confirmed diastolic pressure parameters were not identified.