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Based on a review of the hospital grievance policy and 15 closed grievance files on 10/26/15, it was determined that for 2 of 15 hospital grievances, the hospital failed to contact the complainant when the resolution of the grievance was anticipated to go beyond 7 days, as specified in hospital policy.

The hospital policy "Complaints or Grievances (Patient), Addressing" (effective 08/05/2014) reveals in part, "Procedure B. 7. b. Grievances shall, when possible, be resolved within 7 days," and "(c) If a resolution cannot be completed within 7 business days, then written correspondence will be sent to the complainant by Patient Relations within 7 business days of receipt of the grievance stating that resolution written correspondence will be sent within 30 business days (see Appendix A)."

Grievance #3 was submitted on August 3, 2015 and closed on August 19, 2015. No 7-day notification following the initial intake of the grievance was found. The grievance was closed by letter on August 19, 2015.

Grievance #6, submitted on August 10, 2015, was closed on August 25, 2015. No 7-day notification following the initial intake of the grievance was found. The grievance was closed by letter on August 25, 2015.

While it is not a regulatory requirement that the hospital write a letter to the complainant if an investigation extends beyond seven days as stated in hospital policy, contact should be made. Based on this review, the hospital failed to meet hospital policy and Federal guidelines for that contact in 2 of 15 grievances reviewed.

Based on a review of hospital policy and the medical records of one patient restrained at the time of the survey on 10/26/15 for violent behavior and two patients restrained in the past for violent behavior, it was determined that for two of the three patients with a combined 3 episodes of restraint, 1) hospital staff failed to document that the patients had been informed of the rationale for restraints, and, 2) failed to document that the patients were informed of actual behavioral criteria for release from restraint/seclusion. Information which might have assisted the restrained/secluded patients to comply and participate in their own care.

Hospital policy "Restraint and Seclusion, Management of Violent or Self-Destructive Patient Behavior and Behavior Presenting an Imminent Safety Risk to Self and Others (effective 01/22/2015)" reveals in part, "E. Use of Restraints, 2. b. Explain to the patient the rationale for restraint and reassure the patient of frequent observation during the restraint episode."

Patient #2 is a young adult with cognitive deficits who was restrained in what the hospital refers to as 8-point restraints (bilateral wrists restraints and a vest restraint with six points of attachment) when the patient became combative and spitting in the early morning of 10/26/2015. Nursing documentation revealed multiple redirections, though no documentation was found in the medical record indicating that Patient #2 was informed of the reasons for the restraints, nor was documentation found indicating that the patient was informed of specific behavioral criteria for release.

Patient #2 was restrained again later in the morning of 10/26/15 when the patient's behavior escalated again and staff redirection was ineffective. While nursing staff documented redirection, again, no documentation that either the rationale for restraints nor the expected behavioral criteria for release from restraints were explained to the patient was found.

Patient #3 was also a young adult with cognitive deficits who was restrained in 2-point wrist restraints on a day in April, 2015 following a combative episode. No documentation was found during a document review on 10/27/15 confirming that the rationale for restraints or the behavioral expectations for release were explained to the patient.

The hospital policy noted above calls for conveying the rationale of the intervention to the patient. Even though patients #2 and #3 each had cognitive deficits, being informed of the reason for restraints or seclusion and the behavioral expectations for release might have allowed each patient to participate more fully in his or her care and perhaps end the restraint episode earlier.

Based on review of 15 closed and 11 open medical records, staff interviews, and observations of the outpatient procedural area the hospital staff failed to ensure the safety of a demented patient by failing to effect safe hand-offs, failing to formulate a policy and procedure for patients who require an attendant, and failing to review the elopement from a quality perspective. This was true for one of 26 patients reviewed.

Patient #1 was a resident at a long term care facility who required a constant sitter (nursing aide familiar with the patient employed by the patient's long term caregiver) for care and personal safety due to dementia. Patient #1 was scheduled for an outpatient procedure and a doctor visit in September, 2015. The patient was registered for the procedure and was directed to the near-by radiology waiting room accompanied by the sitter. Interview with a radiology technician on 10/26/15 confirmed that the patient had been escorted to a changing area outside the procedure room while the patient's sitter had been requested to stay in the waiting room. The technician was aware that the patient required constant observation and was accompanied by the sitter. The patient completed the procedure and was instructed to change back into his/her clothing. A different radiology technician, who had not been apprised of the patient's need for a sitter, directed the patient to the hallway to go to the physician appointment. The patient, lacking the mental capacity to complete tasks independently, became lost and left the hospital. The patient's sitter inquired about the status of the procedure and learned that staff could not locate the patient.

Hospital security staff were immediately notified of the lost patient and broadcast an alert of the patient's physical description, conducted a sweep of the entire building looking for the patient, and also notified Baltimore City Police. The security staff notified risk management of the missing patient via email, however no further review was completed by the quality or risk departments to determine the reasons this patient was able to elope or if anything could be put into place to prevent future occurrences.

Interview with the risk manager on 10/26/15 revealed that the outpatient radiology center has no policy currently in place to direct staff of procedures to follow when patients lack mental or physical capacity and require the need for constant observation by a family member, sitter, or hospital staff.

Failure of outpatient center staff to ensure the safety of patients by effectively communicating patient needs, failing to have a policy in place directing the permissions or restrictions on sitters accompanying patients to procedure areas, and the failure of risk or quality departments to identify that these risk factors existed, places patients, especially those who may lack physical or mental independence, at risk for harm.

Based on a review of the medical records of one patient restrained at the time of the survey on 10/26/15 for violent behavior and two patients restrained for violent behavior in the past, it was determined that for two of the three patients with a combined three episodes of restraint, the hospital failed to release patients #2 and #3 at the earliest possible time.

Patient #2 was restrained on the morning of 10/26/15 when the patient's behavior escalated into an attack on a staff person and staff redirection was ineffective. Documentation revealed that, for the last hour of this restraint episode, the patient was alternately documented as quiet or asleep on the every 15-minute observation sheet, yet the restraint were not terminated until the completion of this hour.

Patient #3 was also a young adult with cognitive deficits who was restrained in 2-point wrist restraints on a day in April, 2015 following a combative episode. A review of the nursing observation flow sheet for this patient revealed that for the last three hours of the restraint episode Patient #3 was described variously as quiet, talking, laughing, eating dinner, or receiving medication. No behavioral documentation was found for the last 45 minutes of this episode. The patient was released from restraints three hours and 45 minutes after the last documentation of violent or dangerous behavior.

Failure to release patients from restraints at the earliest possible time can lead to physical harm to the patients and can lead to further escalation of behavior, especially in patients with cognitive deficits who may not understand the delay.