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Based on complaints and grievance reports and policy and procedure review the facility failed to ensure that at the resolution of a patient grievance that the hospital provided the patient with written notice of its decision. Findings include:
During complaint and grievance report review on 12/19/12 at approximately 1100 it was found that in 8 out of 12 reports reviewed the complainant didn't receive a response letter from the facility.
During policy and procedure review on 12/19/12 at approximately 1200 it was found in the policy titled, "Patient Complaint Process, Patient relations Coordinator Program", states under response process/grievance, "The response will be in writing at a minimum which includes the decision that contains the name of the hospital, contact person, and the steps taken on behalf of the person to investigate the grievance, the results of the grievance process, and the date of completion".

Based on medical record review, interview and policy and procedure review the facility failed to ensure that restraint orders were being signed, dated and timed by a physician in 10 out of 13 (#1, #2, #3, #4, #13, #21, #22, #23, #26 and #27) restrained patients.

During medical record review on 12/19/12 at approximately 1130 it was revealed that patient #1's restraint orders dating from 12/17/12 through 12/18/12 were incomplete. On these restraint orders in the physician's signature box the date and time sections were blank. The medical record lacked nursing flow sheets for restraints for the date 12/17/12 midnight to 0800.

During medical record review on 12/19/12 at approximately 1155 it was revealed that patient #2's restraint orders dated 12/18/12 were incomplete. The telephone order section was not completes and in the physician's signature box the time section was blank.

During medical record review on 12/19/12 at approximately 1205 it was revealed that patient #3's restraint orders dating from 12/17/12 through 12/18/12 were incomplete. On these restraint orders the telephone order section was not completed and in the physician's signature box the date and time section was blank. The restraint order sheet for 12/18/12 lacked documentation of a patient assessment and medical record lacked nursing flow sheets for restraints for the date 12/18/12 from 0800 to 1130.

During medical record review on 12/19/12 at approximately 1215 it was revealed that patient #4's restraint orders for the dates of 12/7/12, 12/10/12 thru 12/17/12 were incomplete. On the restraint order for 12/7/12 in the physician's signature box the signature, date and time section was blank. The restraint order sheets for 12/10/12 and 12/11/12 lacked documentation of a patient assessment. On the restraint orders for 12/12/12 thru 12/17/12 in the physician's signature box the date and time section was blank. During these restraint dates it was told to this surveyor that the patient is taken out of restraints when his wife is visiting and placed back in restraints when the wife leaves, but there are no restraint discontinuation or re-start orders in the patient's chart. This was confirmed by staff F.
During medical record review on 12/19/12 at approximately 1600 it was revealed that patient #13's restraint orders for 6/10/12 and 6/13/12 were incomplete. On the restraint orders for 6/10/12 in the physician's signature box the date and time sections were blank. On the restraint orders for 6/13/12 had no start time for the restraint initiation.


During medical record review on 12/19/12 at approximately 10:55 a.m. it was revealed that patient #21's restraint orders dating from 12/6/12 through 12/18/12 were incomplete. On these restraint orders in the physician's signature box the date and time sections were blank. During an interview with staff F on 12/19/12 at approximately 11:00 it was confirmed the restraint orders were incomplete. Staff F stated " They aren't filling them out like they are supposed to. "

During medical record review on 12/19/12 at approximately 11:15 a.m. it was revealed that patient #22's restraint orders dating from 12/11/12 through 12/12/12 and 12/15/12 through 12/17/12 were incomplete. On these restraint orders in the physician's signature box the date and time sections were blank. The medical record lacked restraint orders and nursing flow sheets for restraints for the dates 12/13/12 and 12/14/12. On 12/19/12 at approximately 11:22 a.m. findings were confirmed with staff F who stated " Those aren't complete either and in the spirit of full disclosure flow sheets are missing for those dates, 12/13 and 12/14. The charting in the computer matches what's in the chart and there is no order for removal of restraints, I don't know where the orders or flow sheets are. "

During medical record review on 12/19/12 at approximately 11:30 a.m. it was revealed that patient #23's restraint order for 12/18/12 was incomplete. On this restraint order in the physician's signature box the time section was blank. During an interview on 12/19/12 at approximately 11:35 a.m. staff F stated " We have been talking to doctors to have them date and time but this one forgot the time. "

During medical record review on 12/18/12 at approximately 1130 it was found in patient #26 medical record and security report that the patient was placed in leather restraints at approximately 1715 on 3/17/12 and there was no initial order for these restraints in the patient's chart until 2100.
During medical record review on 12/18/12 at approximately 1145 it was found in patient #27 medical record and security report that the patient was placed in leather restraints at approximately 2020 on 6/18/12, per policy the physician must renew leather restraint orders every four hours, there was no restraint renewal order for this patient on 6/19/12 at 0001 or 0400.


These findings were confirmed during the above medical record reviews by staff G.
During policy and procedure review on 12/18/12 at approximately 1230 it was found in the policy titled, "Restraint Usage", states under initial and renewal order for behavioral restraints, "Restraint orders are time limited-the maximum time frame for a behavioral restraint order is 4 hours...Re-assessment of patient condition and re-order must occur every 4-hours" and " a restraint order needs to include: ...date, start, and stop times ... "

Based on medical record review and interview the facility failed to ensure that each order for a restraint used for the management of violent or self-destructive behavior can only be renewed in accordance with the following limits for up to a total of 24 hours: 4 hours for adults 18 years of age or older in 1 out of 5 (#27) patient medical records. Findings include:
During medical record review on 12/18/12 at approximately 1145 it was found in patient #27 medical record and security report that the patient was placed in leather restraints at approximately 2020 on 6/18/12, per policy the physician must renew leather restraint orders every four hours, there was no restraint renewal order for this patient on 6/19/12 at 0001 or 0400.
This finding was confirmed during the above medical record review by staff G.

Based on medical record review and policy and procedure review the facility failed to monitor restrained patients as required by hospital policy for 13 out of 13 (#1, #2, #3, #4, #13, #18, #21, #22, #23, #24, #25, #26, #27, #28) restrained patients. Findings include:
During medical record review on 12/18/12 and 12/19/12 at different intervals of time it was revealed that the medical records for patients #1, #2, #3, #4, #13, #18, #21, #22, #23, #24, #25, #26, #27, #28 contained documents titled " Restraint Flow Sheet " and were not being completed by nursing staff as required per policy. The Restraint Flow Sheet contains a section labeled " TIME, behavioral restraints every 15 min, med/surg restraints once every 2 hours ". This section contained the following areas to be checked every 2 hours:
Safety Check
Skin Integrity
Circulation
Breathing
Privacy and modesty maintained
Evaluate readiness for discontinuation

On 12/18/12 at approximately 11:00 a.m. a review of the facility's policy titled " Restraint Usage " dated 03/2011 revealed " ...will be visually observed a minimum of every hour ...observation/documentation should include: Safety check, skin integrity, circulation to extremities, breathing, privacy & modesty maintained, and evaluation to determine if criteria met for discontinuation ... " The facilities flow sheet didn't coincide with the restraint flowsheet documentation policy, therefore the flowsheets were not being completed as required.

Based on medical record review, interview and policy and procedure review the facility failed to ensure that in 2 out of 5 (#24 and #25) patient medical records reviewed that a face-to-face assessment was completed. Findings include:
During medical record review on 12/19/12 at approximately 1200 it was found in patient medical record #24 that upon initiation of leather restraints the physician failed to complete a face-to-face assessment.
During medical record review on 12/19/12 at approximately 1210 it was found in patient medical record #25 that upon initiation of leather restraints the physician failed to complete a face-to-face assessment.
These findings were confirmed by staff G at the time of review.
During policy and procedure review on 12/19/12 at approximately 1300 it was found in the policy titled, "Restraint Usage", states, "The face to-face physician restraint assessment is to be documented on the restraint order form".