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Based on policy and procedure review, document review and staff interview, the governing body failed to delegate, in writing, the responsibility for the operation, review and resolution of grievances.

Findings include:

Review of the facility policy and procedure addressing the grievance process did not indicate the governing body had delegated the responsibility for grievance resolution to a grievance committee or individual.

On 7/31/13, the Performance Improvement Coordinator reported the governing body had not delegated the responsibility for the grievance process to a committee or staff member in writing. The coordinator reported the governing body was not responsible for the grievance process and a staff member was handling grievances.

Based on policy and procedure review, document review and staff interview, the facility failed to specify time frames for review of the grievance and the provision of a response.

Findings include:

Review of the policy and procedure entitled "Consumer / Family Complaint / Compliment / Suggestion" procedure revealed the facility did not establish the time frames for the review of the grievance and the provision of a response to the grievance.

On 7/31/13, the Performance Improvement Coordinator confirmed the policy and procedure entitled "Consumer / Family Complaint / Compliment / Suggestion" was the facility's grievance procedure. The coordinator confirmed there were no time frames established for grievance resolution or for the provision of the response to the grievance.

Based on policy and procedure review, document review and staff interview, the facility failed to provide patients with written notice of the hospital's decisions regarding greivances.

Findings include:

Review of the policy and procedure entitled "Consumer / Family Complaint / Compliment / Suggestion" procedure revealed the facility did not provide written notice of the hospital's investigation of grievances or the results of the grievances and did not provide the name of a hospital contact person.

On 7/31/13, the Performance Improvement Coordinator confirmed the policy did not provide for written notice of the hospital's investigation of grievances, the results of the grievances and did not provide the name of a hospital contact person.

Review of patient greivances for the past six months prior to survey did not reveal evidence the person making the greivance was notified in writing of the facility contact person, the investigative process or the outcome of the greivance.

Based on policy and procedure review, document review and staff interview, the facility failed to follow the current hospital policy for restraint and seclusion.

Findings include:

Review of the facility policy and procedure entitled "Restraint and Seclusion Of Consumers " last review/revise date 4/21/11, revealed physicians were responsible for conducting the face-to face evaluation within one (1) hour of the episode/initiation of restraints regardless of the duration of the seclusion and/or restraint. The policy and procedure did not define the meaning, function or training requirements of a qualified nurse (QRN) and did not indicate the QRN could conduct face to face evaluations following the initiation of restraint/seclusion.

Record review of patients who were placed in restraints revealed QRNs were conducting the initial face to face evaluations of patients in restraints and seclusion.

On 8/31/13, the Director of Nursing (DON) reported certain registered nurses were trained to be QRNs in March of 2013 and the QRNs have been conducting the initial face to face evaluations since that time. The DON reported the facility's policy and procedure was not updated to reflect the use of QRNs.

On 8/31/13, the Performance Improvement Coordinator confirmed the facility's practice regarding restraint did not comply with the current policy and procedure in place. The Performance Improvement Coordinator reported the facility was working on a new restraint and seclusion policy and procedure but it had not been approved yet.

Based on policy and procedure review and staff interview, the facility failed to establish a death reporting policy that identified reporting time frames or situations requiring reporting to Centers for Medicare and Medicaid Services (CMS).

Findings included:

The policy and procedure entitled "Restraint and Seclusion Of Consumers" last revised 4/21/11 was reviewed. The policy and procedure did not address the following reporting requirements to CMS when a death occurs:

1) A death was reported when it occured while a patient was in restraint or in seclusion.
2) A death was reported if it occured within 24 hours after the patient had been removed from restraint or seclusion.
3) A death was reported if it occured within one week after the use of restraint or seclusion where it was reasonable to assume that the use of restraint or seclusion contributed directly or indirectly to the patient's death.

In addition, the policy and procedure did not indicate the death report must be submitted to the CMS Regional Office by telephone, no later than the close of the next business day in which the hospital knows of the patient's death.

On 8/31/13, the Performance Improvement Coordinator confirmed the reporting policy did not address the required reporting parameters.

Based on policy and procedure review, inpatient handbook review and staff interview, the faciltiy failed to fully inform each patient of the visitation rights.

Findings include:

Review of the facility policies entitled "Visiting Procedures" last revised 2/18/13, and "Consumer Rights" last revised 7/19/12 revealed no evidence patient's were notified of their right to have visitors he or she designated, including but not limited to, a spouse, a domestic partner (including same sex domestic partner), another family member, or a friend. The patient handbook did not contain the same information regarding visitors.

On 8/31/13, the Performance Improvement Coordinator confirmed the policy and procedure did not include the required visitation rights information.