HospitalInspections.org

Based on staff interview and document review, it was determined the hospital's governing body failed to ensure the established grievance procedures were followed in one (1) of twenty (20) written grievance reviewed in the survey sample.

Findings:

The hospital's grievance tracker was reviewed from January 01, 2024 to present. The grievance log contained documentation of nineteen (19) patient grievances. The log failed to contain documentation of a grievance related to Patient #1.

An interview was conducted with Staff Member #26 on October 1, 2024 at 2:10 PM. Staff Member #26 stated that written complaints should be entered in the grievance log as soon as they are received and reviewed.

The emailed complaint received by Staff Member #18 on September 01, 2024 regarding Patient #1 was reviewed and contained allegations related to inappropriate infection control practices, inadequate nursing care, patient rights violations, and concerns with care coordination. Staff Member #1 responded to the grievance allegations via email on September 01, 2024. The written response reads in part: "I will be working with you in your efforts to find clarification of [Patient #1's] recent hospitalization that you listed in your email. It may take me some time to gather responses from the team that cared for [Patient #1], but I will have a letter for you sometime this month."

During an interview conducted with Member #18 on October 01, 2024 at 12:15 PM, the staff member stated that the investigation into the grievance was not completed.

The facility's policy, IHS Patient Complaint/Grievance Process in the Hospital Policy was reviewed and reads in part: Patient Grievance - 1. Written or verbal complaint (when the verbal complaint about patient care is not resolved by the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, or issues related to the hospital's compliance with the Centers for Medicare and Medicaid Services' (CMS) Hospital Conditions of Participation (CoP)...Complaints and grievances will be recorded in the complaint module of the Safety Always database and will include documentation of actions associated with case investigation, resolution, and response....All grievances are responded to in writing. It is expected that many grievances can be resolved within 7 days. If the grievance cannot be resoled within 7 days, the hospital will provide a written acknowledgement within that time period. IN the acknowledgement, the hospital will notify the complainant of the expected period of time (in most case, 30 days) needed in order to resolve the grievance.

Based on staff interview and document review, it was determined the facility's patient visitation policy failed to address the use of behavior contracts to restrict visitation privileges. Additionally, the facility failed to document the behavior that met the hospital's policy for limiting visitation (Visitor A) for Patient #5.

Findings:

The medical record for Patient #5 contained documentation that the patient was hospitalized several times since November of 2023 with the most recent hospital admission occurring September 19, 2024. The hospital ethicist documented in Patient #5's medical record on September 19, 2024 (for the most recent hospitalization) that Visitor A requested overnight visitation, but due to a prior behavioral contact, would only be permitted to visit until evening hours, not overnight.

The surveyor requested evidence of the behavioral contract and visiting restrictions referenced in the above noted medical documentation for Visitor A. The hospital was unable to provide a written behavioral contract.

An interview was conducted with Staff Member #13 at 11:15 AM on October 01, 2024. Staff Member #13 stated Visitor A was presented a written behavior contact earlier in the year but refused to sign it. Staff Member #13 was asked about hospital policies regarding behavior contracts for visitors. Staff Member #13 stated, "I don't really know how it works."

An interview was conducted with Staff Member #17 on October 01, 2024. Staff Member #17 stated that behavioral contracts were implemented with visitors to outline the expectations of visitor behavior at the hospital and may be used to restrict or limit visitation based on visitor behavior. Staff Member #17 stated that the ethics team creates these agreements, gives them to the visitor, and the visitor can decide or not to take the written copy of the agreement.

An interview was conducted with Staff Member #28 on October 01, 2024. Staff Member #28 stated there was no hospital policy related to behavior contracts for visitors. Staff Member #28 stated these contracts are usually not written, and are merely a restatement of hospital expectation of visitor behavior that are already posted on signs throughout the hospital and in patient rights documents. These behavior contracts and concerns with visitor behavior are regularly re-evaluated and are in effect for a particular hospital admission, not indefinitely. Staff Member #28 stated that ethics staff can make recommendations about visitation, but has no authority to restrict patient visitors. This decision is left to unit leadership. Staff Member #28 stated that if a visitor is no longer displaying threatening or disruptive behaviors, they should be permitted to visit.

Staff Member # 9 was interviewed on October 01, 2024 regarding visitation on the unit Patient #5 had been admitted to in September 2024. Staff Member #9 stated that all patients were permitted visitors. Overnight visitors from 11:00 PM - 8:00 AM were limited to one (1) visitor per patient. Staff Member #9 stated that Patient #5 was not permitted to have Visitor A overnight, but could have a different visitor of their choosing. Staff Member #9 stated that these restrictions had been put in place close to a year ago prior to their working on the unit and had not been revisited to their knowledge.

The medical record for Patient #1 contained documentation regarding a written behavioral agreement dated August 29, 2024 for Visitors B and C. The written agreement states that both Visitors were asked to leave the hospital and not return before 9:00 am the following day. Additionally, the behavioral agreement stated that if any phone calls are received from those visitors prior to that time, visitation will be limited until 4 PM.

The hospital's policy, "Visitation: Open Visiting Hours" was reviewed and reads in part:

"Limitations:

...Respectful behavior 1. Out of respect to all our patients, visitors are requested to refrain from the use of loud voice or inappropriate language (for example, foul language), offensive comments, and behaviors that undermine a culture of safety. a. An INOVA healthcare provider, administrator, or security officer has the right to ask visitors who are undermining the culture of safety, non-compliant visitors and those whose behavior is not conducive to a healing environment, to leave the patient care unit."

The hospital did not have a written policy for the use of the behavior contracts outlined above to restrict visitation. Also, the hospital did not have a written policy that describes the content of these contracts and who could implement them. Additionally, the reported behavioral contract for Visitor A was not available for review.