The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on record review and interview, the facility failed to have a specific timeframes for response to patient grievances.

Findings included:

Review of the facility policy-Patient Grievance (Complaint), dated as revised 11/2008, showed the policy did not have a specific timeframe to respond to patient grievances.
Review of the facility policy-Patient Concerns/Complaint, dated as revised 09/2010, states in the procedure "if no satisfactory resolution is reached for the patient, a letter will be sent by the administrator addressing the concern." It did not have a time timeframe for response to the patient.

During review of the policy on 12/27/12 at 4:30 p.m., the risk manager confirmed there was no specified timeframe found.
Based on record review and interview, the facility failed to ensure 2 of 6 staff applying physical restraints received periodic training (A & B); and failed to ensure staff received training prior to applying restraints to 1 of 4 patients with restraints used during their hospital stay (#10).

Findings included:

Review of the security report, entirely written by security staff A, stated on December 1, 2012 at around 2:14 a.m.: "a Code Gray was called out over the intercom at ORMC for room 806. As I (staff A) arrived to the 8th floor I saw a nurse waving me down the hall, as I approached her I could hear shouting coming from around the corner. When I came upon the group I observed a .... (patient #10) in blue jeans and no shirt stumbling down the hall pushing the nurse staff off of him. I stated to the patient to refrain from pushing the nurse staff members and he refused. At this time I stepped in between the patient and hospital staff to prevent any injuries from occurring. I then grabbed ahold of his hands to prevent him from hitting me and the staff members because he was still being combative. Also his fiance got ahold of his hand and would not release him so I told her "Madam, you are hindering me and I need you to let go," she stepped back and I was able to get a proper hold on the patient. As I turned the corner with the patient to escort him back to the room (security) officers (F & B) arrived on the scene. At this point the patient was compliant but as we entered room 806 the patient became combative and attempted to leave the room again. So I had to physically restrain him by grabbing ahold of his arms to prevent him from leaving. At this time the patient was still resisting by kicking out at us and trying to force himself off the bed. When officers (D, C & E) arrived we placed the patient in 4 point restraint and left the room. No injuries reported. End of the report. Reporting officer: Staff A."

Review of the assistant nurse manager statement dated 12/01/12 (and on duty) at 1:50 p.m. read: "Patient (#10) began having a grand mal seizure @ approximately 01:50 a.m. per pt.'s wife. She called staff for assistance. After seizure ended. pt. slept for 5 minutes. Wife warned me to be careful because when he comes out of seizures, he is very combative. Left the room and again she called for help. Pt. observed to be getting out of bed and pushing her. Called Code Gray. Pt. got back in bed with staff assist but again tried to get back up. He was unsteady on his feet, pushing wife. She continued to call for help as pt. ambulated down hall with an unsteady gait. Unable to re-direct or reason with pt. Protective services arrived as pt. began to get more combative. Pt. restrained with 4 point locked restraints."

Review of statement from the registered nurse caring for patient #10, dated 12/01/12 at 2:39 a.m., read: "Pt. in room 806 had a seizure at about 1:50 a.m. after getting the patient stable and comfortable while he was still sleeping, the nurses exited the room. The pt. wife/girlfriend called out about 2-3 minutes later asking for help. Upon entering the room again the patient was trying to get out of bed. Pt. wife repeatly told him to stay in bed. He continued to get out of bed pushing her and attempting to exit the room. The pt. got back in bed calmly for 2-3 mins., and again attempted to storm out of the bed and out the room. Security was called and the other nurses and I followed him down the hall. We repeatly tried to calm him while keeping a distance. Security arrived and walked the patient back to his room and restrained him to the bed."

During a phone interview on 12/27/12 at 4:27 p.m., the security supervisor said usually security staff would assist staff with restraining a patient if necessary. Normally, security staff would apply the restraints to the patient for nursing staff. He also said security staff receive restraint training at hire, but unless they had difficulties, there is no on-going or periodic training.

Review of the security human resources file for the security staff involved with the restraint event showed the following. Security A was hired 10/17/12; still in the 90 day training period, has not completed restraint training yet. Staff A was the first responder to the Code Gray. Security B was hired 9/19/12; still in the 90 day training period during the 12/01/12 event.

Review of the New Hire Team Member 90 day Introductory Appraisal showed completed restraint training as of 12/18/12. Restraint training was not completed on the day of the restraining event, 12/01/12.

During an interview on 12/27/12 at 4:30 p.m., the human resources consultant said newly hired staff have 90 days to complete required training. She also confirmed security officers A and B had not completed restraint training as of 12/01/12.

Review of the facility policy "Restraints Use in the Acute Care Setting" dated as revised 6/2012, read, "Outlines the procedure for use of a restraint in the acute care setting. Definitions - Qualified Staff: Those staff who received education/training and demonstrate competence in the safe use of restraint. Policy: educate staff to demonstrate competency in safe use of a restraint."

Review of the facility policy "Crisis Assistance (Violence) in an Acute Care Unit Plan (Code Gray)" dated as revised 2/2012, read in the procedure: "If the call for crisis assistance involves a patient who it is determined by medical staff to need restraints, Security team members will comply with Reference B (which is the facility restraint policy).