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 reviews and interview, the facility failed to ensure that for one of one patient's (Patient #1) significant other's complaint/grievance, a written notice of its decision was provided to the patient's significant other..

Findings included:

Record review on 02/12/14 of facility policy entitled Patient Complaint, last revised August 2011, revealed but was not limited to the following: "Procedure: The Administration will initiate an investigation into significant complaints that cannot be resolved immediately. The investigation and patient response will occur within 45 days of receipt of this type of complaint. The person making the complaint will be provided with a response addressing the facility's determinations regarding the complaint, the name of the individual at the facility to contact for further information and steps taken by the facility to investigate the complaint."

Record review on 02/12/14 of an email, dated 11/20/13, from the Chief Operating Officer to the Vice-President of Quality revealed but was not limited to the following: " On Monday November 18th a man presented himself in my office with a letter of complaint to the Administration. He was clearly angry and stated he had expected his complaint to be responded to by Administration after complaining to (another staff) two months ago about what he considered to be substandard and insulting treatment provided to his domestic partner when his partner was hospitalized at the (facility). He did leave a message for me to call the next day. I returned the call, apologized that he was dissatisfied with his care, and acknowledging that we would discuss the complaint with (the physician) and the director of the hospitalist program."

Interview on 02/12/14 at 8:05 AM by phone with Patient #1's significant other revealed he had filed a written complaint regarding the care received by his domestic partner while hospitalized at the facility. He stated he had not received a written reply regarding the outcome of his complaint..

Interview on 02/12/14 at 3:00 PM with the facility's Chief Operating Officer confirmed the complainant brought a written complaint to her office regarding the care Patient #1 received at the facility. She confirmed the facility looked into the complaint but the complainant was not provided a written decision regarding the outcome of the facility investigation regarding the care received by Patient #1.
Based on record reviews and interviews, the facility failed to ensure that for one of one patients (Patient #1) who required medically necessary restraints during his admission of 09/04/13 to 09/09/13, a physician's order was available for these restraints.

Findings included:

Record review on 02/12/14 of the Restraints Policy, last reviewed 10/2013, revealed but was not limited to the following: "All patients have the right to be free from restraints that are not medically necessary or are used for purposes other than patient benefit and safety. Restraint is defined as manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. The order for restraints will not be written as a PRN (as needed) order or a standing order. Any order for restraints must be in accordance with the order of a physician or independent licensed practitioner permitted by the state and hospital to order a restraint. The order for the restraint must specify the reason for the restraint, the type of restraint, the extremity or body part to be restrained, and the duration of the restraint."

Record review on 02/12/14 of Restraint Orders for Patient #1, dated 09/04/13 at 2310 PM and given by phone by Physician #1, revealed the following: "Attempt less restrictive measures including positioning, addressing comfort measures, companionship, adjusting lighting in the room, and redirecting patient focus. Reason for Medical/Post Surgical Restraint: Inability to respond to direct requests or to follow directions, picking, pulling or direct attempt to manipulate vital catheters, lines, and tubes, unsafe for self-ambulation, unsteady recent falls, impulsive, does not request assistance. Type: upper and lower extremity restraint. Time Limit: 24 hours (non-violent or non-self destructive). This was the only restraint order in Patient #1's medical chart.

Record review of Patient #1's Nursing Plan of Care revealed that upper and lower extremity restraints were applied to Patient #1 from 09/04/13 at 1800 PM to 09/07/13 at 1759PM and again on 09/07/13 at 2315 to 09/08/13 at 0758AM.

Interview on 02/12/14 at 3:30 PM with the facility Chief Nursing Officer revealed the Restraint Order, dated 09/04/13 at 2300, was the only Restraint Order available for Patient #1.