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 provide written notice of its decisions and steps taken to investigate the grievance for 1 of 1 patients (#1) who verbalized grievances out of a total of 6 sampled patients, resulting in increased risk of all patients being denied written notice of the results of grievance investigations. Findings include:

Policy Review:
On 5/31/17 at 1400 a review of the facility's "Patient Concerns and Grievances" policy, MH-01.1, dated 01/15/2013, documented:
Grievance-A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospitals compliance with the CMS Hospital Conditions of Participation, or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 XFR 489.

Receipt of Grievance-
B. 3. The Office of Recipient Rights will conclude all grievances, including those with allegations of abuse and neglect, in seven (7) days, unless extensive investigations is required, in which case the ORR will notify the grievance in writing and inform him or her when the investigation will be resolved and that the conclusion of the investigation will not exceed thirty (30) days from the day that it was received.
B. 5. If the Recipient Rights Advisor is not able to resolve the grievance to the grievant satisfaction the grievant will be advised their grievance will be reviewed by the Grievance Committee.

Record Review and Interview:
On 5/31/17 at 1430 a review of the facility's complaint and grievance logs titled (Patient Concerns Summary Report) dated 1/2017 through 5/2017 was conducted with Recipients Rights Staff D. A concern was received on 4/11/17 and closed on 4/13/17 that was "not substantiated." The concern documented patient #1 "was punched unprovoked from behind by a male peer, in which he suffered a broken tooth and bruised lip". When queried Staff D explained that she had been in her role for less than 2 months and was not aware of the particular grievance. When further queried regarding if "not substantiated" indicated the patient had acceptable the facility's response to their investigation Staff D explained it was only their responsibility to determine if the facility was at fault or not for the concern. When asked to provide written evidence that patient #1 had received written correspondence that documented the investigation was resolved. Staff D stated, "I don't have anything else."

On 6/1/17 at approximately 1100 an interview was conducted with the Chief Operating Officer Staff A. When queried regarding patient #1's grievance Staff A explained that he had internal electronic mail that indicated the patient wanted to be compensated for his broken tooth. When asked to provide evidence that documented the patient received and accepted the facility's response to the investigation. Staff A stated, "I will look to see if the previous Recipient Rights Office Staff K may have filed it somewhere else.

On 6/1/17 at 1150 Staff A explained he only had internal mails that documented the patient wanted to know who was going to pay for his dental work.

On 6/1/17 at 1305 a phone interview was conducted with the former Recipient Rights Staff L. Staff L explained she had spoken to patient #1 on almost every 2-3 days following the altercation on 4/10/17. Staff L stated, the patient always asked how were they (the facility ) was going to go about with getting his tooth repaired. Staff L said the patient had a hard time grasping what he should do. When asked to explain if the grievance investigation was on-going she stated, "No. It was closed on 4/13/17." When asked to explain how the grievance was resolved if the patient continued to asked her every 2-3 days who was going to take care of his broken tooth, Staff L stated, "I told him to go to his insurance company."
When asked to explain if she had provided the patient with written notice of its resolution of the grievance Staff L reiterated the patient had trouble grasping what he should do.

Additionally, the facility failed to provide evidence of its resolution of the grievance that documented the patient had received written notice of their decision prior to the exit of the survey.

Based on interview and record review, the facility failed to follow their policy for monitoring patients while in restraints for 1 (#5) of 2 patients reviewed for restraints out of a total of 6 sampled patients, resulting in the increased potential for less than optimal outcomes.
Findings include:

On 5/31/17 at 0950 while accompanied by Registered Nurse (RN) Nurse Manager Staff F a tour of the 3rd floor nursing unit was conducted. Staff F explained there were no patient's currently restrained. A review of the restraint/seclusion logs revealed patient #5 had been restrained 3 times during his admission to the facility.

On 5/31/17 at 1130 a review of patient #5's medical record was conducted with Registered Nurse (RN) Nurse Manager Staff F. Patient #5 was [AGE] year old male admitted to the facility on [DATE].

Physician's orders for 4 point restraints for patient #5 were dated for 5/16/17 at 0620, on 5/18/17 at 1155, and on 5/19/17 at 0305.

Further review of the medical record revealed patient #5 was restrained on the following dates and times.
On 5/16/17, the patient was restrained between the hours of 0620 and 0645 (25 minutes).
On 5/18/17, the patient was restrained between the hours of 1145 and 1415 (2 hours 30 minutes).
On 5/19/17, the patient was restrained between the hours of 0305 and 0545 (2 hours 40 minutes). However, there was no evidence in the medical record that documented patient #5 was monitored by the Registered Nurse every hour on 5/18/17 nor on 5/19/17.

On 6/1/17 at approximately 1145 an interview and record review was conducted with the Chief Nursing Officer Staff (B).
When queried Staff B explained it was the Registered Nurses responsibility to monitor patients who were restrained every hour and document their assessments.

On 6/1/17 at 1130 a review of the facility's "Restraints and Seclusion" Policy 2.4, dated 08/23/2013, documented:
VI. Placing a Patient in 4-Point Restraint
"...10. A Registered Nurse monitors the patient frequently and documents the patient's status every one (1) hour. This assessment includes, but is not limited to, ensuring adequate circulation, full range of motion, condition of skin, security of restraints, and proper body alignment."
IX. Documenting the Restraint Episode
"...8. The RN will document the following on the BACK of the SECLUSION/RESTRAINT DOCUMENTATION FORM:
a. Initial progress note describing specific patient behavior. Interventions/alternatives used and/or considered prior to application, all calls to physicians and criteria for discontinuation discussed with the patient
b. RN ongoing assessment supporting continuous need or release from restraint/seclusion every one (1) hour."