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Based on record review and interviews with hospital staff, the hospital failed to ensure complaints alleging patient neglect and harm are treated as grievances and are investigated as part of the hospital's grievance process and all complaints/grievances are incorporated in the hospital's Quality Assessment and Performance Improvement Program (QAPI). One of one allegations of neglect and harm was not entered into the hospital's grievance process, investigated and a written response sent to the complainant. The hospital's QAPI meeting minutes for 2012 did not have any evidence of review of complaints and grievances.

Findings:

1. An allegation of neglect and harm received by the health department and also received by the hospital was not entered into the hospital's grievance process, investigated and a written response sent to the complainant.

2. Review of the hospital's QAPI meeting minutes for 2013 did not have review of the hospital's grievances. The QAPI dashboard had a catagory titled grievances, but there was no data entered.

3. Hospital Staff C stated on 08/19/13 in the afternoon that the hospital had received the complaint by telephone and he had talked to the complainant the next day after discharge. He stated he had not entered the complaint in the hospital's grievance process.

4. Two (C & F ) of four nursing personnel files reviewed did not have evidence of restraint training and one (G) of four did not have evidence of current restraint training.

Based on review of hospital documents and training documentation provided, it was determined that the hospital failed to train staff and verify competency for the use of all restraint devices within the hospital. This occurred in three of four ( C, G, and H ) employee files reviewed.


Findings:

A hospital policy, titled, " Restraints, " documented, " ...All staff that has direct patient contact shall receive education and training in the proper use of restraints during orientation and on an annual basis thereafter ... "

Employee training data was provided to surveyors and reviewed on 8/19/2013. Three (C, G, and H ) of four personnel, who provide active patient care and whose personnel training records were reviewed, did not have current restraint training. This finding was discussed with Staff A, B, and C. No further documentation was provided

Based on review of patient medical records, hospital documents and staff interview, the hospital failed to:

a. Develop a death reporting policy that addressed the requirements of reporting to CMS (Centers for Medicare and Medicaid Services) and the documentation required.

b. Report deaths associated with the use of restraints to CMS. This occurred in one of one (#2) patients who died while restrained.

c. Ensure the medical record contained documentation of the date and time CMS was notified of the death of a patient during the use of restraints.

Findings:

1. The restraint and seclusion policy did not provide guidance to staff regarding the requirements of reporting restraint deaths to CMS and charting the information with date and time in the patient's medical record. Staff B confirmed this finding.

2. The surveyors requested the hospitals tracking log for deaths in restraints, none was provided. Staff B confirmed the hospital does not track deaths in restraints.

3. Review of hospital documents showed no evidence of reporting Patient #2's death to CMS. This was confirmed by Staff B on the afternoon of 8/19/2013.