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Based on interview with the Acting Chief Nursing Officer, review of the Complaint Policy and review of 1 randomly selected patient complaint, the Hospital failed to ensure that response letters were formulated to the complainant identifying the steps taken in the Hospital's investigation and the outcome of the investigation.

Findings include:

The Complaint Policy/Procedure, reviewed 1/5/12, indicated that the Unit Manager screened all complaints for resolution and responded in writing to all complainants. The written response described the steps taken on behalf of the patient to investigate the complaint and the results of the complaint process. When a final resolution could not be determined within 7 days, the written response described the steps underway to complete the process and the estimated date of completion.

The Surveyor requested a complaint, dated 7/16/12, to review that was filed by Patients #12 and #13, young siblings, who complained that their personal computers had blocks to certain sites that Patients #12 and #13 did not authorize to be placed.

Review of the complaint investigation indicated that the complaint was being investigated and a resolution had not yet been determined. There was no evidence that a written response had not been sent to the Complainants.

The Surveyor interviewed the Acting Chief Nursing Officer (CNO) on 8/2/12 at 7:00 A.M. The Acting CNO said that when she reviewed the complaint file and determined that a response letter had not been sent, she looked at other complaint files and discovered that noone at the Hospital was providing response letters to any of the complainants.

Based on review of Patient #1's clinical record, review of the Hospital's investigation and interview with the Day Supervisor, Nurse #1 and Certified Nurse Aide (CNA) #1, the Hospital failed to ensure that the shower room door was closed while CNA #1 was cleaning to prevent Patient #1 and other patients from entering, falling and fracturing his/her hip.

Findings include:

The Demographics Sheet indicated that on 8/23/11, Patient #1 was admitted to the Dementia Unit and diagnoses included dementia (reduced blood flow to the brain resulting in impaired cognition and functioning).

The Post-Fall Assessments, dated 1/18/12 to 4/28/12, indicated that Patient #1 had a history of falling.

The Behavior Tracking, dated 5/3/12 to 5/26/12, indicated that Patient #1 displayed behaviors such as grabbing, intrusiveness, threatening and agitation.

The Nursing Reassessment, dated 5/13/12, indicated that Patient #1 walked independently.

The Behavior Tracking, dated 5/26/12 at 10:00 P.M. indicated that Patient #1 was walking in the hallway, yelling, swearing, and wondering why people were in his/her house.

The Surveyor interviewed Nurse #1 on 8/2/12 at 2:25 P.M. Nurse #1 said she was the Charge Nurse on 5/26/12. Nurse # 1 said she observed Patient #1 walking down the hallway in an agitated state and charging at people. Nurse #1 said that CNA #1 was cleaning the shower room and the door was propped open.

The Surveyor interviewed CNA #1 on 7/31/12 at 11:30 A.M. CNA #1 said that he was cleaning the shower room which included mopping the floor. CNA #1 said he propped the shower room door open while he was cleaning. CNA #1 said that Patient # 1 entered the shower room, started to back out, lost his/her balance and fell onto his/her buttocks.

The Interdisciplinary Notes (Notes), dated 5/27/12 from 6:17 A.M. to 1:30 P.M., indicated that Patient #1 was experiencing right hip pain, the Attending Physician was notified and ordered a right hip x-ray. The Notes indicated that the right hip x-ray was positive for a fracture and Patient #1 was transferred to an acute care hospital for further treatment.

The Surveyor toured the Dementia Unit on 7/31/12 at 11:40 A.M. with the Day Supervisor present. The Surveyor observed that all doors to common areas, such as the shower room, were closed and locked.

The Day Supervisor said the shower room door was to be kept closed and locked at all times for safety to prevent patients from entering the shower room and injuring themselves.

Based on observations of Patient #2, Patient #11 and the Dementia and Transitional Units, review of Patients #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11's clinical records and review of the Restraint Policy, the Hospital failed to ensure that restrictive devices used to enable feeding, provide patient safety or provide comfort/rest periods were appropriately classified as restraints.

Findings include:

PATIENT #2:

The Surveyor conducted tours of the Dementia Unit on 7/31/12 at 8:15 A.M. and 11:40 A.M. and on 8//2/12 at 11:00 A.M. with the Day Supervisor and Acting Chief Nursing Officer (CNO) present.

During the tour of the Dementia Unit conducted on 7/31/12 at 8:15 A.M., interview with the Day Supervisor and observation of Patient #2 indicated that Patient #2 compulsively ambulated the Unit and did not voluntarily stop for meals and/or rest periods. Patient #2 would ambulate to the point of exhaustion, putting his/herself at risk for injury.

Observation of the noontime meal on 7/31/12 at 11:40 A.M. indicated that a staff member was assigned to the Solarium where Patient #2 was seated in a highback wheeled chair with a Velcro belt on. Observation indicated that Patient #2 was fidgeting with the Velcro belt, but was unable to purposefully release the Velcro belt.

The Policy/Procedure titled Restraints, dated 12/21/09, indicated that a restraint was any manual method, physical/mechanical device, material or equipment that immobilized or restricted the patient's mobility. All restraint use required an assessment to identify medical problems that may be causing behavioral changes, identification of less restrictive interventions that have been determined to be ineffective and a physician's order that included the device, the specific reason for use and the time frame for use. The physician order for a restraint used for medical purposes was to be renewed every day. Restraint use must be documented on the Restraint Record.

The History and Physical (H&P), dated 1/5/12, indicated that Patient #2 had a diagnosis of Dementia with agitation and severe cognitive impairment. The H&P indicated that Patient #2 compulsively ambulated when not in bed. The H&P indicated that staff had difficulty keeping Patient #2 stationary during meals and attempts were made to feed Patient #2 while he/she was ambulating. The H&P indicated that although Patient #3 was exhausted, he/she continued to ambulate with eyes closed, leaning to the right with the head tilted back.

The H&P, dated 1/5/12, indicated that Patient #1's family agreed that Patient #1 could be placed in a chair with a Velcro belt during meals to prevent choking/aspiration.

The Physician Order, dated 1/26/12, indicated that Patient #2 was to be continually supervised while in the chair for meals.

The Physician Order, dated 4/27/12, indicated that rest periods in the chair with the seat belt were to be instituted for 30 minutes twice a shift with constant supervision.

The Interdisciplinary Treatment Plan regarding falls risk and self-care deficit with adverse behaviors, dated 1/23/12 and updated 4/27/12, indicated that Patient #2 was to be seated in a chair with a Velcro seatbelt to prevent choking/aspiration for a maximum of 30 minutes and for rest periods for 30 minutes twice a shift under constant supervision.

The Interdisciplinary Treatment Plan, updated 7/3/12, indicated that if Patient #2 became restless in the chair, stop feeding and reapproach in 5-10 minutes, but did not address removing the Velcro belt (restraint).

Review of Patient #2's clinical record regarding compliance with the Restraint Policy indicated that the record did not include: identification of less restrictive interventions that have been determined to be ineffective, daily renewal of the physician's order and documentation on the Restraint Record the periods of time during which the velcro belt was applied.

The Day Supervisor and the Acting CNO said that the steps outlined in the Restraint Policy were not followed.


PATIENT #11:

The Face Sheet indicated that Patient #11 was admitted to the Hospital on 10/5/11.

The Admission H&P, dated 10/5/11, indicated that Patient #11 had a diagnosis of Advanced Huntington's Disease (a progressive neurological disease that affects the patient's ability to care for self and move) and was housed in a Posey net bed so that he/she did not throw his/herself out of the bed.

Observations during the tour of the Transitional Care Unit on 8/2/12 at 11:00 A.M. with the Acting CNO indicated that Patient #11 used a Posey net bed (a bed with a concave mattress. All sides of the bed were padded and a net tent enclosed the the mattress which unzipped to take the patient in/out of the bed). Observation of Patient #11 indicated that Patient #11 had severe choreic movements (involuntary spasmodic twitching or jerking in muscle groups not associated with the production of purposeful movements). Patient #11's spouse, present at the time, said that the Posey net bed kept Patient #11 safe and free from injury and was comforting to Patient #11.

The Acting CNO said that Patient #11's spouse had advocated for the bed due to Patient #11's history of falls out of bed related to his/her movements. The Acting CNO said that Patient #11's chorea was so severe that he/she would end up in the opposite direction from when first put in bed.

The Physician Order, dated 10/12/11, included an ongoing order for the Posey net bed.

The Interdisciplinary treatment Plan regarding self-care deficit, dated 11/17/11 and updated 7/12, included net bed along with hourly checks to ensure Patient #11 was lying away from the netting.

Review of Patient #11's clinical record indicated that there was no assessment of Patient #11's use of the Posey net bed to determine if continued use was appropriate, no identification of less restrictive interventions attempted and determined to be ineffective, the physician's order did not specify the reason and time frame for use and a Restraint Record was not maintained to indicate the times the Posey net bed was in use and its effectiveness.


DEMENTIA UNIT SOLARIUM:

Observations during the tours of the Dementia Unit on 7/31/12 at 8:15 A.M. and 11:40 A.M. and on 8/2/12 at 11:00 A.M. with the Day Supervisor present indicated that the Solarium contained five Enfold chairs, chairs that were scoop shaped with a concave seat and paired with an unevenly-shaped ottoman to form an S-shape. Observation indicated that when a patient sat in the Enfold chair, they were in a semi-reclined position with their knees elevated.

Interview with the Acting CNO indicated that the chairs were used by patients on the Dementia Unit for rest periods as they requested or as needed.

The Surveyor interviewed the Rehab Director in person on 8/2/12 at 10:15 A.M. The Rehab Director said that Patients #3, #4, #5, #6, #7, #8, #9 and #10 were not evaluated for use of the Enfold chair to determine if they were able to get in/out of the Enfold chair independently or if the Enfold chair restricted their mobility, thereby serving as a restraint.

Review of the clinical records for Patients #3, #4, #5, #6, #7, #8, #9 and #10 indicated that Patients #3 through #10 were not assessed to determine if the Enfold chair were: 1) restraints/restrictive devices, 2) not ordered by the physician, 3) not addressed in the plan of care and 4) when in use, were not documented on the Restraint Record.