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Based on review of 10 complaint and grievance files, it was determined that in 5 out of 10 files the hospital failed to provide the patient written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

The hospital policy under grievance states any verbal complaint that cannot be resolved in 24 hoours by staff present shall be considered a grievance. All written complaints shall be considered grievances.

Based on review of written grievance/complaint file for patient #3 the hospital failed to notify the patient of receipt of her complaint nor notify the patient by letter of the grievance resolution. Four other grievances could be found on the complaint and grievance log but no documentation that letters were sent to the complainant that there grievances were received nor a resolution letter once the investigations was completed.

Patient #3 is a 41 year old female admitted to Potomac Ridge Adventist Behavioral Health on 4/1/09. The patient's lab work for RPR was positive which meant the patient had possibly been exposed to syphilis. The patient complained that on 4/8/09, she was informed of some information regarding her positive blood results in front of of the nurse's station where other patients and the nurses could hear. She stated the person was an Indian nurse but in fact the investigation identified the individual as a physician. The Patient Advocate notified the Medical Director via e-mail of the patient grievance against the physician and ask that the grievance be addresed. The complaint/grievance log documented the actions taken on behalf of the patient but the complaint file revealed no written acknowledgement to the complainant nor response letter regarding resolution of the grievance.

Based on record review, the facility failed to terminate Patient #1's seclusion at the earliest possible time.

Patient #1 was placed into seclusion from 7:15 pm to 9:15 pm according to the facility's Care and Observation Code form. His behavior was documented as "mumbling incoherently" from 7:15 pm through 7:45 pm and from 8:15 pm through 8:30 pm, and as "lying or sitting" at 8:45 pm, and finally as "sleeping" at 9:15 pm at which time he was noted as being "out of seclusion." However, "mumbling incoherently" and "lying or sitting," behaviors which constituted the majority of Patient #1's time in seclusion, do not indicate that the patient's behavior is a threat to the immediate physical safety of the patient, a staff member, or others.

A reveiew of the facility's staff training revealed that the hospital failed to document Staff #1's completion of the annual Mandt (behavior management) competency as evidenced by:

Staff #1 had been employed at the facility for the last four years. During review of Staff #1's personnel file, it was noted that Staff #1's computerized training record failed to demonstrate that they had ever completed the required annual Mandt training since their hire date four years ago.

Based on review of the medical record it was determined that the facility nursing staff failed to assess as soon as possible, or at the cessation of the restraint episode, Patient #1's documented physical injuries as evidenced by:

Based on record review, Patient #1 was physically held on 9/19/09 from 7:42 pm to 7:45 pm in order to receive IM medication. The RN entered a nursing noted into the record stating that the patient physically resisted staff and might have hit his face against the cement wall. The RN also documented "slight bleeding from mouth" on the Seclusion and Restraint Record and also that she was unable to closely examine the patient because of his level of violent behavior. Based upon review of medical record there is no documented evidence in the record that Patient #1 ever received any medical assessment or followup for this injury.