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Based on a review of policies and procedures, complaint/grievance reports, and personnel interviews, the hospital failed to provide the patient with written notice of its decision that containined 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. Four of four grievances (Pt's 1,2,3,4) reviewed did not contain a written response to the complainant containing the required elements.

1. The morning of 12/2/2010 surveyors reviewed the complaint/grievance log. Four of four (Pt's 1,2,3,4) complaints reviewed in the log could not immediately be resolved at the time of initiation of complaint. Four of four (Pt's 1,2,3,4)
grievances were marked resolved on the grievance log, but there was no written response to the complainant. Hospital Staff D stated in the afternoon of 12/2/2010 that the hospital believed the grievances/complaints were resolved before the patient/complainant had been dismissed from the hospital. Staff D also stated that the hospital believed since they had been resolved during the patient's hospital stay they did not require a written response even though they did not meet the requirement that the complaint is resolved at the time of the complaint by staff present. These complaints required an investigation and were not resolved at the time of the complaint by staff present.

2. This finding was presented to administration at the exit conference. No further documentation was provided.

Based on review of medical records, review of policy and procedure, and staff interviews the hospital failed to identify the use of medication to manage patient's behavior as a chemical restraint.

Findings:

1. Patient #1 is a 86 year old female admitted to the facility on 6/24/10 with gastrointestinal bleeding, peptic ulcer disease, and septic shock secondary to methicillin resistant staph aureus infection. On 7/3/10 documentation by nursing indicated Patient #1 "has become extremely agitated, paranoid, and angry." Documentation also indicated Patient #1 was combative and attempting to get out of bed. None of the nursing documentation stipulated any measures were used to reorient or redirect Patient #1. There was no documentation there had been an assessment of the patient's condition which might be triggering the abnormal behavior. At 0315 on 7/3/10 a verbal order for "Haldol 5mg IM q 2-4 hours prn agitation" was received by Staff D. The order was given by the "on call physician". Haldol was not listed on the patient's medication reconciliation list or admission medications. There was no documentation the patient had ever needed or received Haldol prior to this admission. There was no documentation Patient #1 had been assessed by a qualified professional prior to the administration of Haldol. On 7/5/10 documentation in the physician progress notes indicated Patient #1's daughter asked the attending physician why the patient received Haldol. The physician documented "you will have to ask the doctor who took the call that night". The hospital failed to identify the use of the medication as a chemical restraint.

2. In the morning on 12/02/2010 surveyors reviewed the restraint policy. There was no policy for use of medications as a restraint. Later that morning, surveyors met with Staff B. Staff B stated the facility did not train staff on the use of chemical restraint because they did not use chemical restraints for behavior management. The above findings were reviewed with Staff B. This information was also reviewed with Staff A, B, and C on the afternoon of 12/02/2010 during the exit conference. No further documentation was provided.

Based on review of hospital hospital documents and training documentation provided, and interviews with hospital staff, the hospital failed to ensure all staff who have direct patient contact are trained and kept current in the proper and safe use of restraints. Of the licensed personnel involved in patient #1's care, five of five (D,E,F,G,H) licensed personnel did not have training documented in their personnel file

Findings:

1. In an interview the morning of 12/2/2010, Staff B told surveyors chemical restraint was not used at the facility for behavior management. Review of the policy for restraint did not include use of medications as chemical restraint. This finding was discussed with Staff A, B, and C. No further documentation was provided

2. The hospital's policy required staff to be trained during initial hire orientation and annually thereafter in use of restraints. Employee training data were provided to surveyors and reviewed on the afternoon of 12/2/2010. Five of five personnel actively involved in the care of patient #1 did not have chemical restraint training. Staff D, who selected the type and initiated the restraints, did not have orientation or training in the use of chemical restraints. This was confirmed at the time with Staff B.