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Based on interview and record review, the hospital failed to implement its grievance and complaint P&P for one of four sampled patients (Patient 1) when Patient 1's grievance was not resolved within seven days, the patient was not notified that the hospital was still working to resolve the grievance, and the patient was not informed of the results of the grievance review or the date the investigation was completed. This failure posed a risk for delays in addressing patient concerns and not ensuring timely resolution of grievances.

Findings:

During a review of the hospital's P&P titled, "Grievance/Complaint Process," dated January 2023, the P&P showed "Patient Grievance is defined as a written or verbal concern (when verbal concern about patient care is not resolved at the time of the concern by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the ... compliance with regulatory agencies ... The grievance review process will assure that the grievance is investigated and in a timely manner. ... On average, a time frame of 7 days for the response will be considered appropriate. The patient will be provided with a written notice of:... the results of the grievance process ... the date the investigation was completed ... If we are unable to resolve the issue on the spot, within seven (7) calendar days following the grievance receipt, the patient will be informed of this fact and of the anticipated length of the investigation ... The hospital should inform the patient or the patient's representative in writing that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written final response, usually within 30 days."

On 9/10/25 at 1108 hours, medical record review for Patient 1 was initiated with the Director of PI.

Patient 1's medical record showed the patient was admitted to the hospital on 4/15/25 and discharged on 8/26/25.

Review of the hospital's Grievance Complaint Log 2025 showed the hospital received a grievance from Patient 1 on 7/23/25, and an acknowledgement letter was provided to the patient on 7/31/25.

Review of the acknowledgement letter dated 7/31/25, showed it was hand-delivered to Patient 1. The letter indicated the hospital was currently investigating Patient 1's concerns.

During an interview on 9/10/25 with the Director of PI, the Director of PI verified the grievance had not been resolved within 7 days as per the hospital's P&P. Additionally, the patient was not notified in writing that the hospital was continuing to investigate the grievance and would follow up with a final written response within 30 days. The patient was also not informed of the results of the grievance review or the date the investigation was completed, as required by the hospital's P&P.

Based on interview and record review, the hospital failed to ensure that the plan of care for one of four sampled patients (Patient 3) was updated to reflect the use of restraints. This failure posed a risk of substandard outcomes for the patient.

Findings:

Review of the hospital's P&P titled Restraints: Violent Behavior or Seclusion dated June 2023 showed the use of restraint or seclusion is in accordance with a written modification to the patient's plan of care. Use available restraint flow sheets and order forms and narrative notes to document all pertinent information in the electronic medical record including but not limited to plan of care/treatment plan.

During a concurrent interview and record review on 9/11/25 at 1100 hours, with the Director of PI and the ED Manager, Patient 3's medical record was reviewed. Patient 3's medical record showed the patient was admitted to the hospital on 8/27/25 and discharged on 8/28/25.

During a review of the ED Notes dated 8/27/25 at 2136 hours, the ED Notes showed a Code Gray was called due to Patient 3 cursing at staff, attempting to elope, squaring up, posturing, and swinging at staff.

Review of Patient 3's Restraints Violent or Self-Destructive STAT order dated 8/27/25 at 2136 hours, showed to initiate 4-point locked restraints due to imminent risk of harm.

During a review of Patient 3's Violent or Self-Destructive Restraint Flowsheet, the Flowsheet showed the restraints were discontinued on 8/28/25 at 0550 hours.

However, further review of Patient 3's medical record did not show Patient 3's plan of care was updated to reflect the use of restraints.

On 9/11/25, the Director of PI and the ED Manager verified the findings.

Based on interview and record review, the hospital failed to ensure the nursing staff documented the initiation time, type, and location of the restraints for one of four sampled patients (Patient 3). This failure could create the risk of substandard outcomes for the patient.

Findings:

Review of the hospital's P&P titled Restraints: Violent Behavior or Seclusion dated June 2023, showed to use available restraint flow sheets and order forms and narrative notes to document all pertinent information in the electronic medical record.

During a concurrent interview and record review on 9/11/25 at 1100 hours, with the Director of PI and the ED Manager, Patient 3's medical record was reviewed.

Patient 3's medical record showed the patient was admitted to the hospital on 8/27/25 and discharged on 8/28/25.

During a review of the ED Notes dated 8/27/25 at 2136 hours, the ED Notes showed a Code Gray was called due to Patient 3 cursing at the staff, attempting to elope, squaring up, posturing, and swinging at the staff.

Review of Patient 3's Restraints Violent or Self-Destructive STAT order dated 8/27/25 at 2136 hours, showed to initiate 4-point locked restraints due to an imminent risk of harm.

During a review of Patient 3's Violent or Self-Destructive Restraint Flowsheet, the Flowsheet showed the restraints were discontinued on 8/28/25 at 0550 hours. An entry dated 8/27/25 at 2202 hours, documented the less restrictive alternatives attempted, the clinical justification for restraint use, and the criteria for discontinuation. However, there was no documentation indicating when the restraints were initiated, the type of restraints applied, or the specific location (e.g., bilateral wrists and ankles) to which the restraints were applied.

On 9/11/25, the Director of PI and the ED Manager confirmed the findings. The ED Manager stated the nurse was expected to document the time of restraint initiation, the type of restraints applied, and the location on the patient's body where the restraints were placed, such as bilateral wrists and ankles.

Based on interview and record review, the hospital failed to ensure the use of restraints for the management of violent or self-destructive behavior was renewed within four-hour for one of four sampled patients (Patient 3). This failure posed a risk of unnecessary restraint use and substandard outcomes for the patient.

Findings:

During a review of the hospital's P&P titled Restraints: Violent Behavior or Seclusion dated June 2023, the P&P showed for the continuation of restraints or seclusion, all telephone or written orders are time limited as follows: 4 hours for adults.

During a concurrent interview and record review on 9/11/25 at 1100 hours, with the Director of PI and the ED Manager, Patient 3's medical record was reviewed.

Patient 3's medical record showed the patient was admitted to the hospital on 8/27/25 and discharged on 8/28/25.

During a review of the ED Notes dated 8/27/25 at 2136 hours, the ED Notes showed a Code Gray was called due to Patient 3 cursing at the staff, attempting to elope, squaring up, posturing, and swinging at the staff.

Review of Patient 3's Restraints Violent or Self-Destructive STAT order dated 8/27/25 at 2136 hours, showed to initiate 4-point locked restraints due to an imminent risk of harm.

Review of Patient 3's physician orders showed that the next restraint order was not entered until 8/28/25 at 0215 hours, more than four hours after the initial order.

Review of Patient 3's Violent or Self-Destructive Restraint Flowsheet showed the restraints were discontinued on 8/28/25 at 0550 hours.

During an interview on 9/11/25 with the Director of PI and the ED Manager, the Director of PI and the ED Manager confirmed that the continued use of restraints was not renewed within the required four-hours timeframe as per the hospital's P&P.

Based on interview and record review, the hospital failed to ensure the nursing staff reassessed and monitored one of four sampled patients (Patient 3) while the patient was in restraints as per the hospital's P&P. This failure had the potential to result in unsafe care for the patient.

Findings:

During a review of the hospital's P&P titled Restraints: Violent Behavior or Seclusion dated June 2023, the P&P showed a staff who is trained and competent assesses the patient at the initiation of restraint or seclusion and periodically thereafter to include as appropriate to the type of restraint or seclusion and patient condition:
- Every 15 minutes: assessment of psychological status/behavior, physical and psychological comfort, circulation, and continuous observation.
- Every 2 hours: assessment of skin care and range of motion in the extremities, nutrition and hydration, hygiene and elimination, and vital signs.

During a concurrent interview and record review on 9/11/25 at 1100 hours, with the Director of PI and the ED Manager, Patient 3's medical record was reviewed.

Patient 3's medical record showed the patient was admitted to the hospital on 8/27/25 and discharged on 8/28/25.

During a review of the ED Notes dated 8/27/25 at 2136 hours, the ED Notes showed a Code Gray was called due to Patient 3 cursing at the staff, attempting to elope, squaring up, posturing, and swinging at the staff.

Review of Patient 3's Restraints Violent or Self-Destructive STAT order dated 8/27/25 at 2136 hours, showed to initiate 4-point locked restraints due to an imminent risk of harm. Another restraint order was entered on 8/28/25 at 0215 hours.

Review of Patient 3's Violent or Self-Destructive Restraint Flowsheet showed the restraints were discontinued on 8/28/25 at 0550 hours.

Review of the Flowsheet showed on 8/28/25 at 0330 hours, the patient was monitored for behavioral/psychological comfort, physical comfort, circulation, and continuous observation.

However, further review of Patient 3's medical record failed to show that nursing staff completed the required assessments and monitoring during the restraint episode from 8/27/25 at 2136 hours to 8/28/25 at 0550 hours. There was no documentation indicating that the nurse assessed and monitored the patient's psychological status and behavior, physical and psychological comfort, circulation, and provided continuous observation every 15 minutes. In addition, there was no documented evidence the nursing staff assessed skin integrity, range of motion in the extremities, nutrition and hydration, hygiene and elimination, and vital signs every two hours, as required by the hospital's P&P.

During an interview on 9/11/25 with the Director of PI and the ED Manager, the Director of PI and the ED Manager verified the findings.