HospitalInspections.org

Based on observation, document review and interview, it was determined the facility failed to provide patients with information to file a grievance with the State Agency whether or not they chose to utilize the hospital's grievance process. The failed practice had the potential to affect all patients admitted to the facility. Findings follow:

A. Review of the Complaint and Grievance Process, revised 02/02/07 revealed the patient was notified of the State Survey Agency, phone number and address.

B. While touring the facility at 1200 on 01/05/10, the name, address and phone number of the State Agency was observed posted just outside Administration. The information was not posted in the patient area or anywhere else in the facility.

C. Review of the Patient Handbook and the Patient Rights provided on admission revealed the patient was not provided with the name, address and phone number of the State Agency where complaints or grievances could be lodged. The Patient Rights addressed grievances and complaints separately. The "Grievances" section of the Patient Rights stated, "You or the individual designated by the Hospital will be made aware of the State Department of Health to which you may address grievances". The "Complaints" section directed the patient to address complaints, including potential abuse or neglect, to the Patient Representative or the Administrator and did not mention the State Agency.

D. Review of the Patient Handbook and the Patient Rights provided on admission revealed the patient was not made aware they could notify the State Agency of a grievance without first using the hospital's grievance process.

E. The failure to provide patients with the name, phone number and address of the State Agency and to make them aware they could file a grievance with the State Agency without notifying the facility was confirmed during interview at 1300 on 01/05/10 with the Director of Clinical Services.

Based on policy review, clinical record review and interview, it was determined the facility failed to ensure Patient #3 was placed in restraints "as needed" without an order for each episode of restraint. The failed practice had the potential to affect every patient in restraints. The findings follow:

A. Review of Policy R02-N Restraints and Seclusion, revised 07/09, revealed a written order, which must be renewed daily, based on an examination of the patient by the physician or Licensed Independent Practitioner (LIP) was written in the medical record when restraint use was clinically appropriate. The policy also stated if a patient was released from restraints before the current order expired and then returned to restraints, a new order must be obtained.

B. Review of Physician's Orders for Patient #3 revealed an order at 1330 on 11/09/09 stating "May be unrestrained when family here".

C. Review of Patient #3's Restraint Order/Assessment Sheets for 11/01 through 11/02/09 and the nursing Restraints records for 11/01/09 revealed the following:
1) An order at 0700 for daily continuation of a left wrist restraint.
2) Documentation the restraints were removed at 1500 and replaced at 1900 on 11/01/09.
3) A lack of an order for the new restraint application at 1900 on 11/01/09.

D. Review of Patient #3's Restraint Order/Assessment Sheets and the nursing Restraints records for 11/14 through 11/15/09 revealed the following:
1) An order at 0530 on 11/14/09 for daily continuation of left and right wrist restraints.
2) Documentation the restraints were removed at 0400 on 11/14/09 and replaced at 0700 on 11/15/09.
3) A lack of an order for the new restraint application at 0700 on 11/15/09.
4) The next Restraint Order/Assessment Sheet was to initiate restraint at 1230 on 11/15/09. It also stated "May be left off when family in room".

E. Review of Restraint Order/Assessment Sheets for Patient #3 revealed verbal orders for restraints on 10/28, 11/16, 11/24, 11/25, 11/26, 11/2, 11/28 and 11/30/09. Each verbal order was signed by the physician, but was not dated as to when it was signed. It could not be determined the physician signed the verbal order daily as per facility policy.

F. A verbal order for restraint was received on 12/01/09. As of 1210 on 12/5/09, the physician had not signed the order.

G. The Director of Clinical Services confirmed the above at 1245 on 01/05/09.