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Based on medical record review, policy and procedure review, and staff interview, there was no evidence that the hospital established a process for patients to lodge a grievance with the State Agency (Oklahoma State Department of Health-OSDH). This occurred in twelve (#1 through #12) of twelve clinical records reviewed.

Findings:
The hospital's Patient's Rights policy did not address patients being able to contact the State Agency directly to lodge a grievance.

Surveyors asked for the patient rights handouts and admission packet. There was no documented evidence in the patient rights handouts and admission packet that patients were given the State Agency contact information, including the OSDH website, for lodging complaints and grievances.

This information was provided to administration at the exit conference. No further information was provided.

Based on review hospital policies and procedures, grievance log and interviews with hospital staff, the hospital failed to ensure a written response with all the required elements was sent/provided to each complainant with 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. This occurred for three of three grievances reviewed.

Findings:
The hospital's grievance policy correctly identifies that grievances will be investigated and a written response with all the required information on investigation, resolution and contact information will be mailed to the complainant.

Three of three complaints (Complaints #1, 2 and 3) reviewed did not show evidence a written response, with the required elements, had been sent to the complainants.

On the afternoon of 01/14/14, Staff C was asked for the written response(s) for Complaints #1, 2 and 3, none was provided.

Based on review of hospital documents, medical record review and staff interview, the hospital failed to ensure restraints were used only to ensure the immediate safety of patients and staff and discontinued at the earliest possible time. The hospital did not review and analyze restraint use through the quality assessment and performance improvement (QAPI) program.

Findings:

In the morning of 01/14/14, the surveyors requested a list of restrained patients at the hospital. The list provided to the surveyors was incomplete. Medical record #5 was not on the restraint list for November and #11 was not on the list for October. This was confirmed by Staff C on the afternoon of 01/14/14.

The surveyors requested QAPI and Patient Safety Committee meeting minutes that showed review and analysis of restraints with plans of action when indicated to reduce the use of restraints. The information provided contained statistical data. The only analysis reviewed was if an order had been obtained and the restraint order had been signed by the physician. It contained no information that showed the clinical aspects of restraints had been reviewed to ensure restraint uses were appropriate. Meeting minutes did not reflect restraint use had been analyzed with action plans to reduce use.

In the morning of 01/15/14, Staff A was asked if the hospital reviewed or analyzed the clinical aspect of restraint usage, Staff A stated no.

Based on staff interview, review of hospital documents and medical record review, the hospital failed to ensure patients or their support persons were informed of the patient visitation rights. This occurred in twelve of twelve (#1 through 12) medical records reviewed.

Findings:
On the morning of 01/14/14, surveyors requested and reviewed the hospitals patient rights handouts and admission packet. Review of the documents did not contain a notice of visitation rights.

Review of medical records #1 through 12 did not contain documentation the patients or their support person were informed of the visitation rights.

This information was provided to administration at the exit conference. No further information was provided.

Based on policy and procedure review, medical record review and staff interview, the hospital failed to ensure verbal orders were used infrequent. This occurred in twelve of twelve (#1 through 12) medical records reviewed.

Findings:
On 01/14/14 and 01/15/14 twelve medical records were reviewed. All the records contained frequent use of verbal orders. For example, but not inclusive: Patient #11 for the time period of 10/11 through28/13, twenty-five (25) of fifty-one (51) physician orders were documented as telephone/verbal orders.

A hospital monthly spreadsheet comparing written orders to telephone/verbal orders for the calendar year 2013 was reviewed. The spreadsheet documented verbal orders were used in at least half or more instances, than the total number of the orders that were written.

On 01/14/14, Staff C stated verbal/telephone orders usage has increased in the hospital, but the no plans of corrective actions to decrease use of verbal orders had been developed.

Based on review of hospital policies and procedures, medical records and interviews with hospital staff, the hospital failed to ensure information in patient's medical records were accurately written. This occurred in one (Record #5) of twelve medical records reviewed.

Findings:

1. The discharge/transfer papers contained in Patient #5's medical records documented Staff N obtained telephone consent from a family member on 11/12/13 to send the patient to a skilled nursing facility.

2. Staff F stated on the afternoon of 01/14/14 at 1400 that the family member listed above had stated she was not contacted and did not give consent. Staff F stated that when Staff N was interviewed, she confirmed she had not talked with the family member. The hospital developed alternate discharge plans for the patient.