HospitalInspections.org

Based on record review, policy review and interview, it was determined the facility failed to protect and promote the rights of patients as evidenced by: (A117) failure to inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights; (A 118) failure to provide grievance and complaint information; (A 171) failure to provide complete restraint orders and (A 175) failure to monitor patients in restraints as ordered.

Based on medical record review and interview the facility failed to provide a copy of an "Important Message from Medicare" (IM) to 3 out of 4 patients (#2,#7,#14), which could potentially deprive patients of the information necessary to exercise their rights. Findings include:

During medical record review of patient #2 on 5/11/2011 at approximately 1130, it was revealed that the IM had not been given to, or signed by the patient. Patient #2 had been admitted on 5/1/2011 and had signed his consent for treatment, however, had not signed his IM.

This finding was confirmed during an interview with staff H at approximately 1140.

During medical record review of patient #14 on 5/12/2011 at approximately 1145, it was revealed that the IM had not been given to, or signed by the patient. Patient # 14 was admitted on 5/5/2011 and had signed his consents for treatment, however, had not signed his IM on 5/12/2011.

This finding was confirmed during an interview with staff L at approximately 1150.

Based on medical record review and interview the facility failed to provide grievance information to every patient in a timely manner. Grievance information was not given to 1 out of 1 patients (#17), resulting in the potential for the patient to lack the knowledge to file a complaint or grievance with the facility. Findings include:

During medical record review in the Emergency Department on 5/11/2011 at approximately 1030, it was revealed that patient #17 had not been given any grievance information. Patient #17 was not yet admitted to the hospital, however, had reported to the emergency department at approximately 2230 on 5/10/2011 and was "waiting for a bed" per staff E. The "patient's right's packet"which contained the grievance and complaint information, was still in the chart at approximately 1030 on 5/11/2011.

During an interview with staff E on 5/11/2011 at approximately 1040 it was stated that "No written information is posted or given to any patients regarding patient rights or grievances until the patient is admitted to the hospital." When staff E was asked what patients do if they have a concern or complaint regarding their care before they are admitted to the hospital, it was stated "I don't know, probably tell their nurse or a staff member, or they can always call after they are discharged."

Based on medical record review and interview the facility failed to renew restraint orders and/or complete the orders for restraints, with 4 out of 4 patients (#2, #14, #15, #16), resulting in the potential for patients being restrained without an assessment completed by a provider to ensure the need for restraints. Findings include:

During medical record review on 5/12/2011 at approximately 1130, the restraint management flow sheet revealed that to order restraints, the following areas were to be completed: 1. Mental Status 2. Reason for Restraints 3. Device 4. Alternatives Tried 5. 15 Minute Checks 6. Notification of Next of Kin 7. Date 8. Time 9. Duration and 10. Physician Signature. In the 4 out of the 4 charts reviewed, all of them contained incomplete orders.

Interview with staff L confirmed the above findings on 5/12/2011 at approximately 1145.

Based on medical record review and interview the facility failed to monitor restrained patients in 3 out of 4 (#14, #15, #16), records resulting in the potential for physical harm to the patients. Findings include:

During medical record review on 5/12/2011 at approximately 1130, it was revealed on the, "Restraint Documentation Flow Sheet", that the following area's were to be "Checked every 2 hours" while restraints were in use:
1. Nutrition/Hydration
2. Toileting
3. ROM (Range of Motion)
4. Repositioning/Restraint Release
5. Circulation
6. Hygiene
7. Mental Status
8. Observation.
In patients #14, #15 and #16 monitoring was not completed every 2 hours as required. Required checks were completed anywhere from every four to twelve hours.

During an interview on 5/12/2011 at approximately 1145 this was confirmed with staff L.