HospitalInspections.org

Based on medical record (MR) review, emergency room (ER) record review, and staff interview, it was determined the facility failed to ensure 31 of 31 ER patients and 3 of 14 inpatients were informed of the patient's rights prior to receiving care at the facility. This affected ER records numbers 1 through 31 and MR numbers 1, 4 and 5. This had the potential to negatively affect all patients served by the facility.


Findings include:

A review of 31 ER records and MRs # 1, 4, and 5 revealed no documentation that the patient rights had been discussed with the patient nor was there any documentation that the patient rights had been provided to the patient or their representative before they received care at the hospital.

An interview conducted on 4/12/12 at 11:10 AM with Employee Identifier # 1, Director of Nursing, confirmed the aforementioned findings.

Based on observation, medical record (MR) review, emergency room (ER) record review, review of the hospital's written patient rights and staff interview, it was determined the hospital failed to make available to the patients or their representatives the State agency phone number or address for filing a grievance. This affected 31 of 31 ER records reviewed (ER record #s 1 through 31) and 3 of 13 medical records reviewed (MR #s 1, 4 and 5). This had the potential to affect all patients who were served at the facility.


Findings include:

On 4/10/12 at 11:30 AM the surveyor toured the emergency room area. The surveyor observed the hospital's "Patient Bill of Rights" was posted in the entrance area of the ER. Review of the hospital's "Patient Bill of Rights" revealed no documentation of the phone number and address for lodging a grievance with the State agency. Neither the State agency telephone number or address was posted anywhere in the hospital.

During an interview on 4/10/12 at 11:40 AM, Employee Identifier (EI) # 1, Director of Nursing (DON), stated that the "Important Message from Medicare" contained the State agency phone number. EI # 1 stated that this form was only given to Medicare Patients who were admitted to the hospital and confirmed neither the State agency telephone number or address for filing a complaint or grievance was made available to any patients except Medicare patients who had been admitted to the hospital.

Review of 31 ER records and 14 MRs revealed there was no documentation that ER patients #'s 1 through 31 and MR # 1, MR # 4 and MR # 5 or their representatives were informed of their right to voice complaints verbally or in written form to the hospital, nor was there documentation the patients/representatives received information on how to lodge a complaint with the State agency.


An interview conducted on 4/12/12 at 11:10 AM with EI # 1 confirmed the aforementioned findings. During the interview, EI # 1 again stated that they do not give notice of the Patient Rights to any patients except patients who have Medicare and are admitted as an inpatient to the hospital.

Based on review of facility policy and medical records and interview with facility staff, it was determined the facility failed to ensure written Physician orders were timed and specified the type of restraints for 2 of 2 patients who were restrained for non-violent or non-self destructive behavior. This affected Medical Record (MR) # 11 and # 3 and had the potential to affect all patients served by this facility.

Findings include:

Facility Policy

Subject: Restraints...

Purpose: To establish guidelines and procedures for the use of restraints, seclusion, or protective devices with the goal of protecting the patient from harm and/or danger and provide care in a safe setting...

Orders for Restraint:
Written order for initial and continuing use of restraint are time limited.
Restraints may be ordered by physicians, physician assistants, and nurse practitioners.
Verbal orders may be accepted by nurses.
All patients will have a comprehensive assessment performed prior to the application of restraints or medical protective devices to determine that the risks with the use of restraints are outweighed by the risk of not using them...

Type of Restraints
There are two fundamental types of restraints: A restraint is either a Medical/Surgical Restraint (non-violent, non-self destructive) or Emergency/Violent/Self-Destructive Behavior restraint...

Medical/surgical Physician order:
A physician's order must be obtained for medical restraints or seclusion and must specify the reason for the restrain and the type of restraint. Restraint orders shall be renewed every 24 hours. Orders for the use of restraints or seclusion must never be written as a standing order or on an as needed basis (PRN). As needed (PRN) orders are not permitted...

If the patient's behavior for which the restraint was originally used, continued or reoccurs after an early release from the restraint and, if the behavior is part of the same episode that prompted the initial order, the nursing staff may utilize the most recent order, if is still within the 24-hour time frame...


Emergency Restraint-Seclusion, Management of violent or self-destructive behavior...

The use of restraint or seclusion must be selected only when less restrictive measures have been found to be ineffective to protect the patient, a staff member or others from harm, in accordance with the order of a physician or other licensed independent practitioner.

Restraints may be applied by a nurse in emergency or crisis situations if a patient's behavior becomes aggressive or violent, presenting an immediate, serious danger to his/her safety or that of others. Less restrictive interventions should have been attempted and deemed ineffective at this point... Orders for the use of seclusion or a restraint must never be written as a standing order or on an as needed basis (PRN)...

Emergency Restraint Physician Order:
Each written order for an emergency physical restraint/seclusion maximum time limit is:
Four (4) hours for adults, 18 years of age or older; ...

The nurse will assess the patient at these specified time periods and call the physician with his/her results, and request that orders be renewed for another period of time, not to exceed time limits as stated above...

... Restraint Documentation:
Each episode of restraint is documented in the patient's medical record, consistent with policies and procedures.

The medical record may include:
Clear description of the patient's condition or behavior that warranted restraints.
The patient's response to the intervention used, including the rationale for continued use of restraints.
Previous behavior and alternative attempts prior to restraint implementation.
Reason used for continuation and discontinuation of restraint device...
Document the time the restraint is released and response of patient to release of restraint and any action taken.
Type of restraint applied or intervention selected.


1. MR #11 was admitted to the facility on 11/11/09 with Dehydration, Mass obstructing distal esophagus, Large hiatal hernia and severe Ileus. Review of the Physician's Orders dated 11/11/09 revealed, "... 10 Insert NG (nasogastric) feeding tube... 3) Will need soft restraints to maintain NG tube..." There was no documentation of the time the order was written or the type of "soft restraints" to be used.

Review of the Nurses Notes dated 11/11/09 at 9:15 AM, the nurse documented the physician was at the bedside and new orders were received, soft wrist restraints were applied to the patient's wrists and secured to the bed. On 11/11/09 at 10:45 AM the nurse documented the patient had pulled out the NG tube and the restraints were removed at that time. On 11/11/09 at 1:45 PM the nurse documented having placed an NG tube, reapplied the wrist restraints and a posey vest. The restraints remained in placed throughout the rest of 11/11/09. On 11/12/09 at 9:00 AM the nurse documented having entered the room, vest and soft wrist restraints were intact and found the NG tube laying on top of the patient's covers out of the nare. There was no doumentation the restraints were removed.

Review of the Physician's Orders dated 11/12/09 revealed orders, "... 4) May leave out NG feeding tube and restraints..." There was no documentation of the time this order was written, but was noted by the Registered Nurse on 11/12/09 at 10:30 AM.

Review of the Physician's Orders dated 11/13/09 revealed orders, "... CT (Computerized Tomography) of abd (abdomen) and pelvis with & without contrast, if needed... 6) Restraints as needed..." This was a PRN order and there was no doumentation of the type of restraints to be used.

Review of the Nurse's Notes dated 11/13/09 at 10:10 AM, revealed the nurse documented, "...Soft wrist restraints applied to wrists & posey to chest..."




28969

2. MR # 3 presented to the emergency room on 11/29/09 unresponsive after having a seizure.

A review of the medical record revealed the patient had a Foley catheter and was receiving Intravenous (IV) Dilantin. After the Dilantin infusion was completed the patient became confused and aggressive and was standing up in the middle of the stretcher. An order was received "....Restrain pt (patient) as necessary for safety." Review of the nurse's documentation revealed bilateral wrist restrains and a vest restraint was applied.

Review of the physician's order revealed the order was a PRN order and did not include the length of time or the type of restraint to be used.

An interview on 4/12/12 at 11:10 AM with Employee Identifier # 1, Director of Nursing, confirmed the aforementioned findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observation of the dietary department, it was determine the facility failed to ensure the hood vent was clean and in good repair. This had the potential to affect all patients and staff who consume food from this dietary department.


Findings include:

On 4/10/12 at 10:40 AM, the surveyor observed the dietary department. During this time, the surveyor observed the hood vent located directly above the stove had multiple layers of peeling paint located in the interior aspect of the hood vent.

The hood vent was located directly over the stove. The peeling paint had the potential to contaminate food being prepared for patient and staff consumption.