HospitalInspections.org

Based on interview and document review, it was determined the facility failed to inform two (2) of four (4) (Patient #1 and 14) labor and delivery patients of their patient rights.

Findings:

A review of the facility's policy titled "Patient Rights" effective date 07/01/2020 states in part:
"Ensure that all patients receiving care and/or patient representatives are informed of their rights.... All Company-affiliated facilities must provide each patient with a written statement of patient rights at the time of registration and again at the time any patient or patient's representative has questions regarding their rights. The written statement of patient's rights must be provided to the patient in their preferred language or manner that can be understood...."

On 02/20/2024, the surveyor reviewed the medical records for Patients #1 and #14, labor and delivery patients in the Maternal Infant Unit (MIU), with Staff Member #15. Staff Member #15 was unable to locate a signed "Conditions of Admission and Consent for Inpatient and/or Surgical Care (COA)" for Patient #1 and #14. The facility's COA document includes the "... 20. Acknowledgement of Notice of Patient Rights and Responsibilities ..." that requires "Initials" to confirm acknowledgement of patient rights and a space at the end of the document for the "Patient/Patient Representative Signature". Staff Member #15 advised after conferring with the registration staff, there was a note in the electronic medical record (EMR) for Patient #1 and #14 stating that the COA was "unable to obtain", with no other information as to the reason it was not obtained. No other evidence was provided that the patients' were informed of their rights or provided with a written statement of patient rights at the time of registration as per the facility's "Patient Rights" policy.

During a tour of the MIU 02/21/2024 at 9:25 a.m., Staff Member #35 stated that when patients present to the MIU, the patient checks in with the secretary at the registration desk on the unit to provide some basic patient information. The nurse has the patient sign specific consents but the nurses do not have the patients sign the facility's COA that includes informing the patient of their patient rights. Staff Member #35 confirmed that there is no patient rights information given to the patient by the nurses on the MIU. Staff Member #35 stated that the patient speaks via telephone with the facility's registration department located near the emergency department for additional information, but the registration staff do not come to the MIU to see the patient.

Based on staff interview and document review, it was determined the hospital failed to ensure the medical record documented the behavior requiring restraint, restraint orders specified the reason for the restraint, the type of restraint ordered was appropriate, restraints were applied as ordered for the documented behavior and restraint devices were not used without a valid order in two (2) of two (2) patients reviewed in the survey sample (Patients #9 and 17).

Findings:

The facility's policy, Seclusion, Restraints, and Restraint Alternatives was reviewed and reads in part: Orders for restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used,and the behavior-based criteria for release....Order for Restraint with Violent or Self-Destructive Behavior. Orders for restraint or seclusion must be time limited and must specify clinical justification for the restraint or seclusion, the date and time ordered, duration of restraint or seclusion use, the type of restraint, and the type of restraint and behavior based criteria for release. Orders for restraint or seclusion must not exceed: 1. Four hours for adults, aged 18 years and older...To continue restraint or seclusion beyond the initial order duration, the RN determine that the patient is not ready for release and calls the ordering physician or licensed practitioner, authorized by state law to order restraints, to obtain a renewal order. Renewal orders for restraint/seclusion may not exceed: 1. Four hours for adults, aged 18 years or older.

The medical record for Patient #9 contained evidence that the patient was ordered soft wrist restraints on 01/21/24 at 9:35 PM for "attempting to remove device." The medical record contained no documentation of the patient attempting to remove a device. The device type was not specified in the medical record.

The medical record for Patient #9 contained an order for soft bilateral upper extremity restraints on 01/22/24 at 8:46 PM for twelve (12) hours for attempting to remove device. The medical record contained no documentation that the patient was attempting to remove a device. An order was then placed for an enclosure bed for "extreme injury risk" at 6:37 PM on 01/22/24. The medical record did not contain documentation of the rationale for placing the patient in both an enclosure bed and soft wrist restraints simultaneously. The enclosure bed was not obtained for the patient for approximately four (4) hours after the physician ordered the restraint at 10:40 PM. The physician was not notified of the delay in obtaining the bed and no alternate interventions were documented for the patient's "extreme injury risk" while waiting to obtain the bed.

The medical record for Patient #17 contained documentation that a 56-year-old with Alzheimer's disease came to the emergency department (ED) on 01/26/24 with agitation and violent behaviors. The patient was placed in restraints at 5:03 PM on 01/26/23 (soft restraints to all four extremities) for attempting to kick staff members. The patient continued in four point restraints for the next 24 hours. On 01/27/24 at 5:30 PM, the four point restraints were discontinued and an order for an enclosure bed was placed. Documentation in the medical record indicated that the patient continued in four point restraints and four side rails from 5:30 PM to 10:03 PM with no orders for the four point restraints or the use of four bed rails.

Patient #17 continued in the enclosure bed restraint and a new order was placed for the enclosure bed on 01/30/24 for a "violent/self-destructive" restraint for patient "attempts self harm." The length of the order was indicated as 12:27 PM to 4:27 PM. The restraint order discontinued after four hours and no renewal order was written. Despite no order for the enclosure bed, nursing documentation indicated that the patient remained in the bed from 4:27 PM on 01/30/24 to 4:06 PM on 01/31/24. On 01/24/24, an order was written to continue the enclosure bed for 24 hours. The indication on the order was documented as "attempts to remove device." The medical record contained no documented evidence that the patient was attempting to remove their device. Staff member #31 confirmed that the enclosure bed would not keep a patient from removing a device and there was no documented clinical reason for the restraint in the medical record.

An interview was conducted with staff member #24 on 02/21/24 at 2:00 PM. Staff member #24 advised that it was not common for a patient to be placed on two (2) different restraint types (i.e. wrist restraints and an enclosure bed) simultaneously and the patient would have to have extreme/aggressive/agitated behaviors to warrant it.

Interviews were conducted with staff member #17 and staff member #18 during record review on 02/21/24. Staff members #17 and 18 reviewed the above noted patient restraint concerns in the medical records. The staff members confirmed that orders for violent restraints should be renewed every four (4) hours and non-violent restraints every 12-24 hours depending on circumstance.

Based on medical record review, facility policy review and interview, it was determined the facility failed to conduct required fall assessments, failed to conduct monitoring of patients after a fall, and failed to use interventions identified to reduce the fall risk for three (3) inpatients.

Findings:

The Fall Prevention Policy was reviewed and reads, in part:
"2. Fall risk and physical assessment will occur at the following intervals:
a. Upon admission;
b. Once per shift;
c. Following a change in medical condition or level of care; and
d. Post fall, if applicable.
...DOCUMENTATION: 1. Each patient will have a fall scale score and risk level documented within the Electronic Medical Record (EHR) according to the timeframes outlined in this policy...
2. Following the calculation of a fall score and risk level, the nurse will document all active, applicable interventions pursuant to the individual needs of each patient...
POST-FALL PROCESS:
1. Injury assessment a. Prior to being moved, the patient will be immediately assessed for obvious injuries and to determine level of severity. Assessment will include: vital signs, neurological, musculoskeletal, circulatory, integumentary, psychological status, and pain.
i. Record vital signs and neurological checks at least hourly for 4 hours, then every 4 hours for 24 hours. Notify attending provider of any changes...
a. For each patient fall, the nurse will document in the Post Fall Assessment intervention within the EHR [electronic health record]."

Patient #6 was admitted to the facility on 11/23/23 for "weakness" and a medical history that included Parkinson's disease. Upon admission, Patient #6 was identified as a moderate fall risk with the following interventions in place: bed alarm, low bed and supervised/assisted ambulation.

Between 11/23/23 and 12/1/23, there were four (4) times a fall risk assessment was not documented during the night shift (11/16/23, 11/27/23, 11/28/23, 11/29/23). During the day shift, there were three (3) times where a moderate to high fall risk score was calculated, but there were no interventions documented (11/28/23, 11/29/23, 11/30/23).

Patient #6 fell on 11/25/23 at approximately 1:30 p.m. and nursing documentation did not demonstrate hourly neurological checks and vital signs post-fall.


Patient #8 was admitted to the facility on 11/21/23 at approximately 2:27 p.m. for "alcohol withdrawal". The fall assessment was documented on 11/22/23 at 6:14 p.m. Patient #8 was identified as a high fall risk and the only intervention listed was "low bed".

Patient #8 fell on 11/23/23 at approximately 3:13 p.m. and nursing documentation did not demonstrate hourly neurological checks and vital signs post-fall.

Patient #8 fell again on 11/27/23 at approximately 2:00 a.m. There was no fall risk assessment performed following the fall and nursing documentation did not demonstrate hourly neurological checks and vital signs post-fall.

Between 11/22/23 and 12/8/23, there were nine (9) times a fall risk assessment was not documented during the night shift (11/22/23, 11/23/23, 11/24/23, 11/25/23, 11/29/23, 11/30/23, 12/01/23, 12/02/23, 12/03/23 . There were three (3) times on night shift a high fall risk score was calculated, but there were no interventions documented (11/26/23, 11/28/23, 11/29/23). During the day shift, there were two (2) times a fall risk assessment was not documented (12/03/23, 12/08/23).


Patient #9 was admitted on 12/4/23 for a "hypertensive emergency". A fall risk assessment was performed on 12/16/23 at 8:51 p.m., Patient #9 was identified as a medium fall risk with "interventions noted, hourly rounding".

Patient #9 fell on 12/16/23 at approximately 11:30 p.m. and a fall risk assessment was not performed following the fall . Patient #9 fell again on 1/21/23 at approximately 8:50 p.m. and a fall risk assessment was not performed following the fall.

Staff Member #16 confirmed that an assessment should be documented every shift (one for day shift, one for night shift). Additionally, if a patient experiences a fall, the staff should perform neurological checks and vital signs per the policy.