HospitalInspections.org

Based on review of facility documents, medical records (MR), Department of Health's (Department) database, and staff interview (EMP), it was determined the facility failed to conform to all State laws:

Holy Spirit Hospital was not in compliance with the following State law:

The Medical Care Availability and Reduction of Error Act, 40 P.S. § 1303.101 et seq. § 1303.313 Medical Facility reports and notifications (a) Serious event reports A medical facility shall report the occurrence of a serious event to the department and the authority within 24 hours of the medical facility's confirmation of the occurrence of the serious event. The report to the department and the authority shall be in the form and manner prescribed by the authority in consultation with the department and shall not include the name of any patient or any other identifiable individual information. (b) Incident reports A medical facility shall report the occurrence of an incident to the authority in a form and manner prescribed by the authority and shall not include the name of any patient or any other individual information. (c) Infrastructure failure reports. A medical facility shall report the occurrence of an infrastructure failure to the department within 24 hours of the medical facility's confirmation of the occurrence or discovery of the infrastructure failure. The report to the department shall be in the form and manner prescribed by the department.

This is not met as evidenced by:

Based on review of facility documents, medical records (MR), Department of Health's (Department) database, and staff interview (EMP), it was determined the facility failed to report a serious event to the Department and the Patient Safety Authority within 24 hours of the occurrence.

Findings include:

A review on October 12, 2017, of the facility's "Identification of Events and Patient Safety Reporting" policy last reviewed January 10, 2017, revealed "...External reporting...Serious events and infrastructure failures, as defined in the Medical Care Availability and Reduction Error Act (Act13) and as interpreted by Geisinger Health System policy must be submitted via PA PSRS no later than 24-hours after confirmation that the event meets the criteria."

A review of the Department's database revealed the facility reported the above incident on October 12, 2017, to the Pennsylvania State Reporting System (PSRS), as an incident (an event, occurrence or situation involving the clinical care of a patient in a medical facility which could have injured the patient but did not either cause an unanticipated injury OR require the delivery of additional health care services to the patient) and not a serious event (an event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death OR compromises patient safety AND results in unanticipated injury requiring the delivery of additional health care services to the patient).

A review on October 12-13, 2017, of MR1's Nursing Progress Note dated September 23, 2017, from 5:11AM to 7:10AM revealed "...pt agitated & belligerent with pts agitation escalating while Dr in room assessing pt & security guards physically restrained pt in bed while RN & Dr attempting to apply b/l wrist restraints. While attempting to apply wrist restraints pt coded and & code blue called by RN @ 0518am with CPR initiated..."

An interview conducted on October 12, 2017, at 11:00 AM with EMP1 confirmed the facility did not report the event as a serious event.

Based on a review of incident reports (IR), medical records (MR), and staff interview (EMP), it was determined the facility failed to provide good quality care by failing to ensure the patient's safety during restraint application for one of 10 medical records (MR1) reviewed.

Findings include:

A review on October 12-13, 2017, of an Incident Report dated September 26, 2017, at 5:09AM revealed "...{name redacted} and {name redacted}, the patients nurse assisted Security in attempting to place the patient in 4 point restraints. Security, the nurse and the doctor attempted to try and calm the patient down. The patient attempted several times to kick staff and security. {name redacted} held the patients hands while {name redacted}, his nurse applied the restraints to his left wrist. The patient continued to kick, yell and thrash around on the bed attempted to not be restrained. {name redacted} was attempting to grab his right wrist when the patient then stopped struggling and {name redacted} noticed that the patient began to foam at the mouth and his eyes began to close. {name redacted} got off the bed and immediately alerted the doctor. {name redacted} turned the patient over on his back and began to check his vitals. The doctor told {name redacted} to announce a code blue..."

A review on October 12-13, 2017, of MR1 Nursing Progress Note dated September 23, 2017, from 5:11AM to 7:10AM revealed "...pt agitated & belligerent with pts agitation escalating while Dr in room assessing pt & security guards physically restrained pt in bed while RN & Dr attempting to apply b/l wrist restraints. While attempting to apply wrist restraints pt coded and & code blue called by RN @ 0518am with CPR initiated..."

A review on October 12-13, 2017, of Hospitalist Services - Nocturnist Event Note - Code Blue dated September 23, 2017, at 6:24AM revealed "...He physically attempted to push past the security guards and leave, but was immediately restrained and forced back into his bed by both security guards. The guards attempted to hold the patient down while the nurse and I attempted to place restraints on the patient's upper extremities, which he was flailing around. During the altercation, the patient bit one of the security guards on the arm. While the patient was forcibly being held down, he suddenly went limp and became completely unresponsive. His entire face turned blue and he seemed to be foaming at the mouth. A code blue was called..."

An interview conducted on October 13, 2017, at 8:15AM with OTH1 revealed the surveyors were not allowed to interview requested employees.

Based on review of facility documents, incident reports (IR) medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure restraints were in accordance with the order of a physician or other licensed independent practitioner for three of 10 medical records reviewed (MR1 and MR2 and MR3).

Findings include:

Review of facility policy and procedure "Restraint and Seclusion" last reviewed September 12,2017, revealed "...Responsibilities: Providers are responsible for: Assessing and documenting the need for restraint usage by identifying the clinical justifications and associated risk factors on the Restraint/Seclusion Order Set. Prompt/Immediate ordering of the least restrictive type of restraint required by the patient...6. In an emergency, restraint may be initiated prior to obtaining order. RN must obtain restraint order promptly/immediately..."

1. Review of an Incident Report on October 12-13, 2017, dated September 23, 2017, 6:51AM revealed "...Just after the left arm was put in the restraint, the patient foamed at the mouth and became discolored..."

Review of an Incident Report on October 12-13, 2017, dated September 26, 2017, 5:09AM revealed "...{name redacted} held the patients hands while {name redacted}, his nurse applied the restraints to his left wrist..."

Interview conducted on October 12, 2017, at approximately 1:00 PM with EMP1 confirmed there was no order for wrist restraints.


2. Review of MR2 on October 13, 2017, at approximately 11:27AM revealed the patient had an order for wrist restraints on October 12, 2017, and then the order was changed to mitts on October 13, 2017. Further review of MR2 revealed the patient was wearing both wrist and mitt restraints. There was no order for wrist restraints.

Interview conducted on October 13, 2017, at 11:27AM with EMP3 confirmed there was no order for wrist restraints.

3. Review of MR3 on October 13, 2017, at approximately 11:35AM revealed the patient had an order for wrist restraints on July 25, 2017. Further review of nursing documentation revealed that on July 26, 2017, both wrists and right ankle were restrained. There was no order for ankle restraints.

Interview conducted on October 13, 2017, at 11:35AM with EMP3 confirmed there was no order for ankle restraints.

Based on a review of facility documents, incident reports (IR) personnel file(PF) and staff interview(EMP) it was determined the facility failed to train staff in the application of restraints for two of seven personnel files reviewed (PF1 and PF3).

Findings include

A review on October 12-13, 2017, of facility policy Restraint/Seclusion last reviewed September 12, 2017, revealed "...Staff members who are involved in the application of restraints, implementation of seclusion, providing care for a patient in restraints or seclusion, or with assessing and monitoring the condition of a patient in restraint or seclusion will have education and training during orientation and annually as part of a competency evaluation..."

A review of PF1 on October 12-13, 2017 at 1:00PM revealed restraint training was completed on December 16, 2014. The facility could not provide evidence that PF1 had participated in orientation restraint training and annual restraint training since 2014.

A review of PF3 on October 12-13, 2017 at 1:10PM revealed the facility failed to provide evidence that PF3 had participated in orientation restraint training and annual restraint training since 2015.

A review of incident reports on October 12, 2017, for PF1 and PF3 revealed they responded to incident involving MR1 on September 23, 2017.

Interview on October 13, 2017 at 1:20PM with EMP7 confirmed PF1 did not have annual restraint training since 2014 and that PF3 did not have restraint training since 2015.

Based on a review of medical records (MR), incident reports (IR), and staff interview (EMP), it was determined the facility failed to ensure the safe application and use of all types of restraints for one of 10 medical records(MR1) reviewed.

Findings include:

A review on October 12-13, 2017, of Incident Reports dated September 26, 2017, at 5:09AM revealed "...{name redacted} and {name redacted}, the patients nurse assisted Security in attempting to place the patient in 4 point restraints. Security, the nurse and the doctor attempted to try and calm the patient down. The patient attempted several times to kick staff and security. {name redacted} held the patients hands while {name redacted}, his nurse applied the restraints to his left wrist. The patient continued to kick, yell and thrash around on the bed attempted to not be restrained. {name redacted} was attempting to grab his right wrist when the patient then stopped struggling and {name redacted} noticed that the patient began to foam at the mouth and his eyes began to close. {name redacted} got off the bed and immediately alerted the doctor. {name redacted} turned the patient over on his back and began to check his vitals. The doctor told {name redacted} to announce a code blue..."

A review on October 12-13, 2017, of MR1 Nursing Progress Note dated September 23, 2017, from 5:11AM to 7:10AM revealed "...pt agitated & belligerent with pts agitation escalating while Dr in room assessing pt & security guards physically restrained pt in bed while RN & Dr attempting to apply b/l wrist restraints. While attempting to apply wrist restraints pt coded and & code blue called by RN @ 0518am with CPR initiated..."

A review on October 12-13, 2017, of Hospitalist Services - Nocturnist Event Note - Code Blue dated September 23, 2017, at 6:24AM revealed "...He physically attempted to push past the security guards and leave, but was immediately restrained and forced back into his bed by both security guards. The guards attempted to hold the patient down while the nurse and I attempted to place restraints on the patient's upper extremities, which he was flailing around. During the altercation, the patient bit one of the security guards on the arm. While the patient was forcibly being held down, he suddenly went limp and became completely unresponsive. His entire face turned blue and he seemed to be foaming at the mouth. A code blue was called..."

An interview conducted on October 13, 2017, at 8:15AM with OTH1 revealed the surveyors were not allowed to interview requested employees.

Based on a review of facility policy, medical records (MR) and staff interview (EMP), it was determined the facility failed to report a death to CMS within one week of restraint or seclusion use.

Findings include

Review on September 12-13, 2017, of facility policy Restraint/Seclusion last reviewed September 12, 2017, revealed "...Each death known to the hospital that occurs within one week after restraint or seclusion, where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to the patient's death..."

A review on October 12-13, 2017, of MR1's Nursing Progress Note dated September 23, 2017, from 5:11AM to 7:10AM revealed "...pt agitated & belligerent with pts agitation escalating while Dr in room assessing pt & security guards physically restrained pt in bed while RN & Dr attempting to apply b/l wrist restraints. While attempting to apply wrist restraints pt coded and & code blue called by RN @ 0518am with CPR initiated..."

A review of Progress Note dated September 28, 2017, revealed "...He was pronounced dead at 1411."

A review of a Death Summary dated September 28, 2017, revealed "...CT scan was suspicious for diffuse anoxic brain injury. This was followed up with an MRI which confirmed our findings of diffuse anoxic brain injury..."

Interview conducted on October 16, 2017, with EMP5 confirmed that this death was not reported to CMS.