HospitalInspections.org

Based on review of 6 open and 5 closed medical records it was determined that the hospital failed to provide one patient with the initial Important Message from Medicare (IM) within 2 days of admission.


The IM is a standardized form that notifies Medicare patients of their hospital discharge appeal rights and must be provided to each Medicare beneficiary who is an inpatient within 2 days of admission. The IM is to be signed and dated by the patient to acknowledge receipt. Furthermore, the hospital is required to present a copy of the signed IM to the patient within 2 calendar days before the patient's discharge.


Patient #2 was a female on her late seventies who was admitted in late January 2016. The patient's medical record was reviewed on 2/4/2016. No initial IM had been completed and placed in the patient's medical record. Thus the hospital failed to provide Patient #2 the IM within 2 days of her admission.


Failure to provide a Medicare patient the Important Message from Medicare has the potential to violate the patient's rights to the discharge appeal.

Based review of 6 open and 5 closed records, it was determined that the hospital failed to use an independent interpreter throughout patient #11 ' s 3 day admission as evidence by:

Patient #11 was a Spanish-speaking male in his late 60 ' s who became violent in the community, and was brought in by police on emergency petition in late January. In the emergency department (ED), at 1403, the physician obtained the patient's history and performed an assessment. The physician never indicated that the patient was Spanish speaking.


Patient #11 ' s son and daughter were present in the ED. The son stated that patient #11 was recently diagnosed with dementia. Nursing noted that patient #11 was throwing his dentures at staff. Patient #11 was placed in 4-point restraints at 1432. A nursing note of 1639 stated " Pt appears more calm, all restraints removed. " There was no documentation indicating that interpreter services were obtained during the physician medical screening examination, or during patient #11 ' s restraint process.


Patient #11 was admitted to a medical unit at 2146. The nursing Admission Profile performed day one of admission at 0048 revealed patient #11 ' s preferred language was Spanish; that an interpreter was needed; and that the interpreter was his daughter. At 0109, an order for " Interpreter needed " was written by " System " based on the entry into the records stating "Yes " for interpreter needed. However, the medical record documentation indicated that the hospital failed to obtain objective, independent interpreter services for the patient.


The nursing Learning Assessment on day 1 and day 2 of admission timed at 2000 stated an objective of " Interpreter available " to which was documented " Yes, " followed by the " Interpreter names " of " son per pt preference, " and " daughter per pt request. " Again, no interpreter was obtained to determine an objective baseline of patient #11 ' s preference for an interpreter. A nursing note on day three of admission at 0325 stated " Pt A&Ox3, speaks Spanish, daughter interpreted information per pt preference. "


A psychiatric consult on day 2 of admission at 1402 stated in part, " The patient is seen with the aid of a Spanish translator as he is mostly Spanish speaking ... " This was the first and only time an interpreter was obtained for patient #11 during his stay.


Based on all documentation, the facility failed to provide an objective third party interpreter for patient #11 for his admission other than during the psychiatric consult.

Based on review of 6 open and 5 closed medical records and hospital restraint policy, it was determined that a patient was subjected to an unsafe restraint process.


Patient #11 was a male in late sixties who was brought to the Emergency Department by Emergency Medical Services (EMS) in late January 2016 . The patient had been Emergency Petitioned after he had become violent. He presented with altered mental status. Patient #11 was triaged at 1416.


A order was written at 1434 for "Restraint: Hard x 4" with the comment "May not exceed 4 hours for Ages 18 Years and Up." An Emergency Room Progress Note by an RN at 1443 noted, "Pt placed on 4 point restraints for pt safety for staff members ..." A subsequent progress note at 1500 noted, "Pt sitting on edge of bed in 4pt restraints. Son is at bedside. He is calm and cooperative." At 1600 an RN documented in a progress note "Pt continuing to sit on edge of stretcher in 4pt restraints. Pt. appears to be calm and cooperative at this time and does not appear to be in any distress. Pt. speaking with son at bedside. 1:1 precautions maintained."


Review of hospital policy, "Restraint, Patient" (approved 8/22/2014) revealed no provision for this positioning of a patient in 4-point restraints (hard limb holders).


The medical record revealed an unsafe use of 4-point restraints where patient #11 was able to swing his legs over the side of the stretcher and align his body in a sitting position for an intervention which otherwise requires supine positioning for the protection of a combative patient.


Based on this documentation, the hospital failed to provide a safe and appropriate restraint technique.

Based on review of 6 open and 5 closed records it was determined that the hospital failed to release one patient from 4-point restraints at the earliest possible time.


Patient #11 was a male in his late sixties who was brought to the Emergency Department by Emergency Medical Services (EMS) on late January 2016. The patient was Emergency Petitioned after he had become violent. He presented with altered mental status. Patient #11 was triaged at 1416.


A order was written at 1434 for "Restraint: Hard x 4" with the comment "May not exceed 4 hours for Ages 18 Years and Up." An Emergency Room Progress Note by an RN at 1443 noted, "Pt placed on 4 point restraints for pt safety for staff members ..." A subsequent progress note at 1500 noted, "Pt sitting on edge of bed in 4pt restraints. Son is at bedside. He is calm and cooperative." At 1545 a certified nursing assistant (CNA) noted "pt still talking with his son at this time will continue to monitor." At 1600 an RN documented in a progress note "Pt continuing to sit on edge of stretcher in 4pt restraints. Pt. appears to be calm and cooperative at this time and does not appear to be in any distress. Pt. speaking with son at bedside. 1:1 precautions maintained." At 1615 the CNA noted "pt calm and cooperative his son at bed side will continue to monitor." At 1630 an RN documented in a progress note "pt awake calm and cooperative his son at bed side will continue to monitor." At 1639, an RN wrote in part, " ...Pt appears more calm, all restraints removed. "


As per documentation the hospital kept patient #11 in restraints for more than one and a half hours after he demonstrated calm behaviors. Therefore, the hospital failed to discontinue the use of restraints on patient #11 at the earliest possible time.

Based on a review of 6 open and 5 closed records, it was revealed that 1) nursing failed to develop and document a care plan problem related to patient #1 ' s nutritional intake until the day of discharge; and 2) failed to consistently document patient #1 ' s food intake for more than two days from 5/18 at 1720 to 5/21/2016 at 0900.


Patient #1 is an adult male in his late 80 ' s admitted on May 17, 2015 at 1932 with a diagnosis of pneumonia. Patient #1 had baseline cardiovascular and cognitive diagnoses, and had a change in mental status shortly after admission for which a rapid response was called. Following the rapid response, patient #1 received a Speech Therapy evaluation on 5/18 at 1709 to determine his ability to swallow. The evaluation recommended 1:1 supervision with all oral intake and ordered " Implement Safe Swallow Technique " . The Safe Swallow Technique is a guide to nursing staff on how to assist individual patients with meals. For patient #1, the guidance included " Alternate consistencies, Head of bed 90 degrees, small bites/sips, slowed rate of intake, " and cueing with " verbal guidance. "

Based on patient #1 ' s Speech Therapy assessment, nursing had a role in assisting patient #1 to take in adequate nutrition. However, no timely nursing care plan is found in the record related to patient #1 ' s feeding/nutritional needs until the day of discharge of 5/22.

Additionally, from 5/18 at 1720 following the speech therapy evaluation through 5/21 at 0900, no nursing documentation related to the " Safe Swallow Technique " nor any percentages of meal intakes are noted in the record.

On 5/20, an RN requested that the Speech Therapist see the patient as the RN reported only limited success with po (by mouth) intake, which she documented as " pt refusing/ not able to suck through a straw or spitting. " With the assistance of the Speech Therapist, patient #1 was able to take in a half of the serving of applesauce and a half of a serving of his liquid supplement. The Speech Therapist wrote " Overall po intake appears related to cognitive issues. "

On 5/21 at 0940, patient #1 was placed into two point wrist restraints. Nursing documented offering nutrition/hydration at 1000, 1200, and 1400, but failed to document any actual intake related to the 1000 and 1400 offerings. Documentation reveals only that patient #1 ate 50% of her lunch.

On 5/22/2015 at 0900, nursing documented in patient #1 ' s care plan that the patient's intake was " Very Poor. "

Based on all documentation, nursing failed to develop a care plan related to patient #1 ' s nutritional needs, and failed to consistently document the food intake for patient #1, who due to his dementia, was assessed as needing mealtime assistance.