HospitalInspections.org

Based on review of facility documents, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to inform each patient of the patient's right in advance of furnishing care for five out of eight medical records reviewed (MR2, MR3, MR4, MR6, and MR7).
Findings include:
On July 22, 2022, review of facility policy titled, "Patient Rights and Responsibilities" last approved May 4, 2021, revealed "...Copies of patient's right and responsibilities are displayed in the inpatient and outpatient registration areas of the hospitals and freestanding outpatient sites. All inpatients will receive a copy of their rights and responsibilities at the time of registration or admission. Patient rights and responsibility brochures will be visible and available to patients at each visit...Ambulatory surgery facilities include patient rights and responsibilities statements in preadmission packages and additionally post patient rights and responsibilities statements throughout facilities...". Nothing addresses the patients that come to the hospital as outpatients or come to the hospital and have their procedure prior to being admitted.
On July 22, 2022, a medical record review was conducted.
Review of MR2, MR3, MR4, MR6, and MR7 revealed that patients that were coming in for surgery as outpatients or prior to being admitted, were not given a copy of the patient rights.
EMP7 confirmed findings on July 22, 2022, at 10:30am.

Based on review of facility documents, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to properly use restraints only with an order of a physician or other licensed practitioner for one out of three restraint medical records reviewed (MR10).
Findings include:
On July 22, 2022, review of facility policy titled, "Restraint and Seclusion" last approved August 26, 2021, revealed "...RESTRAINT STANDARDS FOR THE MANAGEMENT OF NON-VIOLENT/NON-SELF DESTRUCTIVE BEHAVIOR...An order should be obtained prior to the application of restraint except in emergency application situations (definition above), in which case the order should be obtained during the application of the restraint or immediately thereafter...".
On July 22, 2022, a review of MR10, admission date of June 13, 2022, revealed, order for nonviolent restraints on June 14, 2022, first ordered at 0358. Corresponding flowsheet documentation had the patient in nonviolent restraints from June 14, 2022, at 0101 until June 21, 2022.
EMP5 confirmed findings on July 22, 2022, at 1:30pm.

Based on review of facility documents, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to properly re-order restraints for one out of three restraint medical records reviewed (MR12).
Findings include:
On July 22, 2022, review of facility policy titled, "Restraint and Seclusion" last approved August 26, 2021, revealed "...RESTRAINT STANDARDS FOR THE MANAGEMENT OF NON-VIOLENT/NON-SELF DESTRUCTIVE BEHAVIOR...Restraint Orders for non-violent non-self-destructive behavior need renewed each calendar day after a determination that the need for the restraint is still indicated...Use of "prn" or "as needed" orders are not permissible...".
On July 22, 2022, a review of MR12, admission date June 14, 2022, revealed, order for nonviolent restraints on June 15, 2022, at 2356, order for nonviolent restraints on June 17, 2022, at 0153, order for nonviolent restraints discontinued on June 22, 2022, at 0055, and order for nonviolent restraints discontinued on June 22, 2022, at 0055. Corresponding flowsheet documentation showed that restraints were discontinued on June 16, 2022, at 1800 and restarted with no new order at 2000. June 17, 2022, flowsheet documentation stated restraints were discontinued at 1000.
EMP5 confirmed findings on July 22, 2022, at 1:30pm.

Based on review of facility documents, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to properly monitor the condition of the patient who is restrained at the interval determined by hospital policy for one out of three restraint medical records reviewed (MR10).
Findings include:
On July 22, 2022, review of facility policy titled, "Restraint and Seclusion" last approved August 26, 2021, revealed "...RESTRAINT STANDARDS FOR THE MANAGEMENT OF NON-VIOLENT/NON-SELF DESTRUCTIVE BEHAVIOR...Patients are monitored and reassessed a minimum of every 2 hours during restraint use or more frequently if indicated...".
On July 22, 2022, a review of MR10, admission date of June 13, 2022, revealed, order for nonviolent restraints on June 14, 2022, first ordered at 0358. Every two-hour monitoring failed to be documented on June 14, 2022, at 1000, June 18, 2022, at 0400 and 0600, and last monitoring documented on June 20, 2022, at 1000.
EMP5 confirmed findings on July 22, 2022, at 1:30pm.