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Based on interview and record review, the facility's Governing Body (GB) failed to ensure the hospital's operation was conducted in an effective, safe, and organized manner by failing to ensure:

1. Medical care was provided in a safe setting for one sampled patient (Patient 1) who was diagnosed with schizophrenia (a mental disorder leading to hallucinations, inappropriate actions, and delusions). (Refer to A0144);

2. The orders, for the use of restraints, were complete and included the type of restraints, extremities to be restrained, and the length of treatment for two of four sampled patients with restraints (Patients 16 and 19). (Refer to A0168);

3. Restraint assessments/reassessments were completed/documented every two hours for two of four sampled patients with restraints (Patients 16 and 20). (Refer to A0175); and

4. There was a doctor of medicine, or a doctor of osteopathic medicine, appointed as the Respiratory Services Medical Director to supervise and oversee the Respiratory Services Department. (Refer to A1153).

The cumulative effect of these systemic problems resulted in the failure of the Governing Body to ensure patients were receiving quality care in a safe and effective manner.

Based on interview and record review, the facility failed to ensure all services provided under a contractual agreement were evaluated for quality, to include care being provided in a safe and effective manner. This resulted in contractual services not being evaluated, and the Governing Body (GB) not being informed if the services being provided complied with all applicable conditions of participation and standards of care.

Findings:

On March 7, 2017, the list of contracted services provided at the facility was reviewed.

On March 8, 2017, the Governing Body (GB) meeting minutes were reviewed, and indicated the GB reviewed and approved contract service agreements when the contract for services was initiated and as needed for renewal.

The was no documented indication the GB received information of the quality of services provided under a contractual agreement for all contracted services.

During an interview with the Contract Manager (CM), on March 8, 2017, at 9:30 a.m., the CM stated the process for review of contracted services was as follows:
- The "Quality Contract Review" form was sent annually to the Director responsible for the contract.
- When the review was received back from the responsible Director, the "Quality Contract Review" form was sent to the Quality Department for their review.
- When the review was received back from the Quality Department, the review was "filed."

The CM stated the quality review of the services provided under a contractual agreement were not taken to the GB. In addition, the CM stated the "Quality Contract Review" initiated in June 2016, for contracted dialysis services, had not been completed by the Quality Department but the contract was terminated, on November 8, 2016. The CM stated the services provided under the Emergency Services Provider contract had not been reviewed.

During an interview with the Chief Quality Officer (CQO) and the CM, on March 8, 2017, at 9:55 a.m., they stated there was no process in place for the GB to review and ensure the services performed, under all contracted services, were provided in a safe and effective manner.

During an interview with the Governing Body (GB), on March 9, 2017, at 10 a.m., they stated all contracted services/contracts go through their legal services, and were presented to the GB for their approval. The GB stated a quality and performance review of each contracted service had not been brought to the GB. The GB stated they were unaware of which contracted services had been or had not been evaluated. The GB stated the hospital did bring contract problems to the GB.

The facility Governing Body Bylaws, dated April 2015, revealed "... Board of Directors ... To provide for compliance with applicable standards, laws, and regulations. ..."

Based on interview and record review, the facility failed to ensure the mechanism/process, of evaluating of services provided under a contractual agreement were provided in a safe and effective manner, and were consistently completed. This failure resulted in contractual services not being evaluated, and incomplete evaluations of contractual services.

Findings:

On March 7, 2017, the list of contracted services provided at the facility was reviewed.

On March 8, 2017, the Governing Body (GB) meeting minutes were reviewed, and indicated the GB reviewed and approved contract service agreements when the contract for services was initiated and as needed for renewal.

The was no documented indication the GB received information of the quality of services provided under a contractual agreement for all
contracted service.

During an interview with the Contract Manager (CM), on March 8, 2017, at 9:30 a.m., the CM stated the process for review of contracted services was as follows:
- The "Quality Contract Review" form was sent annually to the Director responsible for the contract.
- When the review was received back from the responsible Director, the "Quality Contract Review" form was sent to the Quality Department for their review.
- When the review was received back from the Quality Department, the review was "filed."

The CM stated the quality review of the services provided under a contractual agreement were not taken to the GB. In addition, the CM stated the "Quality Contract Review" initiated in June 2016, for contracted dialysis services, had not been completed by the Quality Department but the contract was terminated, on November 8, 2016. The CM stated the services provided under the Emergency Services Provider contract had not been reviewed.

During an interview with the Chief Quality Officer (CQO) and the CM, on March 8, 2017, at 9:55 a.m., they stated there was no process in place for the GB to review and ensure the services performed, under all contracted services, were provided in a safe and effective manner.

During an interview with the Governing Body (GB), on March 9, 2017, at 10 a.m., they stated all contracted services/contracts go through their legal services and were presented to the GB for their approval. The GB stated a quality and performance review of each contracted service had not been brought to the GB. The GB stated the hospital did bring contract problems to the GB.

The facility policy and procedure titled "2016 - 2017 Quality Assessment Performance Improvement Plan" September 2016, revealed "... The 2016 QAPI (Quality Assessment Performance Improvement) areas of focus include: ... Monitor external regulatory compliance indicators including but not limited to: ... Contracted Services. ..."

Based on observation, interview and record review, the facility failed to ensure:

1a. Copies of the Patient Rights and Responsibility document and the Conditions Of Admission document were provided to one sampled patient (Patient 5) upon admission to the facility's Emergency Department (ED); and
b. The "Conditions of Admission," "Advanced Directive Determination," and "Admitting - Patient Information Pamphlets" had been signed by and provided to the responsible party for one sampled patient (Patient 27). (Refer to A0117);

2. Medical care was provided in a safe setting, in the Emergency Department, for one sampled patient (Patient 1) who was diagnosed with schizophrenia (a mental disorder leading to hallucinations, inappropriate actions, and delusions). (Refer to A0144);

3. A plan of care was developed and updated as needed when restraints were initiated for one of four sampled patients with restraints (Patient 20). (Refer to A0166);

4. The orders, for the use of restraints, were complete and included the type of restraints, extremities to be restrained, and the length of treatment for two of four sampled patients with restraints (Patients 16 and 19). (Refer to A0168);

5. Telephone orders for restraints were not obtained two days in a row, and the telephone orders were countersigned by the physician within 24 hours of being obtained for one of four sampled patients with restraints (Patient 20). (Refer to A0172); and

6. The restraint assessments/reassessments were completed/documented every two hours for two of four sampled patients with restraints (Patients 16 and 20). (Refer to A0175).

The cumulative effect of these systemic problems resulted in failure to ensure patients were cared for in a safe manner, and their rights were protected and promoted at all times.

Based on observation, interview, and record review, the facility failed to ensure:

a. Patient 5 was provided with copies of the Patient Rights and Responsibility document and, the Conditions Of Admission document when he was admitted to the facility's Emergency Department (ED); and,

b. The "Conditions of Admission," "Advanced Directive Determination," and "Admitting - Patient Information Pamphlets" had been signed by and provided to Patient 27's responsible party.

These failures may impact the patient or responsible parties understanding of their rights to participate in decisions related to their health care needs and understanding their rights in obtaining and receiving medical treatment.

Findings:

a. An observation of the ED was conducted on March 7, 2017, at 9:30 a.m. Patient 5 was observed seated in the waiting room. An interview was conducted with Patient 5 and his family member who was seated next to him. Both the patient and his family member stated the patient was not given a copy of the Patient Rights or the Conditions of Admission documents.

An interview was conducted with the Patient Access Counselor (PAC) on March 7, 2017, at 9:45 a.m. The PAC stated she assists ED patients with registering in the ED and completing the Conditions of Admission document. The PAC further stated after the document has been signed she gave the patient the carbon copy of the document and attached the Patients Rights to the packet. The PAC stated the patient then waits in the ED waiting room to be called into the ED to see the provider. The PAC stated she did not recall if she gave Patient 5 the packet after he registered with her in the ED.

The PAC looked for Patient 5's packet but was unable to find it.

On March 7, 2017, at 10:45 a.m., another observation of the ED lobby was conducted with the ED Director. An interview was conducted with Patient 5 who stated he had been triaged and was waiting to be seen by the physician. Patient 5 was asked if he found his Patient Rights and Conditions of Admission packet and he again said he was never given the documents. The patient's family member also stated she never saw the documents after the patient initially signed them when he first checked in to the ED.

A review of the policy and procedure, "Patient's Rights (Last Revision:January 2013)" was conducted. The policy indicated, "To define the rights of patients guaranteed under California State law and Federal regulation...(the Facility) uses the California Hospital Associations Patient Rights Statement to describe what rights its patients have in obtaining and receiving treatment...The California Hospital
Association's Patient's Rights statement will be posted in prominent locations, and each patient will be given a copy."




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b. On March 8, 2017, Patient 27's record was reviewed with Registered Nurse (RN) 4. Patient 27 was admitted to the facility on February 27, 2017, for prematurity and respiratory distress.

There was no indication the "Conditions of Admission," "Advanced Directive Determination," and "Admitting - Patient Information Pamphlets" had been signed by and provided to Patient 27's responsible party.

Review of the "NICU Visitors Sign-In Sheet" indicated Patient 27's mother and grandmother had been visiting in the unit everyday since February 27, 2017.

During an interview with RN 4 on March 8, 2017 at 10:45 a.m., RN 4 stated the documents "Should have been signed by now."

Based on interview and record review, the facility failed to ensure Patient 1, diagnosed with schizophrenia (a mental disorder leading to hallucinations, inappropriate actions, and delusions) was provided medical care in a safe setting. This failure resulted in the patient leaving the facility as she walked down the street trying to stop cars. These actions could have resulted in a serious injury to Patient 1 or others.

Findings:

A review of Patient 1's record was conducted on March 7, 2017. Patient 1 presented to the Emergency Department (ED) on February 25, 2017, at 10:04 p.m., with a "psychiatric problem." Patient 1 had a diagnosis of schizophrenia. Patient 1's current medication included lithium (medication to treat bipolar disease, a mental disorder marked by alternating periods of elation and depression).

The triage assessment dated February 25, 2017, at 10:35 p.m., indicated per the patient's family member (FM), the patient believed someone was poisoning her with mercury and stated the bruises on her extremities were mercury trying to get out of her body. In addition the patient's FM indicated the patient had not slept in 10 days, talked to herself and hit herself causing bruising.

The general nursing assessment dated February 25, 2017, at 10:43 p.m., indicated Patient 1 was ill appearing, anxious, inattentive and inappropriate.

An additional nursing note completed on February 25, 2017, at 10:46 p.m. indicated, "The quality of the (patient's) symptoms is described to be feelings of terror and confusion. The patient is experiencing hallucinations described as tactile hallucinations..."

The nursing notes dated February 25, 2017, at 10:59 p.m., indicated the patient's FM, (a minor) stated he called 911 three times this past week in an attempt to get the patient some help but the patient left the hospitals against medical advice.

There was documentation in the record to indicate if a sitter or security personnel had been assigned to watch Patient 1.

A review of the physician's note dated February 25, 2017, at 11:05 p.m., indicated, "... discussed case with patient and (family member), they will go to the crisis center (crisis behavioral center-a psychiatric clinic). We will cab (taxi) them over."

On February 25, 2017, at 11:05 p.m., the nursing notes indicated, "Patient (Patient 1), disoriented, rambling, incoherent, and not making sense."

On February 26, 2017, at 1:57 a.m., the nursing notes indicated patient walked out of the ED and the patient was banging on ED entrance door stating the staff was holding her FM hostage. The notes further indicated, the patient was observed hanging onto a civilian's car side mirror hindering the civilian from leaving, and the patient walked in front of cars trying to stop them.

An interview was conducted with the Registered Nurse (RN) 6 on March 7, 2017, at 10 a.m. RN 6 stated if the patient had a psychiatric concern we would get a psychiatric evaluation, which is available at the facility by tele-psych (video communication with use of a webcam). RN 6 further stated if a patient with a psychiatric problem was transferred to another facility the patient could not be placed in a taxi as the patient might jump out and hurt herself.

An interview was conducted with the ED Director (EDD) on March 7, 2017, at 11 a.m. The EDD stated after Patient 1 left the ED she was picked up by the police and transported to a psychiatric hospital, not to a clinic (the crisis behavioral center). The EDD also stated security should have been called when Patient 1 was admitted to the ED and the patient (Patient 1) should have been on one to one observation for her safety.

Based on interview and record review, the facility failed to ensure a plan of care was developed and updated as needed when restraints were initiated for one of four sampled patients with restraints (Patient 20). This resulted in incomplete documentation, and had the potential to result in restraints being used longer than necessary.

Findings:

On March 7, 2017, at 2 p.m., the record for Patient 20 was reviewed. Patient 20 was admitted to the facility on March 1, 2017, with diagnoses including pneumonia and right tension pneumothorax [a collapsed lung with the buildup of air in the space between the lung and the chest wall].

The record indicated bilateral soft wrist restraints were initially applied on March 1, 2017, at 3:45 p.m., for patient safety, and were discontinued on March 4, 2017, at 10 p.m.

The "Assessment Flowsheet" for restraints, dated March 5, 2017, at 2:56 p.m., indicated bilateral wrist restraints were initiated for patient safety, and the physician was notified.

A physician's order dated March 5, 2017, at 2:56 p.m., indicated medical/surgical bilateral wrist restraints were needed for the patient's safety, and the restraint order was re-written on March 6, 2017, at 9 a.m., for the continued use of medical/surgical bilateral restraints.

The "Assessment Flowsheet" for restraints, dated March 6, 2017, indicated the following:
- At 4 a.m., bilateral soft wrist restraints were in place; the patient met the criteria for continued use of restraints; the patient disrupted therapies/self harm risk; the patient's circulation and skin were assessed and findings were normal; a trial release was done and the patient continued to be at risk; and a food, fluid, and elimination check was completed.
- At 10 p.m. [18 hours later], bilateral soft wrist restraints were in place; the patient met the criteria for continued use of restraints; the patient disrupted therapies/self harm risk; the patient's circulation and skin were assessed and findings were normal; a trial release was done and the patient continued to be at risk; and a food, fluid, and elimination check was completed.

There was no documented indication restraint assessments/reassessments occurred between 4 a.m. and 10 p.m., on March 6, 2017 (18 hours between restraint assessments).

The "Care Plan" dated March 5, 2017, at 8 p.m., indicated bilateral soft wrist restraints had been initiated on March 1, 2017, at 3:45 p.m., and were discontinued on March 4, 2017, at 10 p.m.

There was no documented indication the care plan for restraints had been updated/revised when bilateral soft wrist restraints were reapplied to Patient 20, on March 5, 2017, at 2:56 p.m.

The "Care Plan" dated March 6, 2017, at 6 p.m., indicated bilateral soft wrist restraints had been initiated on March 1, 2017, at 3:45 p.m., and were discontinued on March 4, 2017, at 10 p.m.

There was no documented indication the care plan for restraints had been updated/revised when bilateral soft wrist restraints were reapplied to Patient 20, on March 5, 2017, at 2:56 p.m. (27 hours after the bilateral soft wrist restraints had been reapplied).

During an interview with Registered Nurse (RN) 2, on March 7, 2017, at 2:15 p.m., she reviewed the record and was unable to find documentation of the restraint care plan being initiated until March 6, 2017, at 11:09 p.m. (32 hours after restraints were re-applied to Patient 20, on March 5, 2017, at 2:56 p.m.). RN 2 stated the restraint care plan should have been implemented when the bilateral soft wrist restraints were re-applied to Patient 20, on March 5, 2017, at 2:56 p.m. RN 2 stated the care plan should be reviewed/updated each shift.

The facility policy and procedure titled "Restraints" revised January 2017, revealed "... Documentation: ... Revised plan of care including the criteria used for continuation and discontinuation of restraint devices. ..."

The facility policy and procedure titled "Nursing Care" revised January 2017, revealed "... The plan of care will include ... safety ... The plan will be reviewed every shift and interventions modified as needed. ..."

Based on interview and record review, the facility failed to ensure the orders, for the use of restraints, were complete and included the type of restraints, extremities to be restrained, and the length of treatment for two of four sampled patients with restraints (Patients 16 and 19). This resulted in the Registered Nurse (RN) making the decision on what type of restraints to apply and the time limit for the restraint order.

Findings:

a. On March 7, 2017, the record for Patient 16 was reviewed. Patient 16 was admitted to the facility on March 5, 2017, with diagnoses including frequent falls and hyponatremia (low sodium blood level).

A physician's order dated March 5, 2017, at 11:53 a.m., indicated "Purpose for Restraints: Manage Violent or Self Destructive Behavior."

There was no indication on the order of the type of restraint to be applied, the extremities to be restrained, or the length of treatment.

The "NSG (Nursing) - Restraint Assessment" dated March 5, 2017, at 12 p.m., indicated bilateral soft wrist restraints were applied at 12:15 p.m., for patient safety.

During an interview with RN 1, on March 7, 2017, at 10:30 a.m., she reviewed the record and was unable to find a complete physician's order for the application of restraints for Patient 16, on March 5, 2017. RN 1 stated the physician's order for restraints should have included type of restraint, extremity(ies) to be restrained, and the time frame for restraint application. RN 1 stated the physician's order should have been clarified prior to the use of restraints for Patient 16. In addition, RN 1 stated if the purpose for the restraints was "management of violent or self-destructive behavior" the order limit was four hours and the physician must evaluate the patient in one hour.

b. On March 7, 2017, the record for Patient 19 was reviewed. Patient 19 was admitted to the facility on March 6, 2017, with diagnoses including respiratory failure and altered mental status.

A physician's order dated March 6, 2017, at 10 p.m., indicated a telephone order was obtained for restraints because "patient wakes up on sedation intermittently and disrupts therapy."

There was no indication on the order of the type of restraint to be applied, the extremities to be restrained, or the length of treatment.

The "NSG (Nursing) - Restraint Assessment" dated March 6, 2017, at 10 p.m., indicated bilateral soft wrist restraints were applied at 10 p.m., for patient safety.

During an interview with RN 3, on March 7, 2017, at 1:45 p.m., she reviewed the record and was unable to find a complete physician's order for the application of restraints for Patient 19, on March 6, 2017. RN 3 stated the physician's order for restraints, on March 6, 2017, was an incomplete order, and the RN should have called the physician and corrected the order to include type of restraint, extremity(ies) to be restrained, and the time frame for the restraint application.

The facility policy and procedure titled "Restraints" revised January 2017, revealed "... Orders for restraint must specify the reason (medical necessity and should indicate that restraint use is to improve the patient's well being) for the restraint, the type of restraint, the extremity of body part(s) to be restrained and the duration (time frame) for restraint application. ... In the event that restraints are used for the management of violent or self-destructive behavior, the order is limited to: Four (4) hours for adults. ... A physician must evaluate within one (1) hour. ..."

Based on interview and record review, the facility failed for two days in a row to ensure telephone orders for restraints were received and the telephone orders were countersigned by the physician within 24 hours of being obtained for one of four sampled patients with restraints (Patient 20). This had the potential to result in restraints being used longer than necessary for patient safety.

Findings:

On March 7, 2017, at 2 p.m., the record for Patient 20 was reviewed. Patient 20 was admitted to the facility on March 1, 2017, with diagnoses including pneumonia and right tension pneumothorax [a collapsed lung with the buildup of air in the space between the lung and the chest wall].

A physician's telephone order, for medical/surgical restraints, was obtained on March 1, 2017, at 3:45 p.m., that indicated bilateral soft wrist restraints for up to 24 hours were being initiated for patient interference with essential treatment.

There was no indication the telephone order for restraints had been countersigned by the physician [142 hours after the order had been obtained and initiated].

A second physician's telephone order, for medical/surgical restraints, was obtained on March 2, 2017, at 2 p.m., that indicated bilateral soft wrist restraints for up to 24 hours were being initiated for patient interference with essential treatment.

There was no indication the second telephone order for restraints had been countersigned by the physician/care provider [120 hours after the order had been obtained and restraint treatment was continued].

During an interview with Registered Nurse (RN) 3, on March 7, 2017, at 2:15 p.m., she reviewed the record and was unable to find documentation of the physician/care provider countersigning the restraint telephone orders for Patient 20. RN 3 stated the initial/first telephone order for restraints should have been countersigned by the physician/care provider within 24 hours of being obtained. In addition, RN 3 stated a second telephone order for the use of restraints should not have been obtained because the physician/care provider should have written the order after evaluating the patient and the need for the continuation of restraint usage.

During an interview with the Director Critical Care Services (DCCS), on March 7, 2017, at 2:45 p.m., she reviewed the record for Patient 20, and stated the restraint orders should have been countersigned by the physician within 24 hours of the initiation of the restraints. In addition, the DCCS stated the restraint order for March 2, 2017, should have been a written order by the physician/care provider after a face to face evaluation of the patient. The DCCS stated the restraint order written on March 2, 2017, should not have been a telephone order.

The facility policy and procedure titled "Restraints" revised January 2017, revealed "... Should a verbal order be obtained, this order must be countersigned by the ordering physician within a twenty-four (24) hour time frame. Restraint orders shall be re-written at a maximum of every calendar day. After face-to-face evaluation by the patient's treating physician. ..."

Based on interview and record review, the facility failed to ensure the restraint assessments/reassessments were completed/documented every two hours for two of four sampled patients with restraints (Patients 16 and 20). This resulted in incomplete assessments for the patients with restraints, and had the potential to result in harm, injury, and death to the patient.

Findings:

a. On March 7, 2017, the record for Patient 16 was reviewed. Patient 16 was admitted to the facility on March 5, 2017, with diagnoses including frequent falls and hyponatremia (low sodium blood level).

A physician's order dated March 5, 2017, at 11:53 a.m., indicated "Purpose for Restraints: Manage Violent or Self Destructive Behavior."

There was no indication on the order of the type of restraint to be applied, the extremities to be restrained, or the length of treatment.

The "NSG (Nursing) - Restraint Assessment" dated March 5, 2017, at 12 p.m., indicated bilateral soft wrist restraints were applied at 12:15 p.m., for patient safety.

The "Assessment Flowsheet" for restraints, dated March 5, 2017, indicated the following:
- At 12 p.m., bilateral soft wrist restraints were initiated for patient safety; the physician was contacted; the patient was unable to follow instructions/self harm risk; the patient's circulation and skin were assessed and findings were normal; a trial release was done and the patient continued to be at risk; a food, fluid, and elimination check was completed; and an update was provided to Patient 16's family.
- At 8 p.m. [8 hours later], bilateral soft wrist restraints were in place; the restraints were discussed with the care team and the care plan was modified; the patient was unable to follow instructions/self harm risk; the patient's circulation and skin were assessed and findings were normal; a trial release was done, the patient was resistive and restraint use was continued; a food, fluid, and elimination check was completed; and the patient was unable to express understanding of education due to altered cognition.

There was no documented indication restraint assessments/reassessments occurred between 12 p.m. and 8 p.m., on March 5, 2017 (8 hours between restraint assessments).

During an interview with Registered Nurse (RN) 2, on March 7, 2017, at 10:45 a.m., she reviewed the record and was unable to find documentation of restraint assessments/reassessments between 12 p.m. and 8 p.m., on March 5, 2017. RN 2 stated restraint assessments/reassessments should occur and be documented every two (2) hours.

b. On March 7, 2017, at 2 p.m., the record for Patient 20 was reviewed. Patient 20 was admitted to the facility on March 1, 2017, with diagnoses including pneumonia and right tension pneumothorax [a collapsed lung with the buildup of air in the space between the lung and the chest wall].

The "Assessment Flowsheet" for restraints, dated March 5, 2017, at 2:56 p.m., indicated bilateral wrist restraints were initiated for patient safety, and the physician was notified.

A physician's order dated March 5, 2017, at 2:56 p.m., indicated medical/surgical bilateral wrist restraints were needed for the patient's safety, and the restraint order was re-written on March 6, 2017, at 9 a.m., for the continued use of medical/surgical bilateral restraints.

The "Assessment Flowsheet" for restraints, dated March 6, 2017, indicated the following:
- At 4 a.m., bilateral soft wrist restraints were in place; the patient met the criteria for continued use of restraints; the patient disrupted therapies/self harm risk; the patient's circulation and skin were assessed and findings were normal; a trial release was done and the patient continued to be at risk; and a food, fluid, and elimination check was completed.
- At 10 p.m. [18 hours later], bilateral soft wrist restraints were in place; the patient met the criteria for continued use of restraints; the patient disrupted therapies/self harm risk; the patient's circulation and skin were assessed and findings were normal; a trial release was done and the patient continued to be at risk; and a food, fluid, and elimination check was completed.

There was no documented indication restraint assessments/reassessments occurred between 4 a.m. and 10 p.m., on March 6, 2017 (18 hours between restraint assessments).

During an interview with Registered Nurse (RN) 3, on March 7, 2017, at 2:15 p.m., she reviewed the record and was unable to find documentation of restraint assessments/reassessments between 4 a.m. and 10 p.m., on March 6, 2017. RN 3 stated restraint assessments/reassessments should occur and be documented every two (2) hours.

During an interview with the Director Critical Care Services (DCCS), on March 7, 2017, at 2:45 p.m., she stated when a patient had restraints applied, an assessment/reassessment should occur every two hours, and the assessment/reassessment should be documented.

The facility policy and procedure titled "Restraints" revised January 2017, revealed "... The condition of the restrained patient must be continually assessed, monitored and re-evaluated. ... Patient monitoring - patients shall be observed at least every two (2) hours or sooner to assure that restraints remain indicated, that restraining devices remain safely applied, and to assure safety and dignity and to meet the patient's needs during use. Assessment will include: The patient's physical and emotional wellbeing. Comfort and care needs, including hygiene, elimination, hydration, nutrition. The appropriateness of restraint application. Removal and reapplication. Assessment of the need for continuing or discontinuing restraint. ... Documentation: ... Times of assessments. ... Assessment of patient regarding clinical condition, medical conditions, comfort level, circulation, condition of limbs, skin and attention to hydration, elimination and nutrition at least every two (2) hours. ..."

Based on interview and record review, the facility failed to ensure there was a doctor of medicine, or a doctor of osteopathic medicine, appointed as the Respiratory Services Medical Director to supervise and oversee the Respiratory Services Department. (Refer to A1151)

The cumulative effect of this problem had the potential to result in the standards of care not being followed which may impact the safety, provision of care, and the treatment and services provided by the Respiratory Services Department.

Based on interview and record review, the facility failed to ensure there was a doctor of medicine, or a doctor of osteopathic medicine, appointed as the Respiratory Services Medical Director to supervise and oversee the Respiratory Services Department. This had the potential to result in the standards of care not being followed, which may impact the safety, provision of care, and the treatment and services provided by the Respiratory Services Department.

Findings:

On March 8, 2017, at 8:40 a.m., the Respiratory Services Supervisor (RSS), a respiratory therapist, was interviewed. The RSS stated the Director of Respiratory Care (DRC), also a respiratory therapist, had been on leave since November 2016. The RSS stated she had been overseeing respiratory services.

The RSS stated she and the DRC reported to the Chief Operating Officer who was a nurse. The RSS stated the operation of respiratory services did not have a physician/medical director conducting administrative or oversight activities.

On March 8, 2017, at 1:22 p.m., the Chief Quality Officer (CQO) was interviewed. The CQO stated the facility did not have a Medical Director who oversees the Respiratory Services Department.

An interview was conducted with members of the Governing Body on March 9, 2017, at 10 a.m. The Governing Body stated they were not aware that the Respiratory Services Department did not have a Medical Director.

A review of the Medical Staff Bylaws "(Last Revision: 6/29/16)" was conducted on March 8, 2017. The bylaws indicated, "Each department shall have a chair and chair elect (director) who shall be members of the active medical staff and shall be qualified by licensure, training, experience and demonstrated ability in a least on of the clinical areas covered by the department....Duties...continuous surveillance of the quality of patient care and professional performance rendered by all members with clinical privileges in the department through a planned and systematic process, oversee the effective conduct of the patient care, evaluation and monitoring functions delegated to the department by the medical executive committee in coordination and integration with organization wide quality assessment and improvement activities...develop and implement policies and procedures that guide and support the provision of care, treatment and services."