HospitalInspections.org

Based on observation, documentation review and interview, the facility failed to ensure that each patient, or when appropriate, the patient surrogate is provided patient right information. This finding was evident in 5 of 6 medical records reviewed (Patient #s 24, 25, 26, 27 and 28).

Findings include:

Review of medical record for Patient #24 during a tour of the Medical Unit on 10/5/17 at approximately 12: 30 PM revealed the patient was admitted on 9/26/17. Several documents including the booklet "Your Rights as a Hospital Patient" and the "Consent and Authorization for treatment" were not acknowledged or signed by the patient. In both documents, staff noted that the patient was "Unable to sign".

Hospital policies titled, "General Consent /Informed Consent, Medicare Discharge Notice and Appeals Rights" last reviewed January 2017 notes, "If the patient is incapable of signing the consent a patient surrogate can sign a consent for the patient."

Similar findings were noted in medical record for Patient #s 25, 26, 27 and 28 who were unable to acknowledge the Notice of Right information on admission and there was no documentation that that patients' representative received the information on behalf of the patient.

During interview with Staff E, Patient Access Manager on 10/10/17 at 12:50 PM, she reported that if a patient is unable to acknowledge his or her rights on admission, a follow up is conducted by Admitting staff in the patients' unit. She acknowledged that there was no follow up conducted for these patients.

Based on document review and interview the hospital did not ensure that security officers who provide manual hold during the restraint of patients are trained in First Aid Techniques and are certification in the use of Cardiopulmonary Resuscitation. This was evident in 6 (six) of 6 (six) personnel files (Staff #s J, K, L, M, N and O).

Findings include:

Review of documents titled "Confidential Public Safety Department Incident/ Complaint Report from March to September 2017 noted several incidents where Security Officers were called to assist clinical staff with the application of restraints for management of aggressive patients.

A security report dated 7/30/17, noted that at approximately 1:20 PM, security was called for assistance with a 4-point restraint. The patient was manually held by security staff while restraints was applied by nurses.

Similar findings were noted in security reports dated 3/1/17, 4/30/17, 6/13/17 and 8/3/17, where security officers assisted clinical staff in the application of restraints.

Review of personnel files for Security Officers J, K, L, M, N, and O revealed staff had no training in the use of First Aid Techniques and Certification in the use of Cardiopulmonary Resuscitation (CPR), including periodic recertification.

On 10/6/17 at approximately 12:05 PM, during interview with Staff H, Administrative Director Emergency Service, he stated he was unaware that Security Officers were required to have training in the use of First Aid Techniques and CPR. He confirmed that the Security Officers in the hospital do not have this training.