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Based on review of medical records, facility policy/procedure, and staff interview, the facility failed to ensure patient restraint was used in accordance with a physician's or licensed independent practitioner's order in review of one (#21) of three medical records wherein patients were restrained. This failure created the potential for a negative outcome and did not ensure proper oversight of the patient's restraint.

Findings:

a. Sample medical record #21 was reviewed on 3/27/13. According to nursing documentation, the patient was restrained from 3/6/13 at 4:00 p.m., all day 3/7/13, all day 3/8/13, all day 3/9/13, and from midnight to 6:00 a.m. as well as 7:00 p.m. to midnight on 3/10/13. Physician orders were present in the chart for the dates of 3/6/13, 3/7/13, and 3/8/13. No restraint orders were present in the chart for 3/9/13 or 3/10/13. Additionally, the physician order dated 3/6/13 was initially a verbal order and later signed by the provider. The order did not indicate the reason for restraint, type of restraint, of hour limit of the restraint. These findings were confirmed with the Director of Health Information Technology at approximately 12:30 p.m.

b. The facility's policy titled Restraint and/or Seclusion Hospital Wide, effective 8/18/2011, stated, "The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient... The use of restraints may be authorized for 24 hours time limit to manage non-violent or non-self destructive behavior."

c. On 3/27/13 at approximately 2:30 p.m., the Clinical Data Supervisor confirmed that no additional written orders were found for sample medical record #21. S/he stated it had been identified via the audit log that the orders were missing. When asked the purpose of the audits, s/he stated it was to obtain the missing documentation. Despite that, the record was still incomplete.

Based on review of medical records, facility documents, and staff interview, the facility failed to ensure patient discharge plans disclosed financial interest in the facility's Skilled Nursing Facility (SNF). This failure created the potential for families and patients to create an uninformed decision regarding care.

Findings:

1. One of one (#6) medical records reviewed wherein the patient was transferred to the facility's SNF failed to evidence disclosure of financial interest to the patient, patient's representative, and/or patient's family.

a. Sample medical record #6 was reviewed on 3/26/13 and no financial interest disclosure of the facility's SNF, where the patient was transferred to on two separate occasions, was located in the medical record. At approximately 4:00 p.m., the Director of Continuing Care confirmed this finding.

b. The lists of available local and outlying home health agencies and long term care facilities provided to applicable patients was reviewed. The facility maintained financial interest in a home health agency as well as a skilled nursing facility, which was located adjacent to the facility/hospital. The "Local Home Care Agencies" list stated that Parkview Home Care "is a department of Parkview Medical Center." The "Nursing Homes" list, however, neither listed the facility's SNF as an option nor disclosed ownership/interest in the SNF.

c. An interview was conducted on 3/26/13 at approximately 3:00 p.m. with the Director of Discharge Planning/ Continuing Care. When asked how financial interest in the SNF was disclosed, s/he stated, "Patients are told the Parkview SNF is part of the hospital. It is done by the Discharge Planner." S/he stated that all the local long term care facilities also had SNFs within them but that Parkview's SNF generally only takes patients who just need 7 - 10 days of treatment.

d. A second interview was conducted with the Director of Discharge Planning/ Continuing Care on 3/27/13 at approximately 12:00 p.m. S/he provided the consent for the facility's SNF. The consent did not disclose financial interest by Parkview Medical Center. When asked how patients and families would know the facility had financial interest in the SNF, s/he stated, "It is implied by the name Parkview on the form they sign, which also states they have been given other options [of additional SNFs]."

e. Further review of facility documents failed to evidence financial interest disclosure of the SNF in the facility's general consent or "Caring for You" guide, provided to each patient upon admission and containing information on most aspects of the patient's hospital experience.