HospitalInspections.org

A hospital must protect and promote each patient's rights.

The CONDITION is not met as evidenced by:
Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to patient's rights as follows:

(482.13 Tag A-0154)
The information reviewed during the survey provided evidence that three of three patients sampled for a review of handcuff use (MR1, MR2 and MR3) were placed in hand cuffs.

(482.13 Tag A-0164)
The information reviewed during the survey provided evidence that five of five patients sampled for a review of restraint use (MR1, MR2, MR3, MR4, and MR5) were not considered for least restrictive interventions prior to being placed in hand cuffs or restraints.

(482.13 Tag A-0168)
The information reviewed during the survey provided evidence that three of three patients sampled for a review of handcuff use (MR1, MR2, and MR3) were placed in handcuffs without a physician order.

482.13(e)(11) Tag-0176)
The information reviewed during the survey did not provide documentation in the facility policy that Physician and other licensed independent practitioner training requirements was specified in hospital policy.

Based on a review of facility documentation and staff interview (EMP), it was determined that the facility failed to ensure restraints were only imposed to ensure the immediate physical safety of the patient, a staff member, or others for three of three incidents reviewed (MR1, MR2, and MR3).

Findings include:

Review of the facility's "Patient Rights and Responsibilities Policy" last revised July 19, 2018, revealed "A patient has the right ot freedom from restraints in acute medical and surgical care and /or freedom form seclusion and restraints in behavior management, unless clinically necessary or in an emergency situation to protect the patient or others from harm."

Review of the facility's "Restraint and Seclusion Policy" last revised November 18, 2016, revealed "Restraint - The direct application of physical force to a patient, with or without the patient's permission, to restrict freedom of movement, physical activity, or normal access to his /her body. Physical force may be human, mechanical or a combination thereof. ... Behavioral Restraint and Seclusion - Emergent intervention to protect the patient against injury to self or others because of violent, self-destructive behaviors."

1. Review of facility documentation revealed MR1 was a 66 year old male admitted to the facility with a diagnosis of Acute Alcohol Withdrawal. PT1 was placed in handcuffs on August 29, 2018, from 1425 to 1631 as a result of threatening staff, while a patient on a nursing unit.

Interview with EMP3 on October 17, 2018, at approximately 10:00 AM confirmed the above findings and revealed "It came from administration to keep the cuffs on ..."

2. Review of facility documentation revealed MR2 was a 52 year old male admitted to the Emergency Department for a mental health evaluation. PT2 was placed in handcuffs on July 11, 2018, from 1448 to 1524, as a result of assaulting staff while a patient in the Emergency Department Behavioral Health Unit.

3. Review of facility documentation revealed MR3 was a 41 year old male admitted to the Emergency Department for a mental health evaluation. PT3 was placed in handcuffs on June 25, 2018, from 1236 to 1257, as the result of a local police officers use of handcuffs while a patient in the Emergency Department Behavioral Health Unit.

Interview with EMP3 on October 17, 2018, at approximately 10:00 AM confirmed the above findings and revealed "When police bring a patient into the ED [emergency department] we switch handcuffs and they [patients] stay in them until the doctor gives the order to release them.

Interview with EMP4 on October 18, 2018, at approximately 8:45 AM revealed "They[Washington Health System Police Officers] exchange cuffs [hand cuffs] when the patient is being admitted to the Behavioral Health Unit, until the doctor see's them [patient] are kept in the handcuffs."

Based on review of facility policies and procedures, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure less restrictive interventions were determined to be ineffective, prior to the application of a restraint for five of five medical records reviewed (MR1, MR2, MR3, MR4, and MR5).

Findings include:

Review of facility's "Patient Rights and Responsibilities Policy" last revised July 19, 2018, revealed "A patient has the right ot freedom from restraints in acute medical and surgical care and /or freedom form seclusion and restraints in behavior management, unless clinically necessary or in an emergency situation to protect the patient or others from harm."

Review of facility's "Restraint and Seclusion Policy" last revised November 18, 2016, revealed "Because of the serious consequences of restraints or seclusion such as physical and psychological harm, loss of dignity, violation or patient rights, and even death, emphasis is always placed on the reeducation of restraint interventions. Always attempt the least restrictive alternative. ... Direction For Restraint Use ... C. Restraint will be implemented in the least restrictive manner. ... Reassessment ... D. The continued need for the use of restraint and seclusion will be reassessed and documented at the following frequency: for non-behavioral restraint - every 2 hours and for a behavioral restraint - every 15 minutes."

Review of MR1 on October 17, 2018, revealed a physician order on August 29, 2018, at 1630 for bilateral leather wrist restraints. Further review revealed no documentation that less restrictive interventions were attempted from September 13, 2018, at 1900 thru September 15, 2018, at 2300.

Interview with EMP2 on October 19, 2018, at approximately 9:55 AM confirmed the above findings and revealed "I did not find any."

2. Review of facility documentation on October 18, 2018, revealed MR2 was placed in handcuffs on July 11, 2018, at 1448 thru 1523. Further review revealed no documentation that less restrictive interventions were attempted.

3. Review of facility documentation on October 18, 2018, revealed MR3 was placed in handcuffs on June 25, 2018, at 1236 thru 1257. Further review revealed no documentation that less restrictive interventions were attempted.

Interview with EMP2 on October 18, 2018, at 2:00 PM confirmed the above findings and revealed "your not going to find it."

4. Review of MR4 revealed a physician order for bilateral wrist restraints on August 30, 2018, at 0700, August 31, 2018, at 0700, September 1, 2018, at 0700, and September 2, 2018, at 0700. Further review revealed documentation on August 30, 2018, at 0700 and 1900 of less restrictive interventions attempted, August 31, 2018. at 0700 documentation of less restrictive interventions attempted, September 1, at 0700 documentation of less restrictive intervention attempted, and September 2, 2018, at 0700 documentation of less restrictive interventions attempted, not every two hours as per facility policy.

5. Review of MR5 revealed a physician order for bilateral wrist restraints on September 12, 2018, at 1900, September 13, 2018, at 1900, September 15, 2018, at 0100, and September 16, 2018, at 0100. Further review revealed documentation on September 12, 2018, at 1900 of less restrictive interventions, September 13, 2018, at 1900 of less restrictive interventions, September 15, 2018, at 0100 and 0700 of less restrictive interventions and September 16, 2018, at 0100 and 0700 of less restrictive interventions, not every two hours as per facility policy.

Interview with EMP1 on October 19, 2018, at 10:30 AM confirmed the above findings and revealed "It's[less restrictive interventions documented every two hours] not there."

Based on review of facility documentation, medical records (MR), and staff (EMP) interview, it was determined the facility failed to use restraints in accordance with the order of a physician for three of three medical records reviewed (MR1, MR2, and MR3).

Findings include:

Review of facility policy and procedure "Restraint and Seclusion" last revised November 18, 2016, revealed "Physician's Orders ... A. Restraint is used upon order of a licensed independent practitioner. ... C. The restraint order identifies any rationale for variation from Hospital policies and procedures for monitoring of the patient and for release from restraint before the order expires."

1. Review of facility documentation revealed PT1 was placed in handcuffs on August 29, 2018, from 1425 to 1631. Review of MR1 revealed no documentation of a physician order.

2. Review of facility documentation revealed PT2 was placed in handcuffs on July 11, 2018, from 1448 to 1524. Review of MR2 revealed no documentation of a physician order.

3. Review of facility documentation revealed PT3 was placed in handcuffs on June 25, 2018, from 1236 to 1257. Review of MR3 revealed no documentation of a physician order.

Interview with EMP1 and EMP4 on October 18, 2018, at approximately 9:00 AM confirmed the above findings and revealed "You are not going to find one."

Based on review of facility policy and procedure and staff (EMP) interview, it was determined the facility failed to specify training requirements for physicians and other licensed independent practitioners authorized to order restraints in the facility restraint policy.
Findings include:
Review of facility's "Restraints and Seclusion Policy" last revised November 18, 2016, did not include training requirement for physicians and other licensed independent practitioners.
Interview with EMP1 on October 26, 2018 at 10:00 AM confirmed the policy does not address restraint training for physicians.

Based on review of facility documentation, facility policies, and staff interview (EMP), it was determined the facility failed to report adverse patient events within 24 hours according to facilty policy for four of five events reviewed.

Findings include:
Review of facility Patient Safety Plan, dated February 27, 2017, revealed, "...V. Summaries of Key Elements of Patient Safety Program: A. Internal Reporting System: 1. Health System has in place a system for reporting Reportable Events 24 hours a day, 7 days a week. Reporting is done as soon as possible, but in no event more than 24 hours after the occurrence of discovery of the event."

1. Review of occurrence report dated August 8, 2018 revealed the event was not reported in PSRS (Patient Safety Reporting System) until August 16, 2018.

2. Review of occurrence report dated September 18, 2018 revealed the event was not reported in PSRS until September 20, 2018.

3. Review of occurrence report dated September 22, 2018 revealed the event was not reported in PSRS until September 24, 2018.

4. Review of a second occurrence report dated September 22, 2018 revealed the event was not reported in PSRS until September 24, 2018.

5. Interview with EMP2 on October 18, 2018, at approximately 1:00 PM confirmed the above findings.

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure drugs were administered in accordance with the order of a physician for two of two medical records reviewed (MR4 and MR5).

Findings included:
Review of facility documentation "Registered Nurse Position Description" dated February 27, 2018, revealed "The registered nurse collaborates with other members of the healthcare team to ensure safe, timely, efficient, and effective care that responds to the individual needs of the patient/family. ... Essential Functions: ... c. Implements care in a knowledgeable, skilful, consistent, and continuous manner using the procedures, protocols, education, standards of care, and standardized work as established by Washington Health System."

Review of facility policy and procedure "Physician's Orders" ... All orders for treatment shall be in writing and signed by the attending or consulting physician and include date and time written or entered electronically by the provider."

Review of MR4 on October 19, 2018, revealed a physician order dated April 24, 2018, at 14:22. "Propofol Drip ... 5mcg/kg/min ... Titrate at 10mcg/kg/min every 5 min RASS -1[Richmond Agitation Risk Score]" Further review revealed documentation on August 28, 2018, that the Propofol Drip remained at 20mcg from 1437 thru 2200 with no documentation of a RASS score per physician order.

Review of MR5 on October 19, 2018, revealed a physician order dated September 12, 2018, at 18:34. "Propofol Drip ... Rate Titrate, for RASS -2 ... Titrate at 10mcg/kg/min every 5 min" Further review revealed documentation on September 12, 2018, that the Propofol Drip remained at 30mcg from 2100 thru September 13, 2018, at 0800 with no documentation of a RASS score per physician order.

Interview with EMP1 on October 19, 2018, at approximately 12:00 PM confirmed the above findings and revealed "It's [RASS score] not there."