HospitalInspections.org

Based on record review and interview, the hospital failed to ensure patients received information regarding patients' rights prior to receiving care for 2 (Patients #6 and 9) of 20 patient records reviewed.

This failed practice had the potential to affect all patients due to the lack of pertinent information regarding their care.

Findings:

A policy titled "Rights and Responsibilities of Patients" stated patients had the right to be involved in any decisions regarding their hospital stay and treatment options.

Per CMS requirements, the hospital must provide Form CMS 10611-MOON to all Medicare recipients who are receiving outpatient observation services.

Patient #6

The patient was admitted to outpatient observation services on 01/17/17. On 07/07/17, Staff C provided all documents that were scanned into the EMR. There was no documentation of a MOON notice given to the patient.

Patient #9

The patient was admitted to outpatient observation services on 01/07/17. On 07/07/17, Staff C provided all documents that were scanned into the EMR. There was no documentation of a MOON notice given to the patient.

On 07/07/17 at 4:05 pm, Staff B stated admission clerks were responsible for handing out packets with Medicare notices and the notices should be scanned into the EMR.

Based on record review and interview, the hospital failed to maintain documentation of written notice sent to the complainant who filed a grievance for 2 (Patient#21 and #22) of 4 grievances reviewed.

This failed practice had the potential to affect all individuals who submitted a grievance to the hospital.

Findings:

A hospital policy titled "Opportunities for Improvement (OFI)-Patient Complaint Resolution" documented a grievance requires a written response to the complainant.

Patient #21 submitted a grievance on 02/17/17, no documentation of a written response was sent to the patient.

Patient #22 submitted a grievance on 02/21/17, no documentation of a written response was sent to the patient.

On 07/07/17 at 2:30 PM, Staff A stated letters are sent out to all who submit a grievance.

Based on record review and interview, the hospital failed to ensure all restraint orders are signed by the physician within the timeframe documented in the policy.

This failed practice has the risk of restraint misuse and violation of patient's rights for all patients admitted to the hospital requiring restraints.

Findings:

A hospital policy titled "Restraints" documented all restraint orders should be dated, timed, and countersigned within 24 hours by a physician.

1 (Patient #20) of 2 restraint medical records showed a telephone order for restraints was received on 02/26/17 at 7:46 PM; the physician signed the order on 02/28/17 at 9:21 PM approximately 50 hours later.

On 07/07/17 at 11:40 AM, Staff B stated all restraint orders should be signed within 24 hours.

Based on record review and interview, the hospital failed to:

a. ensure non-violent restraint orders were obtained as hospital policy documented.

b. ensure face-to-face were completed and documented by the physician within the allotted timeframe on 2 (Patient #19 and #20 ) of 2 medical records reviewed.

This failed practice has the risk of restraint misuse and violation of patient's rights for all patients admitted to the hospital requiring restraints.

Findings:

A.

A hospital policy titled "Restraints" documented telephone and verbal orders are not accepted for restraint renewal for medical (non-violent) restraints.

1 (Patient #20) of 2 restraint medical records showed a telephone order for non-violent restraints was received on 02/26/17 at 7:46 PM.

On 07/07/17 at 11:40 AM, Staff B stated staff can only receive telephone orders for behavioral (violent) restraints.

B.

A hospital policy titled "Restraints" documented a face-to-face assessment by the physician would be completed within 24 hours for medical restraints.

Patient #19 medical record showed restraints were ordered on 06/22/17 at 12:32 PM; physician's documentation on 06/22/17 at 11:56 AM did not mention restraints or include a face-to-face assessment. On 06/22/17 at 3:13 PM another order was obtained for restraint; but the physician's documentation on the same day at 3:45 PM did not include the restraints or a face-to-face assessment.

Patient #20 medical record showed restraints were ordered on 02/26/17 at 7:46 PM;
physician's documentation of the patient's History and Physical (H&P) was on 02/26/17 at 6:27 PM, but did not mention restraints or include a face-to-face assessment. No other documentation from the physician was observed.

On 07/07/17 at 12:23 PM, Staff B stated a face-to-face assessment should be completed by the physician within 24 hours and confirmed the medical records do not have a documented face-to-face assessment.

Based on record review and interview, the hospital failed to ensure assessments were documented in alignment with the restraint policy for 1 (Patient #20) of 2 restraint medical records reviewed.

This failed practice had the potential to delay recognition of changes in patient's condition to determine if restraints remained necessary.

Findings:

A hospital policy titled "Restraints" documented patients in behavioral restraints would be observed for correct restraint placement, blood pressure and respiration checks, and re-evaluated for the need for continuation of restraints at least every 15 minutes.

Patient #20 medical record showed on 02/26/17 at 2:00 PM, behavioral restraints were applied to the patient. The medical record also showed documented restraint checks every 30 minutes (instead of 15 minutes per policy) from 4:00 PM to 6:30 PM on 02/26/17.

On 07/07/17 at 11:40 AM, Staff B stated documentation should occur every 15 minutes while a patient is restrained for behavior.

Based on record review and interview, the hospital failed to ensure all nursing staff, including agency staff, completed annual competencies and training/education requirements for 3 (Staff R, S, and U) of 8 personnel files reviewed.

This failed practice had the potential to increase the risk to patient safety.

Findings:

A document titled "Job Description" for a staff registered nurse (RN) documented expectations for staff members are to complete required education.

Staff R and U, registered nurses personnel files did not contain any current competencies for the hospital.

A hospital policy titled "Cardiopulmonary Resuscitation (CPR)" documented CPR is a job requirement for personnel who provide direct care to patients.

Staff S, a registered nurse, personnel file did not contain a current cardiopulmonary resuscitation (CPR) certification.

On 07/07/17 at 1:21 PM, Staff G stated there is no current CPR certification for Staff S; and confirmed Staff R and U personnel files did not contain annual competencies.

Based on record review and interview, the hospital failed to ensure an RN evaluated nursing care for 1 (Patient #8) of 20 patient records reviewed.

This failed practice had the potential to affect all current patients due to the lack of identification of failed nursing interventions.

Findings:

A policy titled "Standards of Nursing Care" stated the nursing care plan was initiated by an RN following the admission assessment and would be reviewed and/or revised as indicated by any RN or LPN staff providing care to the patient. The policy stated daily care requirements including assistance with meeting needs for urinary elimination would be documented in the care plan.

Patient #8

On 04/26/17, Staff M documented "Fluid and Electrolyte Imbalance- Adult" as an active problem in the multidisciplinary care plan. Staff M documented interventions including "Monitor/Document Intake and Output...Urine output should be 0.5- 1 mL/kg/hr", and "Assess amount, color, and clarity of urine". Staff W documented the patient's weight as 82.6 kg, resulting in a lower limit of 41.3 ml/hr for an acceptable level of urine output.

On 04/26/17 at 8:00 pm, Staff L documented a "shift assessment". There was no documentation of the amount, color, or clarity of the patient's urine.

On 04/27/17 at 2:40 am, Staff N documented performing straight catheterization due to the patient's inability to void. There was no documentation of any updates to the patient's plan of care following the need for catheterization.

On 04/27/17 at 8:38 am, Staff O documented a "shift assessment". There was no documentation of a genitourinary assessment. There was no documentation of any updates to the patient's plan of care.

On 04/27/17 at 1:10 pm, Staff J documented performing straight cathterization with a urine output of 400 ml. There was no documentation of any updates to the patient's plan of care following the need for catheterization.

On 04/27/17 at 7:50 pm, Staff K documented a "shift assessment". There was no documentation of the amount, color, or clarity of the patient's urine. There was no documentation of any changes to the plan of care.

On 04/28/17 at 7:42 am, Staff I documented the patient had oliguria (a suboptimal level of urine production) and urinary retention. There was no documentation of the amount, color, or clarity of the patient's urine. There was no documentation of any changes to the patient's plan of care.

Documentation showed urine output between 04/27/17 at 8:38 am and 04/28/17 at 7:58 am (23.5 hours) to be 400 ml, obtained by straight cathterization. The formula in the nursing care plan resulted in calculated urine output of 17 ml/hr (below the acceptable limit of 41.3 ml/hr). There was no documentation the intake and output amounts for the previous 24 hours were totaled and reviewed by nursing staff.

On 07/07/17 at 4:00 pm, Staff B stated nursing staff were responsible for documentation of the intake and output amounts and the amounts should be totaled every 24 hours.