HospitalInspections.org

I. Based on review of policy, procedure, medical records, and staff interview, the hospital failed to ensure nursing staff obtained an order from the authorized health care provider for the use of restraints to prevent patients from interfering with life sustaining medical equipment in 3 of 9 medical restraint records reviewed. (Patients # 1, 2, and 3) The hospital identified no patients in restraint at the time of the survey.

Failure to notify and obtain a physician's order for the use of restraints could potentially place patients at risk for physical and/or psychological harm from the unnecessary and/or inappropriate application of restraints.

Findings include:

1. Review of policy/procedure titled "Restraints", dated 11/14, included in part, "...Frequency of order renewal...Non-violent situation - unless otherwise specified, duration is assumed to be until the end of the next calendar day..."

2. Review of Patients # 1, 2, and 3 medical records lacked evidence that nursing staff obtained a physician order for the use of restraints as a means of physical restraint to prevent the disruption of life saving treatments as follows:

a. Review of Patient # 1's medical record revealed in part, Patient #1 was placed in restraints on 8/22/15 and restraints were discontinued 8/27/15 and lacked an order for restraints on 8/25/15.

b. Review of Patient # 2's medical record revealed in part, Patient #2 was placed in restraints on 7/5/15 and restraints were discontinued 7/18/15 and lacked orders for restraints on 7/8, 9, 10, 11, and 17/15.

c. Review of Patient # 3's medical record revealed in part, Patient #3 was placed in restraints on 7/8/15 and restraints were discontinued 7/17/15 and lacked orders for restraints on 7/9, 10, 11, 13, and 17/15.

3. During an interview on 9/2/15 at 7:35 AM during chart review, Staff A, Nursing Standards Specialist acknowledged the lack of restraint orders every calendar day for Patients # 1, 2, and 3 as stated above.


II. Based on review of policy, procedure, medical records, and staff interview, the hospital failed to ensure nursing staff obtained an order from the authorized health care provider for the use of restraints to control violent behavior in 1 of 7 violent restraint records reviewed. (Patient #4) The hospital identified no patients in restraint at the time of the survey.

Failure to notify and obtain a physician's order for the use of restraints could potentially place patients at risk for physical and/or psychological harm from the unnecessary and/or inappropriate application of restraints.

Findings include:

1. Review of policy/procedure titled "Restraints", dated 11/14, included in part, "...Frequency of order renewal...Violent situation - each order for restraints may only be renewed in accordance with the following limits for up to a maximum of 24 consecutive hours. aa. 4 hours for adults 18 years of age or older..."

2. Review of Patient #4's medical record lacked evidence that nursing staff obtained a physician order for the use of restraints as a means of physical restraint to control violent behavior as follows:

a. Review of Patient #4's medical record included in part, Patient #4 was placed in locked restraints on 7/18/15 at 3:30 AM and restraints were discontinued 7/19/15 at 5:25 AM and lacked an order for restraints on 7/18/15 at 8:00 AM.

3. During an interview on 9/2/15 at 7:35 AM during chart review, Staff A, Nursing Standards Specialist acknowledged the lack of restraint order every 4 hours Patient #4 as stated above.

Based on review of policies and interview with staff, the hospital failed to ensure the patient rights policies included the right of all patients to be informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. The hospital identified a current census of 250 inpatients at the beginning of the survey.

Failure to provide update policies for patient rights with current visitation rights could potentially result in visitors being restricted from visiting or limiting the right of the patients to choose visitors.

The hospital staff identified an average daily census of 260 inpatients and average daily census of 820 outpatients.

Findings include:

1. Review of hospital policy titled "Patient's Rights and Responsibilities/Non-Discrimination", dated 8/15/15, revealed the policy lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

Review of hospital policy titled "Visitation, Patient Directed", dated 7/15 revealed the policy lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 9/2/15 at 7:35 AM, Staff A, Nursing Standards Specialist, acknowledged the Patient Rights and Visitation policies lacked the current patient visitation rights information as required.

Based on document review, observations, and staff interviews, the hospital staff failed to ensure patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend for all inpatients and outpatients. The hospital identified a current census of 250 inpatients at the beginning of the survey.

The hospital staff identified an average daily census of 260 inpatients and average daily census of 820 outpatients.

Failure to provide all patients with current visitation rights could potentially result in limiting or restricting access of visitors to patients that infringed on their right to have a support person present when they are provided any type of care, services, or treatment modalities.

Findings include:

1. Review of patient handout, "Patient Rights and Responsibilities", dated 5/95, revealed the document lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 8/31/15 at 3:20 PM, Staff B, Admissions Registrar, stated the area registers inpatients, outpatients for Lab, Radiology, and Obstetrics. Staff B stated they provide the patients with patient handout, "Patient Rights and Responsibilities".

During an interview on 8/31/15 at 3:40 PM, Staff C, Registrar Emergency Department, stated the area registers outpatients for Emergency Department, and after hours outpatients for Lab and Radiology. Staff C stated they provide the patients with patient handout, "Patient Rights and Responsibilities".

During an interview on 9/2/15 at 7:35 AM, Staff A, Nursing Standards Specialist, acknowledged the patient handout "Patient Rights and Responsibilities" lacked the current patient visitation rights information as required by the regulations.

I. Based on review of policy, procedure, medical records, and staff interview, the hospital failed to ensure nursing staff obtained an order from the authorized health care provider for the use of restraints to prevent patients from interfering with life sustaining medical equipment in 3 of 9 medical restraint records reviewed. (Patients # 1, 2, and 3) The hospital identified no patients in restraint at the time of the survey.

Failure to notify and obtain a physician's order for the use of restraints could potentially place patients at risk for physical and/or psychological harm from the unnecessary and/or inappropriate application of restraints.

Findings include:

1. Review of policy/procedure titled "Restraints", dated 11/14, included in part, "...Frequency of order renewal...Non-violent situation - unless otherwise specified, duration is assumed to be until the end of the next calendar day..."

2. Review of Patients # 1, 2, and 3 medical records lacked evidence that nursing staff obtained a physician order for the use of restraints as a means of physical restraint to prevent the disruption of life saving treatments as follows:

a. Review of Patient # 1's medical record revealed in part, Patient #1 was placed in restraints on 8/22/15 and restraints were discontinued 8/27/15 and lacked an order for restraints on 8/25/15.

b. Review of Patient # 2's medical record revealed in part, Patient #2 was placed in restraints on 7/5/15 and restraints were discontinued 7/18/15 and lacked orders for restraints on 7/8, 9, 10, 11, and 17/15.

c. Review of Patient # 3's medical record revealed in part, Patient #3 was placed in restraints on 7/8/15 and restraints were discontinued 7/17/15 and lacked orders for restraints on 7/9, 10, 11, 13, and 17/15.

3. During an interview on 9/2/15 at 7:35 AM during chart review, Staff A, Nursing Standards Specialist acknowledged the lack of restraint orders every calendar day for Patients # 1, 2, and 3 as stated above.


II. Based on review of policy, procedure, medical records, and staff interview, the hospital failed to ensure nursing staff obtained an order from the authorized health care provider for the use of restraints to control violent behavior in 1 of 7 violent restraint records reviewed. (Patient #4) The hospital identified no patients in restraint at the time of the survey.

Failure to notify and obtain a physician's order for the use of restraints could potentially place patients at risk for physical and/or psychological harm from the unnecessary and/or inappropriate application of restraints.

Findings include:

1. Review of policy/procedure titled "Restraints", dated 11/14, included in part, "...Frequency of order renewal...Violent situation - each order for restraints may only be renewed in accordance with the following limits for up to a maximum of 24 consecutive hours. aa. 4 hours for adults 18 years of age or older..."

2. Review of Patient #4's medical record lacked evidence that nursing staff obtained a physician order for the use of restraints as a means of physical restraint to control violent behavior as follows:

a. Review of Patient #4's medical record included in part, Patient #4 was placed in locked restraints on 7/18/15 at 3:30 AM and restraints were discontinued 7/19/15 at 5:25 AM and lacked an order for restraints on 7/18/15 at 8:00 AM.

3. During an interview on 9/2/15 at 7:35 AM during chart review, Staff A, Nursing Standards Specialist acknowledged the lack of restraint order every 4 hours Patient #4 as stated above.

Based on review of policies and interview with staff, the hospital failed to ensure the patient rights policies included the right of all patients to be informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. The hospital identified a current census of 250 inpatients at the beginning of the survey.

Failure to provide update policies for patient rights with current visitation rights could potentially result in visitors being restricted from visiting or limiting the right of the patients to choose visitors.

The hospital staff identified an average daily census of 260 inpatients and average daily census of 820 outpatients.

Findings include:

1. Review of hospital policy titled "Patient's Rights and Responsibilities/Non-Discrimination", dated 8/15/15, revealed the policy lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

Review of hospital policy titled "Visitation, Patient Directed", dated 7/15 revealed the policy lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 9/2/15 at 7:35 AM, Staff A, Nursing Standards Specialist, acknowledged the Patient Rights and Visitation policies lacked the current patient visitation rights information as required.

Based on document review, observations, and staff interviews, the hospital staff failed to ensure patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend for all inpatients and outpatients. The hospital identified a current census of 250 inpatients at the beginning of the survey.

The hospital staff identified an average daily census of 260 inpatients and average daily census of 820 outpatients.

Failure to provide all patients with current visitation rights could potentially result in limiting or restricting access of visitors to patients that infringed on their right to have a support person present when they are provided any type of care, services, or treatment modalities.

Findings include:

1. Review of patient handout, "Patient Rights and Responsibilities", dated 5/95, revealed the document lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 8/31/15 at 3:20 PM, Staff B, Admissions Registrar, stated the area registers inpatients, outpatients for Lab, Radiology, and Obstetrics. Staff B stated they provide the patients with patient handout, "Patient Rights and Responsibilities".

During an interview on 8/31/15 at 3:40 PM, Staff C, Registrar Emergency Department, stated the area registers outpatients for Emergency Department, and after hours outpatients for Lab and Radiology. Staff C stated they provide the patients with patient handout, "Patient Rights and Responsibilities".

During an interview on 9/2/15 at 7:35 AM, Staff A, Nursing Standards Specialist, acknowledged the patient handout "Patient Rights and Responsibilities" lacked the current patient visitation rights information as required by the regulations.