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Based on staff interviews, medical record review, and facility document review, it was determined the facility staff failed to provide Medicare recipients the "Important Message from Medicare" (IMM) according to policy for seven (7) out of seven (7) Medicare patients who were admitted for 48 hours or longer. (Patient #2, #3, #5, #9, #11, #12, and #13).

The findings were:

Medical records for the survey sample were reviewed by the survey team with facility navigators throughout the survey process. Patient #3 had two admissions and both of those admissions' medical records were reviewed (seven (7) patients but eight (8) medical records reviewed).

Four (4) Medicare recipients' medical records failed to contain evidence the IMM was provided upon admission or prior to discharge. (Patients #2, #3's first admission, #9, and #13).

One (1) Medicare recipients' medical record failed to contain evidence the IMM was provided upon admission and that patient remained a current inpatient at the completion of the survey. (Patient #5).

Two (2) Medicare recipients' medical records contained evidence the first IMM was provided upon admission but there was no evidence the second IMM was provided prior to discharge. (Patient #3's second admission and Patient #12).

One (1) Medicare recipients' medical records did not contain evidence the first IMM was provided upon admission however, there was evidence the second IMM was provided prior to discharge. (Patient #11).

The facility's policy titled, "Important Message from Medicare" was reviewed on 2/15/18 and read in part, "V. Procedure. 1. All patients with Medicare, Medicare Advantage, Dual Eligible, and Medicare as a secondary provider will receive the IMM. 2. A patient will be presented with an IMM upon admission to an inpatient status and no later than 48 hours after admission. (This will be the first patient signature on the document.) [sic] 3. The second signature for acknowledgment of the pending discharge may be given 48 hours in advance of the pending discharge and no later than 4 hours prior to the discharge. 4. A signed copy of the IMM will be placed in the shadow chart and scanned into the electronic medical record (EMR)."

In the afternoon of 2/15/18, the facility's quality director and the facility's director of case management acknowledged the above listed patients had not received one or both of the IMMs and there was no additional evidence to provide to the survey team.

Based on medical record review and staff interviews it was determined the facility staff failed to apply the type of restraint ordered for two (2) of four (4) patients sampled who had restraints ordered. (Patient #5 and Patient #7).

The findings were:

1. Patient #5's electronic medical record was reviewed on 2/07/18 along with a facility navigator who was a clinical informatics specialist. The patient was a current inpatient at the facility during the survey whose medical record contained evidence the patient had soft limb restraints ordered to the left and right wrists initially on 2/04/18 and those restraints were documented as also being applied on 2/04/18. According to the nursing restraint flowsheet, the patient continued to have left and right soft wrist restraints applied and monitored through 2/07/18. The restraint renewal order on 2/05/18 was written by a nurse practitioner and ordered a "mitt." The physician's renewal order dated 2/06/18 was also for a "mitt." Later that day, on 2/06/18 at 10:07 p.m., a nurse practitioner wrote a restraint renewal order for soft limb restraints to the left and right wrists. The medical record contained no evidence Patient #5 ever had a mitt applied. The only restraints documented were soft limb restraints to both the left and right wrists. One surveyor observed Patient #5 in the medical/surgical intensive care unit (MSICU) on 2/07/18 at 2:45 p.m. and the patient had soft limb restraints to the left and right wrists at that time.

On 2/08/18 at 11:30 a.m., the clinical director of the MSICU, where Patient #5 was located, and the clinical informatics specialist who helped navigate the medical record acknowledged the restraint monitoring showed the restraints were left and right wrist restraints throughout and there was no evidence of a mitt restraint applied.

2. Patient #7's electronic medical record was reviewed on 2/08/18 along with two navigators (the clinical director MSICU and the clinical informatics specialist). The physician's order for restraint was initiated on 01/23/18 at 11:24 a.m. The type of restraint ordered was a "mitt" and the location was ordered for "right wrist." The restraint flowsheet documented that a registered nurse (RN) applied and monitored a soft limb restraint, not a mitt, to the right wrist on 1/23/18 at 11:36 a.m.

On 2/08/18 at approximately 3:15 p.m., the clinical director MSICU and the clinical informatics specialist acknowledged Patient #5's medical record did not contain evidence a mitt restraint was ever applied as ordered.

Based on staff interviews, medical record reviews, and facility document review it was determined the facility staff failed to monitor restraints according to their policy for one (1) of four (4) patients sampled who had restraints ordered. (Patient #7).

The findings were:

Patient #7's electronic medical record was reviewed on 2/08/18 along with two navigators (the clinical director of medical/surgical intensive care unit (MSICU) and the clinical informatics specialist). The physician's order for restraint was initiated on 01/23/18 at 11:24 a.m. The type of restraint ordered was a "mitt" and the location was ordered for "right wrist." The restraint flowsheet documented that a registered nurse (RN) applied and monitored a soft limb restraint to the right wrist on 1/23/18 at 11:36 a.m. There was no more documented monitoring of the restraint. There was also no documentation the restraint was discontinued from the right wrist. The medical record did contain a discontinue restraint order on 1/23/18 at 2:48 p.m. and that discontinue restraint order was acknowledged by an RN (registered nurse) on 1/23/18 at 6:40 p.m.

On 2/08/18 at approximately 3:15 p.m., the clinical director MSICU and the clinical informatics specialist acknowledged Patient #5's medical record did not contain evidence the restraint applied was monitored more than once and also did not indicate when the restraint was discontinued.

The facility's policy titled, "Restraints and Restraint Alternatives" was reviewed throughout the survey. It read in part, "C. Assessment/Monitoring. Patients restrained for medical/surgical reasons are assessed by the RN and monitored by a qualified clinical (i.e. RN, Clinical Technician), at a minimum, Q2H (every two hours) for adults, Q1H (every one hour) for youth/child, or more frequently based on clinical judgment, and according to the patient's need."

Based on interviews and a review of the hospital's policy, and medical staff credentialing/privileging files, it was determined the hospital staff failed to ensure that seven (7) of seven (7) physicians or other LIPs (Licensed Independent Practitioners) sampled for review, completed and passed a written test regarding restraint standards to be authorized to order restraints and seclusion, as was required in the hospital's Policy.

The findings were:

The surveyor reviewed the hospital's Policy titled, "Restraints and Restraint Alternatives" on 02/15/18 at 3:25 p.m. The policy included a section "F" which was titled "Competency and Training Requirements." Section "F" included the competency and training requirements for the "Physicians and other licensed independent practitioners or designee" and read, in part, as follows:
"2. In order to be authorized to order restraints and seclusion, physicians and licensed independent practitioners will be required to pass a written test regarding the restraint standards during their credentialing process, and again whenever significant changes are made to the restraint policy that could affect their ordering of restraints and seclusion."

The surveyor reviewed the credentialing/privileging files of the seven (7) medical staff members sampled for review on 02/15/18 beginning at 3:20 p.m. and ending at 3:40 p.m. The Director of Medical Affairs assisted the surveyor during the review in navigating the credentialing/privileging files. The files failed to contain evidence that any of the seven (7) sampled medical staff members, had ever completed a written test regarding the restraint standards, as required by the hospital's policy (see above). Each of the sampled files contained a document, which the Director of Medical Affairs stated to be an attestation by each medical staff member that they had completed the hospital's self study restraint training. The Director of Medical Affairs stated during the review, the medical staff members would not have a transcript or other evidence the training was actually completed, but that the hospital requires the
attestation with each credentialing/privileging review which occurs upon initial appointment to the medical staff and reappointment to the medical staff every two (2) years. The Director of Medical Affairs stated having no knowledge of any written tests taken by the medical staff for restraints and seclusion. The Director of Medical Affairs left the conference room/surveyor work area stating he/she would check with other hospital management staff about whether or not the medical staff were given a written test regarding restraints and seclusion. The Director of Medical Affairs returned approximately 20 minutes later and stated there was no written test taken by the medical staff regarding restraints and seclusion.

The surveyor presented the above findings, related to restraint and seclusion training/testing for medical staff members, to the Director of Medical Affairs and the Quality Director on 02/15/18 at 4:00 p.m. Both the Director of Medical Affairs and the Director of Quality acknowledged they had no further information or evidence to provide. The Director of Medical Affairs acknowledged the facility failed to provide evidence that seven (7) of seven (7) sampled medical staff members, had taken or passed a written test regarding restraints and seclusion, as required per the hospital's policy.

Based on medical record review, staff interviews, and facility document review, it was determined the facility staff failed to administer blood products as ordered for one (1) of two (2) patients sampled who had received blood products. (Patient #5).

The findings were:

Patient #5's medical record was reviewed on 2/07/18 with a facility navigator who was a clinical informatics specialist. The medical record contained evidence the patient had received two (2) units of packed red blood cells (PRBCs) on 2/05/18.

The first unit was ordered by a nurse practitioner on 2/15/18 at 12:48 a.m. and ordered the PRBCs to be given for a duration of one (1) hour. The nursing documentation noted a registered nurse (RN) hung that unit on 2/05/18 at 4:31 a.m. and stopped the transfusion on 2/05/18 at 6:30 a.m. for a total of two (2) hours. The medical record did not contain evidence that blood transfusion had been slowed or stopped during the time it hung for any reason.

The medical record contained evidence the second transfusion of PRBCs was ordered by a physician for a duration of four (4) hours and it transfused from 2/05/18 at 2:28 p.m. until 2/05/18 at 6:30 p.m.

On 2/13/18 at 11:45 a.m. the facility's clinical informatics specialist and an RN who was a medical/surgical nurse educator (Staff Member #4) acknowledged Patient #5's medical record contained no evidence to explain why the first unit of PRBCs had been given over two hours instead of the one (1) hour as ordered.

The facility's policy titled, "Transfusion/Infusion of Blood Components" was reviewed on 2/08/18 and read in part, "F. Timeframes 2. Blood products must be transfused within four (4) hours of the product leaving Blood Bank storage or before the blood product's expiration date and/or time, whichever comes first." The policy did not address minimum timeframes.