HospitalInspections.org

Based on findings from document review and interview, in 4 out of 22 medical records (MRs) reviewed (for obstetrical Patients #17, #18, #19, #20) the MRs lacked documentation indicating the patients were provided information on patients' rights.

Findings include:

-- Per review of the hospital policy titled "Patient Bill of Rights," last reviewed 8/2012, it states "...all patients and/or their representatives will be informed of their right to receive a copy of the Patients' Bill of Rights.... The admitting clerk will request that the patient or his/her representative sign the form acknowledging receipt of the Patient Bill of Rights."

-- Per review of the MRs on 3/25/14 of Patients #17, #18, #19, and #20, all lacked documentation acknowledging the patient's receipt of the Patient Bill of Rights.

-- Per interviews on 03/25/14 with Patient #17 and his/her representative at 11:30 am and Patient #18 and his/her representative at 11:50 am, they were not informed of their Patients' Rights and did not receive a copy of the Patients' Bill of Rights.

-- The above finding was acknowledged by the Obstetrical Nurse Manager and the Director of Quality Improvement on 3/26/14 at 12:15 p.m.

Based on document reviews and interview, the hospital's policies and procedures (P&P) for restraints and seclusion were not complete.

Findings include:

-- Per review of the P&Ps titled "Behavior Restraint and Seclusion," last reviewed 8/2012, and "Medical/Surgical Restraints," last revised 02/2012, neither contained the following information:

1. Restraint is only used to ensure the physical safety of the non-violent or non-self-destructive patient.

2. Medications or drugs are restraints when used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

3. Orders for restraints or seclusion used for emergency situations must be obtained either during the emergency application or immediately (within a few minutes) after the restraint or seclusion has been applied.

4. Orders for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours:
(A) 4 hours for adults 18 years of age or older;
(B) 2 hours for children and adolescents 9 to 17 years of age; or
(C) 1-hour for children under 9 years of age.

5. When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1 hour after the initiation of the intervention by a physician or other licensed independent practitioner (UP), or registered nurse or physician assistant who has been trained in accordance with the requirements specified in this regulation (in paragraph(f)).

6. If a patient remains in restraint or seclusion for the management of violent or self-destructive behavior 24 hours after the original order, the physician or other LIP must see the patient and conduct a face-to-face re-evaluation before writing a new order for the continued use of restraint or seclusion.

-- During interview with the hospital's Risk Manager on 3/26/14 at 02:10 pm he/she acknowledged the above information was not included in the hospital's P&Ps regarding restraint and seclusion.

Based on findings from document review and interviews, in 2 of 7 medical records (MRs) reviewed for patients identified as needing a discharge plan, the hospital failed to ensure that the discharge planning evaluation documented in the patient's chart was complete.

Findings include:

--Per review of Patient #8's MR, she was discharged back to home after undergoing abdominal surgery for an incarcerated inguinal hernia. On 02/12/14 at 1550, Social Worker (SW) #1 documented that Patient #8 and her daughter were agreeable to a Visiting Nurse Service (VNS) referral for skilled nursing services, that her daughter was her primary caregiver, and that her daughter also provided care to Patient #8's spouse.

There is no documentation of assessment of Patient #8's ability to perform ADLs and whether the patient's support was capable of meeting her care needs beyond the VNS. There was also no indication of whether the patient's insurance coverage would provide for VNS home care post discharge.

--Per review of Patient #12's MR, she was admitted to the hospital with exacerbation of asthma and was discharged on 03/21/14 with orders for oxygen 2 liters at night and home nursing services. On 03/20/14 SW #2 had documented that the patient was seen and given a "discharge planning sheet," that in the past the patient had HCR home care services, and that presently she had Meals on Wheels. On 03/21/14, SW #2 documented that the patient was discharged with HCR home care services for nursing and a physical therapy (PT) evaluation, that Meals on Wheels were in place, and that Patient #12 qualified for oxygen at night and agreed to CRMC home care for her oxygen supplier.

There is no documentation in the discharge planning evaluation of assessments of the patient's ability to perform ADLs and the capability for her actual needs to be met at home. There is also no verification that the patient's insurance coverage would provide for the home health, meal and equipment services.

-- During interview with the Director of Quality on 03/26/13 at 10:30 am, the above findings were acknowledged.

Based on findings from document review and interviews, in 2 of 7 MRs reviewed, information provided to the patients (Patients #8, #12) at discharge did not include when subsequent medication doses were due after discharge. Also, the hospital policy regarding medication reconciliation did not address this necessary discharge instruction.

Findings include:

--Review of Patient #8's MR reveals that the patient was discharged on 02/13/14. Discharge Instructions included 12 medications that were to be continued at home. However, the discharge instructions form lacked the times that the medications should first be taken after discharge from the hospital.

Review of Patient #12s MR reveals that the patient was discharged on 03/21/14. Discharge Instructions included 10 medications that were to be continued after discharge. The discharge instructions form lacked the times that the medications should first be taken after discharge from the hospital.

--Per review of the hospital's policy titled "Medication Reconciliation," last reviewed 08/2012, it did not address a requirement to note the time that medication should be resumed at home after discharge from the hospital.

--During interview with the Risk Manager on 03/26/14 at 3:30 pm, he/she acknowledged that information should be provided to patients regarding the time that medications are to be resumed after discharge.

Based on findings from interview, the hospital did not document evaluations of prior discharge planning for readmissions reviewed.

Findings include:

During interview with the Director of Quality on 03/26/14 at 2:30 pm, he/she indicated that case management staff evaluate the adequacy of previous discharge planning for patients readmitted to the hospital, but also acknowledged the staff do not document these reviews.