HospitalInspections.org

Based on a review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure that services performed under contract were provided in a safe and effective manner.

Findings include:

Review of the facility's Performance Improvement Plan, Reviewed, July 2011 revealed, "Mission: The Board of Trustees of Highlands Hospital supports the goal of continuous quality improvement throughout the organization consistent with the mission of the hospital. The goal is to provide a planned, systematic and integrated approach to measuring, assessing and improving the services provided by the organization."

1. Review of facility quality improvement reports on December 13, 2012, revealed no documentation of quality review of services contracted by the facility.

Interview with EMP3 on December 13, 2012 at approximately 10:00 AM revealed, "We do not do quality on our contracted services"

Based on review of facility documents and credential files (CF), and staff interviews (EMP), it was determined that the facility failed to ensure that physicians and other licensed independent practitioners, authorized to order restraint or seclusion by hospital policy, in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion for 15 of 15 files reviewed (CF1, CF2, CF3, CF4, CF5, CF6, CF7, CF8, CF9, CF10, CF11, CF12, CF13, CF14, and CF15.)

Findings include:
Review of facility policy, "Seclusion and Restraint," dated November 2008, revealed, "Procedures Governing Use of Restraints and Seclusion ...Q. Required in-services are conducted annually for all staff involved in the ordering, monitoring and implementation of seclusion or restraint. In-services provide for the ongoing training and assessing of staff competencies and include training regarding alternative methods and strategies to the use of seclusion or restraint."

1) Review of CF1 through CF15 revealed no documentation of training and competency for restraints and seclusion.

2) Interview on December 12, 2012, with EMP2, at approximately 11:45 AM, revealed, "There is no specific training for physicians [for restraints]."

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure that all orders, including oral orders were dated, timed, and authenticated promptly by the ordering practitioner for five of seven medical records reviewed (MR36, MR37, MR38, MR40, and MR41).

Findings included:

Review of "Highlands Hospital Medical Staff Rules And Regulations" dated April 2011 revealed "11. An oral or a telephone order may be transmitted ... Such orders must be countersigned with signature, date, and time on the patient's chart by the staff member so ordering or the attending physician when the order was placed by a physician in a coverage arrangement within twenty-four (24) hours.

1) Review of MR36 revealed between October 15 and October 16, 2012, there were five verbal orders that were not dated and/or timed by the prescribing physician.

2) Review of MR37 revealed on October 29, 2012, there were three verbal orders that were not dated or timed by the prescribing physician.

3) Review of MR38 revealed between October 15 and October 18, 2012, there were thirteen of sixteen verbal orders that were not dated or timed by the prescribing physician.

4) Review of MR40 revealed between October 29 and November 1, 2012, there were nine verbal orders that were not dated or timed by the prescribing physician.

5) Review of MR41 revealed between October 12 and October 13, 2012, there were three verbal orders that were not dated or timed by the prescribing physician.

Interview with EMP2 on December 12, 2012, at approximately 11:00 AM confirmed the above findings and revealed "We know it's a problem."

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure that physicians obtain the necessary informed consent prior to the start of any procedure or treatment for three of nine MR's (MR16, MR49 and MR50).

Findings include:

Review of facility policy #6.27, Patients Rights and Responsibilities, dated November 2012, revealed, "Communication ... Except for emergencies, the physician must obtain the necessary informed consent prior to the start of any procedure or treatment or both."

Review of facility policy "Patient Consent" dated dated July 2006, revealed, "C. Responsibilities of Physicians and Dentists: 1. It is the physician's or dentist's responsibility to provide the patient with appropriate information about the procedure so that the patient may make an informed decision. ... D. Forms: 1. A written consent form should be used to document the patient's authorization prior to certain procedures. When completed, the form serves as a record of informed consent discussion between the patient and physician, and of the patient's authorization for the procedure after being advised of the risks."

1) Review of MR16 revealed an informed consent dated December 6, 2012, for a gastrointestinal endoscopy procedure which was signed by the patient and a witness. There was no MD signature on the consent.

2) The above findings were confirmed with EMP8 who confirmed, "The physician did not sign the consent."
3) Review of MR49 and MR50 December 13, 2012, revealed consents for administration of blood products, the consents was signed by the patient. There was no physician signature on the consents.
4) Interview with EMP3, December 13, 2012, at approximately 1:00 PM, confirmed above findings.

Based on review of facility documents and medical records (MR), and employee interview (EMP), it was determined the facility failed to ensure the patient's right of choice letter was completed as per policy for three of four medical records reviewed (MR46, MR47, and MR48).

Findings Include:

Review of facility policy "Obtaining Patient Choice For Continuing Care Services" dated March 2009, revealed "Complete the patient information and choice letter."

1. Review of MR46 revealed no documentation that the patient received the information and choice letter.

Interview with EMP12 on December 13, 2012, at approximately 1:45 PM confirmed the above findings and revealed, "I can't say if ... gave them [family] a freedom of choice form."

2. Review of MR47 revealed a patient information and choice letter dated November 11, 2012, with the notation "verbal daughter POA [Power Of Attorney]". Further review of MR47 revealed no documentation of a POA.

Interview with EMP12 on December 13, 2012, at approximately 1:55 PM confirmed the above findings and revealed, "No, there is no documentation of who is POA. It should have been confirmed."

3. Review of MR48 revealed no documentation that the patient received the information and choice letter.

Interview with EMP12 on December 13, 2012, at approximately 2:15 PM confirmed the above findings and revealed, "I'm not finding it [information and choice letter].