HospitalInspections.org

Base on interviews and document review, it was determined the nursing staff failed to document an assessment of the patient in restraints every two (2) hours as per the facility's policy for two (2) of four (4) patients medical records reviewed for restraints.

The findings include:

A review of the medical record for Patient #3 on 3/7/2022 at 2:08 p.m. contained evidence that there was no nursing assessment documented at 6:00 a.m. on 2/9/2022.

A review of the medical record for Patient #4 on 3/7/2022 at 2:19 p.m. contained evidence that there was no nursing assessment documented at 10:00 p.m. on 2/28/2022 and 12:00 a.m. on 3/1/2022.

During medical record review on 3/7/2022 at 2:19 p.m., Staff Member (SM) #1 navigated through the medical records for Patient's #3 and 4 and confirmed that the nursing assessment was missing for those dates and times while the restraints were in place as per the physician's order. SM #1 confirmed that it is the facility's policy to complete a nursing assessment every two (2) hours for patients in restraints.

A review of the facility's policy titled, "Patient Restraint/Seclusion COG.COG.001," states in part:
...7. Monitoring the Patient in Restraints or Seclusion
a. Patients are assessed by an RN immediately after restraints or seclusion are initiated to assure safe application/initiation of the restraint or seclusion.
b. An RN will assess the patient at least every two (2) hours
...12. Documentation Requirements
The medical record contains documentation of:
...j. Assessment of the patient in restraint or seclusion...

Based on staff interview and document review, it was determined the facility failed to implement its policies and procedures to ensure all staff were fully vaccinated for COVID-19. Ninety four (94) percent of facility staff were fully vaccinated, or exempt from receiving the COVID-19 vaccine and the facility was unable to provide completed medical exemption forms for review.

The findings include:

On 3/7/2022, Staff Member (SM) #2 provided documentation that 619 staff members subject to the vaccine requirements. Five-hundred seventy nine (579) out of 619 applicable staff members (approximately 94 percent (94%)) were fully vaccinated or exempt. The facility maintained no listing for staff temporarily delayed. Approximately six (6) percent of, or forty (40) staff members, were documented as having partial vaccination, unverified documentation, no record, or missing documentation.

During an interview on 3/8/2022 at 10:35 a.m., SM #2 stated that if Human Resources (HR) does not have record or documentation of vaccination, exemption, or delay for a staff member, then HR has been reaching out to the staff's director for the staff member to comply.

During an interview on 3/9/2022, SM #2 stated that Human Resources (HR) does not have access to the medical exemption forms completed for staff members. SM #2 stated that there is no mechanism to sort between medical and religious exemptions and that HR does not have access to the exemption forms uploaded by the staff member. SM #2 stated that the exemption request process is that the staff member uploads the completed request form, then the form is verified by Parallon Service Center, Division of HCA, who then confidentially maintains that documentation. The surveyor was unable to review completed medical exemption forms for any staff member to confirm compliance with the facility's policy and the regulation.

The facility's policy titled, COVID-19 Vaccination Requirements for Employees and Staff of HCA CMS Mandate Facilities," states in part:
Purpose: To ensure that Staff of the HCA CMS Mandate Facilities are Fully Vaccinated against COVID-19, and that HCA CMS Mandate Facilities take steps to ensure that all Staff are Fully Vaccinated for COVID-19.
...Procedure:
1. Vaccination Required.
Each HCA CMS mandate facility shall track Staff vaccination to ensure that all staff specified in this policy, except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this policy as provided before, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC due to clinical precautions and considerations, have received, at a minimum:
a. a single dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to the later of January 27, 2022 or the first date such staff provided any care, treatment, or other services for an HCA CMS mandate facility and/or its patients.
b. a single-dose of COVID-19 vaccine, or both doses for a multi-dose COVID-19 vaccine prior to the later of February 28, 2022 or the first date such Staff provide any care, treatment, or other services for the HCA CMS Mandate Facility and/or its patients.
c. Staff newly hired or engaged at or for an HCA CMS Mandate Facility on or after January 27, 2022 will meet these requirements prior to the first date such Staff provide any care, treatment, or other services for the HCA CMS Mandate Facility and/or its patients.
...3. Exemption Requests. Staff may request an exemption form the COVID-19 vaccination requirements in this policy based on an applicable federal law.
...e. The HR [Human Resources] function for each HCA CMS Mandate Facility, as applicable, shall be responsible to track and securely document and maintain exemption requests, information provided in furtherance of such exemption requests, and the response to such exemption request...