HospitalInspections.org

The Condition of Patient Rights is Not Met as evidence by the numerous significant standard level deficiencies cited under this Condition which reflect deficient practices in the areas of seclusion and restraint, patient privacy and patient protections. The practices observed included:

A0143 - Patient medical information was not protected
A0144- Failure to take precautions to prevent a patient with an identified fall risk from falling;
A0166- Failure to update the care plan for 8 patients who placed in either seclusion or restraint;
A0168 - Failure to have an order for a manual restraint for one patient
A0169 - Due to a PRN order for restraint for one patient;
A0178 - Failure to perform a face to face evaluation of one patient who had been in seclusion; and
A0214 - Failure to completely address the reporting of patient deaths while in restraints or seclusion in the hospital policy.

Based on observation and review of the 4th floor physical plant during the morning tour with the Risk Management Staff on the first day of survey (03/19/15) and interview of the licensed 4th floor nursing staff, it was discovered that patients' privacy as related to clinical care information was not being maintained in a private and confidential manner as required. This was evident for 8 patients out of a census of 36 patients.

The findings were:

During the tour with the Risk Management Staff on 03/1 9/15 between 8:30 AM to 9:30 AM, several metal clipboards were observed hanging on the hall handrails directly outside the patient's room and door. The clipboards upon further examination contained patient care records/information clipped to them ( i.e.: toileting mode, turn every 2 hours, bed alarm, pain, medications every shift, and observation entries for a few). The rounding care sheets had the date, patient's room number, and their name in the top right hand comer. The clipboards with patient information was within view for any of the visiting public.

Patients observed with clipboards and patient information in view were as follows:

Room 433-Patient B, Room 429-Patient D in addition to observation entries for 03/1 4-03/1 5/1 5, Room 432-Patient G, Room 41 9-Patient V, Room 41 3-Patient D, Room 417-Patient G, Room-416-Patient L, and Room 415-Patient I.

Failure by the licensed nursing staff to ensure the patient's privacy of care information potentially violated the patient's right to privacy.

Based on observation and review of a patient's medical record, interview of the: 4th floor licensed nursing staff, the 4th floor Administrative Staff (Director of Nursing), Risk Management Staff, and Patient Advocate Staff and review of: the Fall Policy and Procedure, Incident Reports and other operational documents, it was determined that the staff failed to ensure a vulnerable patient's physical safety and well being. This was evident for one out of 19 sampled patient reviews.

The findings were:

Patient #5 was 80 years old, wheelchair bound, and resided at an Assisted Living Facility (ALF). The patient was transported via 911 on 02/18/15 at 15:46 (3:46 PM) and brought to the Emergency Department from the ALF for abdominal pain, generalized weakness, reduced appetite, and confusion. The patient was noted as a poor historian. The patient had other medical conditions and a history significant for: gastrointestinal esophageal disease(GERD), hypertension, spinal stenosis, chronic anemia, osteoporosis, depression, and polymyalgia rheumatic.

The patient was placed on observation status on 02/18/15 to 02/19/15 on 4 East. By 02/20/15 the patient was admitted to the hospital on 4East for a diagnosis of acute urinary tract infection and encephalopathy.

The hospital utilizes the Morse Fall Scale Assessment Tool for assessing patients for Fall Risk, which outlines fall management interventions that are gauged and progressive from low(0-24), medium(25-50), and high (greater than 50). Each category contains a listing of interventions that staff can consider or implement for maintaining patient safety. Interview of the 4th floor nurse manager on 03/19/15 at 10AM revealed that the staff assesses each patient two times in 24 hours for fall risk. A review of Patient #5's fall risk assessment scores between 02/18/15 at 23:00(11 PM) through 02/21/15 at 21:00(9 PM) revealed that the patient was a high fall risk with scores that ranged from 60 to 100. According to the toll the "High Risk Fall Patient" has listed the following suggested interventions:

"1. Encourage family to assist with 24 hour supervision, 2. Remain with patient when
tilting; request that the family provide a sitter, or complete request for a sitter form (SAW) and give to House Administrator".

The low and medium risk interventions included: "rounds every hour, clinical communication (handoff) at transfer, bed/chair alarms, and supervision of ADL(s) ( Activities of Daily Living)."

Interview of the Risk Management Staff and Nursing Administrative Staff (Director of Nursing for Medical Surgical Units) on 03/19/15 - 03/20/15 during both days of the survey, confirmed that the patient had (2) falls with injury. The patient falls were noted in the patient's medical record and the hospital's incident reporting system.

The patient's first unwitnessed fall was on 02/19/15 at 16:25(4:25 PM) while in observation on 4 East-Room 415, after being placed on a bedside commode. The nurse left the patient on the bedside commode to obtain medication. Upon the nurse's return to the room the patient was found on the floor. The staff noted in the interdisciplinary notes dated 02/19/15 at 18:12(6:12 PM) that patient fell attempting to wash hands and denied hitting the head. The patient incurred a large skin tear to the left knee and the hospitalist was notified. lnterview of the Risk Management Staff and Nursing Administrative Staff revealed that the hospitalist did examine the patient on the floor for possible injury. The exact time of the examination was not known as the hospitalist failed to enter an assessment note. The nursing staff assigned to the patient also failed to enter a complete assessment note of the injury as related to a description of the injury to the left knee and other pertinent information such as the time the patient was seen by the hospitalist and treatment. The patient's fall risk score closet to the time of the fall was a 65, meaning a high risk with need for staff to remain with the patient while toileting. A sitter (In-house staff) was placed with patient and remained with the patient until 00:24 on 02/20/15.

The second unwitnessed patient fall was on 02/2015 at 00:45, on the same unit and in room (415). The second fall was approximately 8 hours and 15 minutes after the first fall, and approximately minutes after the patient was without a sitter. A licensed registered nurse was walking down the hall at approximately 12:45 AM on 02/20/15 and responded to the bed alarm sounding from the patient's room. The nurse as the first responder found the patient lying on the floor with head against the wall. The nurse noted in a progress note that the patient had blood on the forehead, left arm, left hand, and knee. The hospitalist was paged but the nursing staff failed to note the exact time the call was made. By 05:03 AM on 02/20/15 a surgical physician's assistant (SPA) assessed the patient (approximately 4 hours post injury) and evaluated the patient's laceration to the right side of the forehead. The laceration measured centimeter (cm) by 2 cm and was located at the right eyebrow and forehead. The patient's right eye was bruised and a skin abrasion or tear continued down the right cheek. The SPA sutured the lacerations and applied dressings. A non-adhesive dressing was applied to the skin tear. The SPA noted the CT Scan of the head showed no acute fracture and the patient tolerated the suture procedure without complications.

The patient underwent two CT Scans of the head on 02/20/15 (01:38 AM and 11 :21 AM) which revealed that the patient suffered a subtle non-displaced fracture of the maxillary sinus and right sphenoid sinus. The sphenoid sinus had a large amount of hemorrhage.

Continued medical record review revealed that the nursing staff conducted neurological assessments/ checks starting at 1:30 AM (after the patient's 1st CT Scan of the head) on
02/20/15, which were within normal limits (WNL) with the exception of cough reflex absence. A second neurological assessment was conducted at 04:00 on 02/20/15 and found WNL. However, the next documented neurological assessment was not conducted until 14:35 or 10 hours after the 04:00 assessment. Neurological checks are normally done post fall with injury per an individual hospital developed protocol as a way to assess the extent of the patient's injury and early identification of any substantial change in the patient' s condition indicating a possible increase in intracranial pressure. Upon review of the hospital policies and procedures, interview of the Risk Management and the Nursing Administrative Staff, it was learned that there was no specific and dedicated neurological assessment policy and procedure for patient post fall neurological assessments. The Risk Management Staff with further interview by the surveyor referred the surveyor to the Fall and Injury Prevention Policy and Procedure that clearly noted in red bold print, " REMINDER: Reference Lippincott's Nursing Procedures & Skills(Hard Copy) for basic nursing procedures and protocols." A review of the information stated that nursing should monitor the patient for signs and symptoms of increased intracranial pressure, although no specific frequency or duration of neurological checks was outlined."


Additional medical record review revealed, a neurological staff member on 02/20/15 at 18:30 noted that the patient had complained of a slight head-ache and was medicated with Dilaudid. The neurological staff member noted the need for frequent neurological assessments as ordered But did not define any actual time parameters to continue through the night and to call the hospitalist or neurologist with any changes in the neurological exam.

Interview of the Risk Management and Nursing Administrative Staff (Director of Nursing for Medical Surgical Units) on 03/20/15 at 2:30 PM, revealed that the hospital on 02/19/15 for the upcoming evening and impending night on 02/20/15, incurred staff call outs for the incoming weather of snow and ice. Attempts to secure in-house staff, as well as agency staff for needed coverage (such as a"sitter" ) were unsuccessful. However, a review of the staffing schedule and assignment sheets revealed that from 7PM - 7AM on 02/19/15 through the early morning of 02/20/15 on the 4th floor the patient census was 25 patients, plus or minus 1 patient, with a staff compliment of: 5RN(s) with one nurse in charge, 2 Nursing Techs(NT), and one Unit Assistant(UA). One NT that was assigned for the shift was pulled and reassigned to another floor/unit based on a higher priority of need . It was not until 6 am on 02/20/15 that the patient had a sitter re-assigned for safety.

Interview of the Risk Management and Nursing Administrative Staff revealed that the staff are trained annually on patient safety and fall prevention with a hospital wide fall reduction initiative in place.

Observation and review of employees files assigned or involved in Patient#5's care revealed that staff had received training on patient safety. Interview of the Human Resource and Nursing Administrative Staff confirmed that the employees were not counseled in writing for where and when the patient' s care became unsafe except for a post fall huddle. Administrative Nursing Staff were unable to confirm or deny whether if the involved employees in Patient #5's care had received any additional training since the patients falls.

Failure by the nursing floor staff to plan and follow high risk fall interventions and provide sitter oversight for a confused and elderly patient created a window of time without adequate patient coverage that likely contributed to the patient's fall with injury twice.

Based on review of 10 open and 9 closed medical records, it was determined that in 8 out of 19 medical records for patients placed in seclusion/restraint the patient's plan of care was not updated.

The hospital has a treatment plan form that has a box at the bottom of the form to document the date a patient is placed in seclusion or restraint. This would not be sufficient to act as a treatment plan which should include assessment of the problem, interventions and evaluation of effectiveness.

Patient # 11 was admitted to 6 East on 2/6/14. The patient was placed in seclusion on 2/7/14. Review of the medical record revealed the box at the bottom of the treatment plan had not been checked and dated nor had the use of seclusion been added to the treatment plan.

Patient #12 was admitted to 6 East on 5/2/14. The patient was placed in seclusion and then 4 point restraint on 5/3/14. Review of the medical record revealed the box at the bottom of the treatment plan had not been checked and dated nor had the use of seclusion been added to the treatment plan.


Patient #13 was admitted to 6 East on 11/1/14. The patient was placed in 4 point restraint on 11 /1/14 at 6:55 am. Review of his medical record revealed the box at the bottom of the treatment plan had not been checked and dated nor had the use of seclusion been added to the treatment plan.


Patient #14 was admitted to 6 East on 10/21/14. The patient was placed in seclusion on 10/21 /14. Review of his medical record revealed the box at the bottom of the treatment plan had not been checked and dated nor had the use of seclusion been added to the treatment plan.

Patient #15 was admitted to 6 East on 10/14/14. The patient was placed in 4 point restraint following self-destructive behavior. Review of the medical record revealed the box at the bottom of the treatment plan had not been checked and dated nor had the use of seclusion been added to the treatment plan.

Patient# 16 was admitted 6 East on 8/21 /14. The patient was placed in seclusion on 8/22/14 at 9:l0AM. Review of the medical record revealed the box at the bottom of the treatment plan had not been checked and dated nor had the use of seclusion been added to the treatment plan.

Patient #17 was admitted to 6 East on 2/16/14. The patient was placed in seclusion on 2/19/14. Review of the medical record revealed the box at the bottom of the treatment plan had not been checked and dated nor had the use of seclusion been added to the treatment plan.

Patient # 18 was admitted to 6 East on 12/31 /14. The patient was secluded then placed in restraint on 01/1/15. Review of the medical record revealed the box at the bottom of the treatment plan had not been checked and dated nor had the use of seclusion been added to the treatment plan.

The use of restraint or seclusion must be in accordance with a written modification to the patient's care plan. The hospital failed to meet the regulatory guidelines of up-dating the care plan for patients placed in seclusion or restraint.

Based on review of the 10 open and 9 closed medical records, it was determined that 1 of the 19 medical records (patient #1 4) had no order for manual hold.


Patient #14 came out of the shower and when asked by staff to put clothing on the patient grabbed at staff and got scratched. The patient did not respond to verbal redirection. Security was notified and the patient began punching staff with closed fist. The patient was given medication intramuscular while in his bed, was assisted into pajamas and taken via a forward take (patient noted to be shouldering security) and was placed in seclusion. Review of patient #14's medical record revealed an order for seclusion but no order for the manual holds for medication and for taking patient to the seclusion area. The hospital failed to meet the regulatory requirement to have orders for seclusion/restraint, in this case an order for manual holds which is a form of restraint.

The use of restraint or seclusion must be accordance with the order of a physician or other license independent practitioner who is responsible for the care of the patient .

Based on review of 10 open records and 9 closed medical records, it was determined that 1 out of 19 medical records reviewed had an as needed (prn) order written for restraint for patient #7.

Patient # 7 entered the Emergency Department after being Emergency Petitioned for being disoriented, talking to himself and walking along the edge of train platform. The patient was administered a chemical restraint. In addition an order was written by the ED physician assistant for 4 point restraint with 1:1 continuous observation on 3/18/15 at 22:56 (10:56 PM). There was a progress note written on 3/18/15 at 23:33 (11 :33 PM) that stated, "if chemical restraint is not enough to keep patient safe will use 4 point restraint." Based on the medical record review the patient did not require the application of 4 point restraint and therefore the order was written as a prn order.

Orders for the use of restraint or seclusion must never be written as a standing order.

Based on review of 10 open and 9 closed medical records, it was determined that 1 out of 19 medical records lacked the face-to-face documentation.


Patient #16 was walking about the unit with their buttocks exposed. The patient refused to cover up and did not respond to verbal redirection of staff. The patient's behavior escalated toward peers and staff. Security was called, the patient was medicated and the patient was walked to seclusion. The patient was secluded per the medical record on 8/22/14 at 9:10AM. The hospitalist was called per the medical record to perform the face-to-face. Review of the medical record revealed no face-to-face documentation. The hospital failed to perform and document a timely face-to-face for patient #16.

Based on observation and review of the hospital's policy, "Seclusion and Restraint Use for the Violent Patient", it was determined that the hospital's policy failed to address reporting of deaths that occur while the patient is in seclusion or restraints.

The findings were:

Review of the hospital's policy and procedure, Seclusion and Restraint Use for the Violent Patient revealed that in section C.1. It stated for death reporting of patients in seclusion and restraint that the death reporting occurs with 24 hours and 1 week after use of restraint and seclusion. The policy did not clearly indicate that the hospital will report each death that occurs while a patient is in restraint or seclusion.

Based on observation and review of patient medical records, it was determined that 2 of 19 patients reviewed did not have a complete care plan that identified and addressed their falls risk. The findings were:

Patient #1 was 80 years old, admitted to the hospital on 03/15/ 15 with abdominal pain. The patient was wheelchair bound, had generalized upper bilateral weakness with right side contractures due to a stroke, and a supra-pubic catheter. The patient was assessed and identified as being a fall risk. A review on 03/19/15 of the patient's care plan located at the front of the paper binder record revealed that the patient's potential for falls was not identified and addressed on the care plan.

Patient #2 was 41 years old and was admitted to the hospital on 03/17/15. The patient on 03/17/15 at 19:15 (7:15 PM) had a Fall Risk Assessment score of 35 (medium fall risk). A review of the patient's care plan in the paper binder record revealed that the patient's potential fall risk was not identified and addressed on the care plan.

Failure by the nursing staff to identity, address, and develop a written care plan on patients assessed with a medium-high fall risk, potentially placed: 1) the patients at risk for having a break in their continuity of care and 2) for staff not having the most current clinical information for the assessment, evaluation, and changes in the patient conditions or outcomes.

Based on observation and review of Patient#5's medical record and interview of the Risk Management and Nursing Administrative Staff on 03/19/15 - 03/20/15, it was determined that the Registered Nurse in Charge failed to assign other nursing personnel as a sitter on 1:1 status to care for Patient #5 between 02/19/15 - 02/20/15 to ensure the patient' s safety and the prevention of falls. Refer to A-144 for details.

Based on observation and review of Patient #5's medical record and interview of the Risk Management and Nursing Administrative Staff on 03/19/15-03/20/15, it was determined that the patient's medical record was incomplete and lacked assessment information important in the planning and the delivery of care. Refer to A-144 for details.

Based on a review of 10 open and 9 closed med ical records, it was determined that 1 of the 19 records contained a verbal order for seclusion on 8/22/14 at 9: 10AM that was not signed by the prescribing physician on the day of the survey March 20, 2015. Refer to Tag A-0178, Patient #16 for details.

During the initial tour of the 4th floor in the morning on day 1 of the survey, the utility closet(housekeeping closet) Room 443J was observed unlocked, open for entry to shelved hand sanitizer, foam soap, and wall mounted dispenser of disinfectant and acid cleaner.

Chemicals that are not secured can pose a safety hazard to patients and visitors who may have exposure through ingestion or contact.