HospitalInspections.org

Based on policy review, document review and interview, the facility did not follow their personnel discipline policy and/or NYS Title 10 Nursing Services 405.5 regulations. This has the potential for missed opportunities for staff education and/or may lead to adverse patient outcomes.

Findings include:

Review on 06/26/18 of policy "Code of Conduct" last reviewed 04/03/18 indicates inappropriate words/actions/inaction includes, but not limited to: disrespectful, insulting or demeaning language, arguments with patients/family members/staff, boundary violations with patients/family members/staff and/or behavior described as bullying and/or intimidating. The hospital will follow facility policies as appropriate when corrective/disciplinary action is indicated.

Review on 06/26/18 of policy "Discipline" last reviewed 10/24/17 indicates that discipline is exercised to correct and to prevent misconduct or incompetence from an employee. Verbal warnings shall be signed and dated by the employee and Supervisor and sent to HR as evidence of discussions concerning performance. Prior to issuing a written warning, the supervisor will review the issues with the Director of HR and then with the employee. The employee is provided with a memo covering the discussion, his/her decision, key facts and ways to improve. A signed copy is placed in the employee's file.

Review on 06/26/18 of the Patient Complaint document dated 10/18/17 by Staff (Q), Nursing Supervisor revealed Patient #1 alleged she was spoken to in a harsh tone on 10/17/17 and experienced inappropriate contact on 10/18/17 by Staff (D), RN.

Review on 06/26/18 of the personnel file for Staff (D), RN revealed no documentation regarding the 10/17/17 and/or 10/18/17 incidents despite having previous verbal/written warnings in his personnel file related to inappropriate interactions with patients, family members and staff occurring in 2013, 2014 and 2016.

Interview on 06/25/18 at 02:02 PM with Staff (H), Nurse Manager revealed he phoned Staff (D), RN to get his account of events which occurred on 10/18/17 due to Patient #1's complaint about removing telemetry, "I think he was abrupt. Maybe some inappropriate behavior or contact, but do not recall where the inappropriate contact occurred." Staff (H) stated that Staff (D), RN has had patient care complaints previously, as he can be abrupt. Although this incident was put into the incident reporting database, it was not placed in Staff (D)'s personnel file.

Based on policy review, medical record review, document review and interview, the facility did not provide Patient #1 with a written notice of decision following reciept of a patient complaint.

Findings include:

Review on 06/26/18 of policy " Patient Complaint Policy " last revised 04/08/16 indicates a grievance is an oral or written complaint that is not immediately resolved at the time of the complaint by staff present. Each issue will be followed up with a written notice of decision. The written response will contain the following elements: date of receiving the grievance, hospital contact person, steps taken in the investigation/dates completed, results of investigation/dates completed and completion date.

Review on 06/26/18 of Nursing Notes and documentation dated 10/18/17 revealed at 08:00 AM the patient reported an incident that occurred overnight, which was reported to the supervisor. Documentation throughout the rest of the day into the early evening indicates the patient continued to be upset and discussed the incident with various nursing staff and Administration.

Review on 06/26/18 of the " Patient Complaint " form dated 10/18/17 written by the Staff (Q) Nursing Supervisor indicates Patient #1 was very upset about an event that occurred last night (10/18/17). The patient appeared tearied eye and reported that she woke up with someone in her room with their hand in her gown. He did not wake her fully to tell her what he was doing. "I told him to stop but he kept going. I told him to stop because what he was doing was hurting me." The patient also stated that the same person came into her room the night before and yelled at her with a harsh tone." It was noted that the information was shared with Staff (B), Director of Nursing, Staff (C), Director of Quality and Staff (H), Nursing Manager.

Review on 06/26/18 of the Confidential Patient Relations Worksheet (incident reporting) revealed "a concern regarding a staff member/employee " was initially entered by Staff (Q), Nursing Supervisor on 10/18/17 who notified Risk Management and the Nurse Practitioner. The investigation was closed on 11/09/17 with no evidence of final conclusion/resolution or that a written notice of decision was sent to the patient.

Interview on 06/25/18 at 10:15 AM with Staff (B), Director of Nursing and Staff (C) Director of Quality revealed Patient #1 complained to the Nurse Manager, alleging that a male nurse had his hand in her gown unsnapping telemetry leads, without letting her know. No physician assessment was performed as the patient did not allege anything to warrant an examination. It was stated that there have been no other accusations or allegations against Staff (D), RN and that he was advised to avoid situations with women. A written notice of decision was not sent to the patient as they considered this a complaint, not a grievance and the case was closed.

Based on policy review, medical record review and interview, facility staff did not ensure that there was a valid physician order for medical/non-violent restraints for 4 of 11 patients (Patient's #11, 16, 18 and 19) in accordance with facility policy. Not obtaining an order for restraints could result in inadequate patient assessment relative to patient condition and need for restraint.

Findings Include:

Review on 06/26/18 of policy "Restraint for Acute Care and Swing Bed, and Downtime Procedures: R-04" last reviewed 08/17 indicates a physician order is to be obtained for the use of protective restraints.

Medical record review on 06/26/18 revealed no evidence of documentation of a physician order for the initial application of medical/non-violent restraints for Patient #11 on 04/16/18 at 03:00PM and Patient #19 on 03/06/18 at 12:30 PM. For Patient #16, the initial order for medical/non-violent restraints on 02/16/18 at 05:52 AM was written by a Physician Assistant and for Patient #18 the 02/27/18 order for medical/non-violent restraints was written by a Physician Assistant.

Interview on 06/26/18 at 11:30 AM with Staff (B), Director of Nursing, Staff (C), Director of Quality and Staff (H), Nurse Manager confirmed these findings.

Based on policy review, medical record review and interview, the facility did not ensure orders for medical/non-violent restraints were renewed in a timely manner for 9 of 11 patients (Patients #10-12, 14-15 and #17-20). Not obtaining a timely order for restraints could result in inadequate patient assessment relative to patient condition and need for restraint.

Findings Include:

Review on 06/26/18 of policy "Restraint for Acute Care and Swing Bed, and downtime procedures: R-04" last reviewed 08/17 revealed obtain physicians order for the use of a protective restraint. The use of restraints shall be reassessed and reordered by a physician on a 24 hour basis.

Medical record review on 06/26/18 revealed no evidence of documentation of a physician renewal order for the use of medical/non-violent restraints for the following patients:
- Patient #10: reapplication on 05/07/2018 and 05/08/2018.
- Patient #11: reapplication on 04/17/18 and 04/18/18.
- Patient #12: reapplication on 06/01/18.
- Patient #14: reapplication on 04/04/18 and 04/05/18.
- Patient #15: reapplication on 02/15/18, 02/16/18, 02/17/18 and 02/18/18.
- Patient #17: reapplication on 03/01/18, 03/02/18 and 03/03/18.
- Patient #18: reapplication on 02/26/18, 02/28/18, and 03/01/18
- Patient #19: reapplication on 03/07/18, 03/08/18, and 03/09/08.
- Patient #20: reapplication on 03/07/18 and 03/08/18.

Interview on 06/26/18 at 11:30 AM with Staff (B), Director of Nursing, Staff (C), Director of Quality and Staff (H), Nurse Manager confirmed these findings.

Based on policy review, medical record review and interview, the facility did not ensure that there was evidence of ongoing medical/non-violent restraint assessments and monitoring for 4 of 11 patients that (Patient's #15, 16, 18 and 19) in accordance with facility policy. Lack of monitoring could lead to an adverse patient outcome.

Findings Include:

Review on 06/26/18 of policy "Restraint for Acute Care and Swing Bed, and downtime procedures: R-04" last facility review 08/2017 revealed an assessment of the patient's condition should be made every 30 minutes or more often as indicated or ordered.

Medical record review on 06/26/18 revealed an assessment of a restrained patients condition was not completed at least every 30 minutes for the following patients:
-Patient #15: On 02/15/18 from 08:00 PM to 11:00 PM. On 02/16/18 from 12:00 AM to 03:00 AM and no assessment until 07:30 AM, from 08:23 AM to 05:50 PM and no assessment until 08:00 PM. On 02/17/18, no assessment from 04:30 AM to 07:00 AM.
-Patient #16: On 02/17/18 from 10:00 AM to 12:30 PM.
-Patient #18: On 02/26/18 from 12:00 AM to 03:00 AM and no assessment until 07:30 AM. On 02/27/18 from 05:00 PM to 06:30 PM with the next assessment at 08:30 PM.
-Patient #19: On 03/07/18 from 06:13 PM to 08:00 PM. On 03/08/18 from 02:00 AM to 03:00 AM, 07:00 AM to 08:00 AM and 07:30 PM to 11:30 PM.

Interview on 06/26/18 at 11:30 AM with Staff (B), Director of Nursing, Staff (C), Director of Quality and Staff (H), Nurse Manager confirmed these findings.

Based on policy review, medical record review and interview, the facility did not ensure alternatives and/or other less restrictive interventions were attempted prior to the use of medical/non-violent restraints for 11 of 11 patients (Patient #10-20).

Findings Include:

Review on 06/26/18 of policy "Restraint for Acute Care and Swing Bed, and Downtime Procedures: R-04" last reviewed 08/17 indicates documentation in the electronic medical record is to include the failure of less restrictive devices and a patient's response and/or cause for removal or reinstituted.

Medical record review 06/26/18 revealed nursing restraint documentation did not include documentation of least restrictive interventions, rational for/continued restraint and did not clearly indicate initiation and discontinuation for medical/nonviolent restraints as follows:
- Patient #10: On 05/05/18, 05/06/2018, 05/07/2018 and 05/08/2018.
- Patient #11: On 04/16/18, 04/17/18, and 04/18/18.
- Patient #12: On 05/31/18 and 06/01/18.
- Patient #13: On 04/20/18.
- Patient #14: On 04/03/18, 04/04/18, and 04/05/18.
- Patient #15: On 02/14/18, 02/15/18, 02/16/18, 02/17/18 and 02/18/18.
- Patient #16: On 02/16/18 and 02/17/18.
- Patient #17: On 02/28/18, 03/01/18, 03/02/18 and 03/03/18.
- Patient #18: On 02/25/18, 02/26/18, 02/27/18, 02/28/18, and 03/01/18.
- Patient #19: On 03/06/18, 03/07/18, 03/08/18 and 03/09/18.
- Patient #20: On 03/06/18, 03/07/18 and 03/08/18.

Interview on 06/26/18 at 11:30 AM with Staff (B), Director of Nursing, Staff (C), Director of Quality and Staff (H), Nurse Manager confirmed these findings.

Based on interview and medical record, nursing staff failed to supervise and evaluate the nursing care provided to Patient #1 relative to telemetry monitoring. This has the potential to negatively impact the continuity of patient care.

Findings include:

Interview on 06/26/18 at 07:15 AM with Staff (D), RN revealed that on 10/18/17, a decision was made by the Physician Assistant that Patient #1 no longer required telemetry monitoring, as she had been stable for 24 hours. Telemetry was discontinued at 02:55 AM.

Medical record review on 06/26/18 revealed that on 10/16/17 at 10:48 AM telemetry was ordered for Patient #1. Telemetry notes dated 10/18/17 at 02:55 AM indicate that telemetry was discontinued due to "controlled atrial fibrillation". The last telemetry strip included in the medical record is dated 10/18/17 at 02:56 AM. However, the order to discontinue telemetry is not entered until 10/18/17 at 05:09 PM by the Nurse Practitioner.