HospitalInspections.org

Based on document review, observation and interview, it was determined that the hospital did not provide patients with information regarding the hospital's grievance process.


Findings include:
Review of the admission information packet given to patients, showed no information regarding the hospital's grievance process.

During observation of the hospital's Emergency Room and patient registration area, on 6/15/17 at 11:45 AM and on 6/21/17 at 12:30 PM, it was noted that information regarding the hospital's internal grievance process, whom to contact including the telephone number and address to contact the State agency, was not posted in the waiting area of the Emergency Department

During interview on 6/15/17 at 11:55 AM, Staff I, the Director of Nursing for the Emergency Room, confirmed the findings.

During interview on 6/21/17 at 10:10 AM, Staff M, Registration Nurse for the Emergency Room stated that the packet provided to patients does not include information about the hospital's grievance process. "Patients are only given information for HIPPA."

Based on record review and interview, it was determined the hospital did not provide patients with information of the patient's right to formulate advance directives. This was evident in three (3) of 17 medical records reviewed. (Patients #14, 15 & 16).


Findings include:

Review of Medical Records for Patients #14, 15 & 16, showed no documented evidence to determine that patients were provided information about advance directives or that the patients had an advance directive.

During interview on 6/16/17 at 10:20 AM, Staff K, Social Worker for the Psychiatric Unit stated that she did not discuss advance directives with these patients.

During interview on 6/21/17 at 10:20 AM, Staff I, Director of Nursing for the Emergency Department confirmed that
patients are not given information about advance directives when they enter the emergency room.

Based on medical record review and staff interview, the hospital (a) did not provide patients with information about the notification process, and (b) failed to establish policy and procedure to ensure that patients admitted to the hospital are asked if the hospital should notify their family/representative and physician of their admission. This was evident in 17 of 17 medical records reviewed.

Findings include:
Review of 17 Medical Records (100%) showed no documented evidence that patients were informed about their rights to notify family member, representative and or physician of their admittance to the hospital.

During interview on 6/15/2017 at 11:00 AM, Staff I, Director of Nursing for the Emergency Room, acknowledged that the staff does not inform patients of their rights to notify family member, representative and or physician of their admission.

During interview on 6/19/17 at 11:00 AM, Staff G, Director of Nursing for Psychiatry acknowledged the findings and stated that patients are not asked who to contact when they are admitted.

During interview on 6/15/17 at 3:00 PM, Director of Quality Assurance (Staff A) stated that the hospital does not have a written policy and procedure for notification of admission to the hospital.

Based on medical record review and interview, the facility failed to ensure that debriefing was documented for patients placed in restraints, as required by the facility's policy. This finding was evident in two (2) of six (6) Medical Records reviewed. (Patient #2 & #4).

Findings:

Review of the Medical Record for Patient #2, revealed the patient was placed in four point restraints on 12/27/16 at 8:38 AM and released at 10:23 AM. The Medical Record Nursing Form titled, "Violent/Self destructive Assessment/Monitoring," lacked documentation that a Registered Nurse completed the "Release and Debriefing" Note when the restraints were removed.

Review of the Medical Record for Patient #4, revealed the patient was placed in four point restraints on 2/15/17 at 6:15 AM and released at 7:45 AM. There was no documention of a patient debriefing, when the restraints were removed.

Review of policy titled, "Restraint and Seclusion (Violent/self-destructive and nonviolent medical management)" effective date 11/2016 documented, "Debriefing: Patient debriefing will be done within 24 hours of the episode and will include patient and family members (if available) and must be documented on the debriefing Form which will become part of the patient's medical record.

Interview with Staff G, Nursing Manager of Behavior Health, confirmed these finding on 06/21/17 at 12:45 PM.

Based on observation, documentation review and interview, the hospital failed to implement written policy and procedure to address reasonable restrictions and limitations on visitation.


Findings Include:

Observation on 6/15/17 at 11:47 AM, was noted that two ladies were visibly upset in the patient waiting area of the Emergency Room. They complained that they were not allowed to see their brother who was brought into the hospital the previous night. They stated they were waiting for more than one hour to see their brother and was told by the Hospital Security that no visitors were allowed, and that the visit must be cleared by a nurse or a doctor.

During interview on 6/15/17 at 11:55 AM, Staff L, Security Officer, stated that he told the ladies that no visitors are allowed because it is a psych area, and all visitors must be cleared by the nurse or the doctor in the Emergency Room. He called the Nurse in the emergency room and was told no visitors were allowed.

Review on the hospital's Policy and Procedure titled, "Patient Visitation Policy," last reviewed 6/10/16, does not state that visitation must be cleared by the physician and or the nurse.
The policy does not include or specify how visitors are informed of the hospital's restriction on visitation.