HospitalInspections.org

Based on policy review, medical record review and interview, the facility does not ensure all patients are informed of their rights for 2 of 20 patients (Patient #9 and #17).

Findings include:

Review on 04/14/21 of policy "Patient Rights Policy" last reviewed 09/2018 indicates a statement of patient's rights is mandated by The Centers for Medicaid and Medicare Services and New York State. A written copy is given to patients. Acknowledgement of the receipt of the Patient Rights statement is made when the patient or their representative signs the "Consent for Treatment and Payment" form.

Review on 04/14/21 of the "Consent for Treatment and Payment" form revealed that by signing the form, the patient or their representative consents to treatment, release of protected health information, and documents the receipt of receiving information on the Bill of Rights including receiving the Bill of Rights brochure, the privacy notice, how to file a complaint and visitation rights.

Review on 04/14/21 of the medical record for Patient #9 during the 03/22/21 to 03/30/21 admission and Patient #17 during the 11/30/20 to12/02/20 admission, revealed no evidence of a consent for treatment form.

Interview on 04/14/21 at 02:47 PM with Staff (A), VP of Quality & Compliance verified these findings.

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Based on policy review, medical record review, and interview, the facility does not ensure there is a physician order for the use of restraints for 2 of 11 patients (Patient #5 and #8).

Findings Include:

Review on 04/14/21 of policy "Restraints" last revised 04/2020 indicates an order must be secured within one hour of application. For Behavioral Health patients, an order must be secured within 30 minutes of application and the physician must complete the face to face evaluation. An order may not exceed 24 hours. A new order must be obtained if restraints are required at the conclusion of the 24-hour time frame.

Review on 04/14/21 of the Restraint Summary log revealed on 11/24/20 from 10:45- 11:55 AM, Patient #5 required 4-point restraints to both his upper and lower extremities. From 03/28/21 to 03/30/21, Patient #8 required a vest restraint.

Review on 04/14/21 of the medical record for Patient #5 for the ED presentation on 11/24/20 revealed no evidence of a physician order for restraint.

Review on 04/14/21 of the medical record for Patient #8 revealed nursing assessments document that medical restraint was implemented from 03/28/21 at 02:00 PM to 04/01/21 at 04:00 PM. An order for restraint was dated/signed on 03/28/21 at 02:52 PM. No evidence was found to indicate a physician reordered restraints after the initial 24 hours.

Interview on 04/14/21 at 02:47 PM with Staff (A), VP of Quality & Compliance verified these findings.

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Based on policy review, medical record review, and interview, the facility does not ensure there is an assessment for the use of restraints for 2 of 11 patients (Patient #3 and #5).

Findings Include:

Review on 04/14/21 of policy "Restraints" last revised 04/2020 indicates when restraint is used, there shall be documentation in the medical record of the face to face evaluation, a description of the patient's behavior, interventions used, alternatives/less restrictive interventions attempted, condition/symptoms warranting restraint use, response to restraint, safety checks, neuro checks, patient needs and release of the restraint.

Review on 04/14/21 of the Restraint Summary log revealed on 04/07/21 at 12:41 AM, Patient #3 required bilateral upper and lower restraints. On 11/24/20 from 10:45 to 11:55 AM, Patient #5 required 4-point restraints to both upper and lower extremities.

Review on 04/14/21 of the medical record for Patient #3 for the ED presentation on 04/07/21 revealed an order for 4-point restraints and 1:1 supervision at 12:37 AM. No evidence of an assessment was found for the use of restraints.

Review on 04/14/21 of the medical record for Patient #5 for the ED presentation on 11/24/20 revealed no evidence of an assessment was found for the use of restraints.

Interview on 04/14/21 at 02:47 PM with Staff (A), VP of Quality & Compliance and at 04:15 PM with Staff (H), RN, verified these findings.