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Based on review of documents and interview, the facility failed to (a) involve the patient or patient's representative in the development and implementation of the discharge plan, and (b)inform the patient or patient's representative of their right to choose among participating hospice programs. This failed practice was noted in 1 of 5 medical records reviewed.


Findings include:


Review of Patient MR#3 identified the following information: This 58 year old female patient was admitted from home to the hospital with a diagnosis of Anemia and Cancer. Social Work notes dated 6/25/15 indicated that the patient anticipated discharge to home with family when medically stable, and possible referral to Metropolitan Jewish Health Systems (MJHS) hospice. The patient was discharged to Metropolitan Jewish Health System (MJHS) Hospice Program on 7/1/2015.
There was no documentation that the patient or patient's representative was informed of the options to select a hospice program, nor evidence that a written list of hospice program options was provided.


The hospital's Policy and Procedure titled "Patient Choice in Agency/Facility Selection," last revised July, 2013, stated the following: "Any patient receiving care at Beth Israel Medical Center who requires home health services, placement in hospice program, or skilled nursing facility will be informed of their right to choose provider and given a list of provider in their preferred location."

The lack of providing the patient or her representative with a list of hospice options was discussed with staff # 4

Based on observation, interview, and the review of medical records, the facility failed to ensure compliance with the policy for the use of restraints. Specifically, staff failed to: (a) identify the use of Physical Restraints, (b) obtain a Licensed Independent Practitioner (LIP) order for use of a Physical Restraint, and (c) document restraint monitoring. This finding was noted in 1 of 4 applicable records reviewed.


Findings include:


During the tour of the H2N Medical/Surgical unit on 07/01/15 at approximately 12:15pm, patient #1 was observed sitting in a chair by the doorway of her room with a lap belt around her waist.

At interview on 07/01/15 at approximately 12.20pm, Staff # 1(RN manager) stated the lap belt around the patient's waist was not a restraint and that the patient can release the belt independently. Staff #2 (Director of Pharmacy) who was also present during the interview, agreed that the lap belt was not a restraint. Upon interview with the patient through Staff #3, a Creole interpreter, the patient was physically unable to release the lap belt when instructed to do so, and to follow instructions .This was confirmed with Staff #3. These findings were also discussed and confirmed with staff # 2.

The facility's Policy: R-3 Restraints, dated 08/1986 and re-issued 08/06/2014 was presented to the surveyors on 07/01/15 at approximately 2.30pm. The Policy states : "(1) Physical Restraint: Any manual method or physical /mechanical device, material, or equipment attached or adjacent to the patient's body that cannot be easily removed and that restricts freedom from movement, physical activity, or normal access to one's body. *As per CMS guidelines " easily removed " means can be removed by the patient in the same manner as it was applied by the staff.
(2) Physical restraints, when used according to the Non-Behavioral (Acute Medical-Surgical Standard) physical restraint are ordered initially and the order renewed every 24 hours.
(3) Self-Releasing Padded Belt- this device may be used as a reminder to call for assistance, as a positioning device or as a restraint. It is designed for self - release and if used in this manner it is not a restraint. If the patient cannot self-release, it is a restraint and requires a (LIP) order."

Review of the patient's medical record found that physician order was: (a) not obtained for the use of lap belt for patient #1 and (b) the medical record did not contain the justification or a psychological assessment of patient's mental status. There was also no documented restraint monitoring activities for patients placed in restraints, as required by the facility's policy.

Staff failed to comply with the policy for the use of restraint and monitoring of a patient placed in restraint.

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Based on interview, and the review of medical records, the facility failed to ensure compliance with the hospital's policy for updating care plans to include the use of restraints. This finding was noted in 1 of 4 applicable records reviewed.


Findings include:


Review of the medical record for Patient #2 on 07/02/15 identified the following: This 72 year old female with history of Lung Cancer, COPD and Seizures, presented to the hospital's Emergency Department on 2/14/15 with Chief Complaint of Seizures three times that day. The patient was admitted to the hospital on 2/15/15 with generalized seizures. On 2/15/15 at 3:30 PM, the nurse noted that the patient is confused, alert, and that the patient was found on the floor. The nurse noted that nursing supervisor and physician were notified and that the patient will be closely monitored. On 2/16/15 at 5:00PM, the nurse noted that the patient is awake, responsive and sitting in chair with Posey in place.

The review of the medical record identified that the patient's Plan of Care was not updated to include the need for and the use of restraint as per the hospital policy.

The hospital's Policy and Procedure titled, "Restraints," last revised 8/6/14, indicates the patient plan of care must be updated to include the need for and use of restraints or seclusion.

Cross refer to citations noted under Tag# A168.

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Based on observation, interview, and the review of medical records, the facility failed to ensure compliance with the hospital's policy for the use of restraints. Specifically, staff failed to: 1) obtain a Licensed Independent Practitioner (LIP) order for use of a physical restraint, and 2) document restraint monitoring. This finding was noted in 2 of 4 applicable records reviewed.


Findings include:


1. Review of the hospital's grievance file identified the following information: On 3/26/15 the hospital received a complaint from the patient's daughter. The complainant alleges that proper precautions were not in place to prevent her mother, Patient # 2 from falling. The investigative notes indicated that a nurse investigated the fall and discussed the findings with patient's daughter. It was noted that the nurse explained to the patient's daughter that her mother recently developed seizures and she was monitored, but not restrained as they are trying to keep less patients in restraints and is addressing their needs through other means. It was noted that although patient was monitored, she was very confused and tried to get out of her chair and bed several times and that one of these attempts was made very fast and the nurse was not able to catch her when she slide to the floor. It was noted that the patient was placed in a chair located in the hallway with staff constantly checking on her with lap belt holding her in place.

Review of the medical record for Patient #2 identified the following: This 72 year old female with history of Lung Cancer, COPD and Seizures, presented to the hospital's Emergency Department on 2/14/15 with Chief Complaint of Seizures three times that day. The patient was admitted to the hospital on 2/15/15 with generalized seizures. On 2/15/15 at 3:30 PM, the nurse noted that the patient is confused, alert, and that the patient was found on the floor. The nurse noted that nursing supervisor and physician were notified and that the patient will be closely monitored. On 2/16/15 at 5:00PM, the nurse noted that the patient is awake, responsive and sitting in chair with Posey in place.

The review of the medical record identified that there was no order for Posey restraint from a Licensed Independent Practitioner (LIP).

The review of the medical record identified that the Registered Nurse did not document the justification for the application of the Posey restraint that includes measures taken to address the behavior prior to the application, the name and title of the Licensed Independent Practitioner (LIP) notified, and the time of the call. The patient's Plan of Care was not updated to include the need for and the use of restraint as per the hospital policy.


The hospital's Policy and Procedure titled, "Restraints," last revised 8/6/14, stated the following: "Application of restraints or seclusion for behavior reasons/modification requires a written order by a Licensed Independent Practitioner (LIP) i.e. MD, DO, NP, PA, on initiation and every 4 hours thereafter. Except in an emergency restraints must be applied upon written order of an LIP after a face to face assessment of the patient's physical and mental status. Alternatives and less restrictive interventions are considered and determination is made if the use of restraints is clinically justified. In an emergency, if a patient presents an immediate danger to self or others, a restraint may be applied by or under the supervision of a Registered Nurse (RN) who is responsible for documenting the circumstances requiring the restraints/seclusion and immediately notify the LIP. The RN must document the justification for the emergency application of restraints, including measures taken to address behavior prior to the decision to apply the restraints, type of restraints applied, and the name, title of the LIP called and time of the call. The patient plan of care must be updated to include the need for and use of restraints or seclusion."

The hospital staff failed to comply with the policy for the use of restraint and monitoring of a patient placed in restraint.

These findings was discussed with Staff # 4.

2. Review of the medical record for Patient #1 on 07/01/2015 revealed the lack of an order by a Licensed Independent Practitioner (LIP) order for the use of a physical lap belt restraint.

During the tour of the H2N Medical/Surgical unit on 07/01/15 at approximately 12:15pm, patient #1 was observed sitting in a chair by the doorway of her room with a lap belt around her waist.

Upon interview with the patient through Staff #3, a Creole interpreter, the patient was physically unable to release the lap belt when instructed to do so, and to follow instructions. This was confirmed with Staff #3. These findings were also discussed and confirmed with staff # 2.

According to the facility's Policy: R-3 Restraints, dated 08/1986 and re-issued 08/06/2014, it is noted that physical restraints are ordered initially and orders are renewed every 24 hours. It also states that when Self-Releasing Padded Belts are used, and if the patient cannot self-release, this device is a restraint and requires a (LIP) order.

Review of the patient's medical record found that physician order was: (a) not obtained for the use of lap belt for patient #1 and (b) the medical record did not contain the justification or a psychological assessment of patient's mental status. There was also no documented restraint monitoring activities for patients placed in restraints, as required by the facility's policy.

Staff failed to comply with the policy for the orders and use of restraint and monitoring of a patient placed in restraint.

Cross-refer to similar findings noted under tag A-159.

Based on observation, interview, and review of medical records, tracking forms, and policies and procedures, it was determined that the facility failed to formulate and implement policies to ensure that tissue specimens are properly identified, transported, tracked, and received by the pathology laboratory.



Findings include:


Review of patient MR#5 on 7/1/15 found that the patient underwent an endoscopy on 12/19/14 in which 2 polyps were removed.

Review of tracking sheets (accessioning forms) and endoscopy unit forms on 7/1/15 at approximately 12:00 PM found that on 12/19/14 (2) polyps were removed from the patient during colonoscopy, and that nursing staff in the endoscopy unit released 2 polyps to the laboratory staff person who was making scheduled rounds every 2 hours to the endoscopy unit to pick up tissue specimens. The polyp specimens were unable to be located and this finding became evident only when the patient made a complaint 7 days later inquiring about the results of the biopsy. If a specimen is not accessioned (a tracking system in which a specific number is assigned to a specific surgical specimen), there was no method in effect for cross checking that would identify missing specimens not received by the laboratory.

Review of the endoscopy unit form, dated 12/19/15, found that the name of the patient (MR #1) is found as #15 out of 17 specimens recorded. Under the column labeled "# specimens" it is recorded as "2 polyps". This entry did not document the time of the removal of the specimens.

Review of the laboratory accession records for 12/19/14 found that there was no record of the laboratory receiving and accessioning this tissue specimen.

Review of laboratory policies and procedures on 7/1/15 found that there was no policy for the processing and transport of tissue specimens from the endoscopy unit. An undated policy titled "Cross check of endoscopy-Surgical specimens" was provided on 7/1/15, and the lab supervisor stated to the surveyor on 7/1/15 that this was not in effect on the date of this incident.

At interview with the Nursing supervisor of Endoscopy on 7/1/15, it was stated that the practice is for the pathology lab staff to make rounds every 2 hours to the endoscopy unit for the purpose of timely transport of tissue specimens from that unit to the lab. This was validated by the clinical lab supervisor, who was also present during this interview on 7/1/15. On 7/2/15, the lab employee who was identified as the person who removed the bag with the 2 polyps from the endoscopy unit was interviewed with her laboratory supervisor, and she stated that she had "no memory of the incident". This employee was one of 3 persons who were accessioning that day.

During tour of the lab 7/2/15, the staff showed the bins that are utilized for the storage of specimens prior to accessioning. Those bins are not labeled. This observation, in which unaccessioned specimens arriving from units are placed in unlabeled bins in the laboratory, could represent potential risk for loss of specimens prior to the point of accessioning.

Based on observation and staff interview, the hospital did not maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.


Findings include:

During a tour of the 4th floor Bernstein Pavilion building on the afternoon of 7/1/2015, the following were identified and brought to the attention of the Director of Engineering who promised to correct the deficiencies.
The following observations were noted during tour of the Psychiatric Unit:
1- The handle and a padlock on the refrigerator at the dining room represented risk for looping.
2- The electric wiring and the copper water coils behind the ice machine were not secure and impose a risk of looping.
3- There were many small drain flies observed in different areas of the Psychiatric Unit.
4- The handrails in the shower room next to the dining area were short and not completed from wall to wall, therefore, these handrails represent a looping risk.
5- The handrails inside all the bathrooms were not extended from wall to wall and being short, they impose a risk for looping.
6- The bulletin board on the wall of the corridor was not secured properly and had gaps around it, which impose a looping risk.
7- The rails of the handicapped shower imposed a looping risk.
8- The lips of the strike plates of all the doors frames were observed to be protruded metals and impose safety risk.