HospitalInspections.org

Based on staff interview, document review, and review of medical records, it was determined that the facility failed to protect and promote the rights of patients.

Findings include:

1. The facility failed to ensure that the patient and/or designated patient representative participated in the plan of care. (Refer to Tag A 0130)

2. The facility failed to ensure that the form for informed consents was filled out completely. (Refer to Tag A 0131)

3. The facility failed to ensure that a family member or patient representative was notified of a patient admission to the hospital. (Refer to Tag A 0133)

4. The facility failed to ensure that an individualized patient assessment for a patient in restraints was completed by a LIP (Licensed Independent Practitioner). (Refer to Tag A 0164)

5. The facility failed to ensure that the use of restraints was in accordance with modifications to the patient's plan of care and in compliance with standards of practice and the facilities policy. (Refer to Tag A 0166)

6. The facility failed to ensure that documentation of the restraints was in accordance with a physician's order. (Refer to Tag A 0168)

7. The facility failed to ensure that the order to continue restraints was in adherence with hospital policy, law and regulation. (Refer to Tag A 0173)

Based on staff interview and review of six (6) medical records of patients in restraints, it was determined that the facility failed to ensure that the patient and/or designated patient representative participated in the plan of care in one (1) out of six (6) medical records.

Findings include:

1. The medical record of Patient #1 was reviewed and the following was identified:

a. Patient #1 had an order for the placement of Non-Violent restraints on 5/29/2020 at 11:07 AM. Documentation by Staff #19 on the restraint flowsheet stated, "MD (Medical Doctor) to Notify" the family of the patient in restraints.

(i) The medical record lacked evidence that the family was notified of the restraints by the physician.

2. Staff #4 confirmed the above findings.

Based on staff interview, review of policy and procedure, and review of medical records, it was determined that the facility failed to ensure that the form for informed consents was filled out completely in two (2) out of eleven (11) medical records reviewed for consents.

Findings include:

Reference: Policy titled, "Informed Consent Policy" states, "...Documentation of the Informed Consent In addition to the Informed Consent Discussion...the INFORMED CONSENT TO OPERATE OF OTHER SPECIAL PROCEDURES form... must be completed and signed..... A properly completed INFORMED CONSENT TO OPERATE OR OTHER SPECIAL PROCEDURES form will include the following: ...Name of the practitioner who is performing the primary procedure(s)... The patient or patient's authorized representative must sign the consent form(s) in the presence of both the practitioner and a witness....."

1. Review of the medical record for Patient #1 identified an INFORMED CONSENT TO OPERATE OR OTHER SPECIAL PROCEDURE form.

a. Part one (1) did not identify the physician who was going to treat the condition.

b. Part one (1) did not identify the condition that was to be treated.

c. The following was indicated in part one (1): Infection Thrombus, Pneumothorax, Air Embolism, Arterial Puncture, Unsuccessful Attempts.

(i) Staff #4 identified the above ask risks associated with the procedure, but not the condition itself.

2. Review of the medical record of Patient #11 revealed an INFORMED CONSENT TO OPERATE OR OTHER SPECIAL PROCEDURE form.

a. The form was signed by a physician and a witness on 5/4/2020 at 7:57 AM, but was not signed by the patient or and authorized patient representative.

3. The above findings were confirmed by Staff #4.

Based on staff interview and review of medical records, it was determined that the facility failed to ensure that a family member or patient representative was notified of a patient admission to the hospital in four (4) out of eleven (11) closed medical records reviewed.

Findings include:

1. Review of the medical record of Patient #1 identified the following:

a. The patient was admitted from the Emergency Department (ED) on 5/15/20 at 7:35 PM to a Medical/Surgical Unit.

b. The ED physician note or nursing note did not indicate that a family member was informed of the patient admission.

c. The medical record lacked evidence that the patient was asked if he/she would like a family member informed of their admission.

2. Review of the medical record of Patient #2 identified the following:

a. The patient was admitted to a Critical Care Unit from the ED on 12/24/19.

b. The ED physician note or nursing note did not indicate that a family member was informed of the patient admission.

c. The medical record lacked evidence that the patient was asked if he/she would like a family member informed of their admission.

3. Review of the medical record of Patient #4 identified the following:

a. The patient was admitted to Neurosurgical Care Unit from the ED on 3/6/20 at 8:17 PM.

b. The ED physician note or nursing note did not indicate that a family member was informed of the patient admission.

c. The medical record lacked evidence that the patient was asked if he/she would like a family member informed of their admission.

4. Review of the medical record of Patient #6 identified the following:

a. The patient was admitted to the Intensive Care Unit from the ED on 4/03/20 at 2:54 AM.

b. The ED physician note or nursing note did not indicate that a family member was informed of the patient admission.

c. The medical record lacked evidence that the patient was asked if he/she would like a family member informed of their admission.

5. The above findings were confirmed by Staff #4.

A. Based on staff interview, review of policy and procedure, and review of six (6) medical records of patients that were restrained, it was determined that the facility failed to ensure that an individualized patient assessment was completed by a LIP (Licensed Independent Practitioner) in two (2) out of six (6) medical records.

Findings include:

Reference: Policy titled, "Restraints" states, "...LIP ORDERS RESTRAINTS FOR NON-VIOLENT, NON-SELF DESTRUCTIVE BEHAVIOR 1. Restraints require and LIP order. a. Except in emergent circumstances, the attending physician or other designated LIP must evaluate the patient, and document the assessment in the physician's progress notes, prior to the initiation of restraints..... 4. ...The LIP will perform and document a face to face assessment of the patient within 24 hours of application of the restraints. The LIP will: a. Discuss the changes to the patient's plan of care and treatments with the RN (Registered Nurse) and identify ways to help the patient gain control, to help eliminate the need for restraints. 5. The LIP will conduct an In-person evaluation of the patient and the ongoing restraint need every 24 hours..... DOCUMENTATION RESTRAINTS FOR NON-VIOLENT, NON-SELF DESTRUCTIVE BEHAVIOR... 2. Clinical notes will provide additional supporting documentation about the restraint episode, including patient and family education provided by the RN. 3. All documentation must be done as soon as possible after the assessment/reassessment occurred to ensure the accuracy of the information and to reflect ongoing care....."

1. The medical record of Patient #1 was reviewed and the following was identified:

a. An order for restraints was placed by Staff #20 on 5/30/2020 at 11:06 AM. The order stated, "... Order: Restraint Evaluate Need to Continue After 24 Hours..."

(i) The medical record lacked evidence of clinical notes of an assessment and/or the discussion of treatments with the RN.

b. An order for restraints was placed by Staff #22 on 5/31/2020 at 10:44 AM. The order stated, "... Order: Restraint Evaluate Need to Continue After 24 Hours..."

(i) The medical record lacked evidence of clinical notes of an assessment and/or the discussion of treatments with the RN.

b. An order for restraints was placed by Staff #22 on 6/1/2020 at 11:59 AM. The order stated, "... Order: Restraint Evaluate Need to Continue After 24 Hours..."

(i) The medical record lacked evidence of clinical notes of an assessment and/or the discussion of treatments with the RN.

2. The medical record of Patient #3 was reviewed and the following was identified:

a. An order for restraints was placed by Staff #23 on 2/6/2020 at 3:16 PM. The order stated, "... Order Details: ...Pulling at tubes and lines, Soft limb, Wrist-Bilateral, I assessed the patient and determined the need for restraints..."

(i) The medical record lacked evidence of clinical notes of an assessment and/or the discussion of treatments with the RN.

3. The above findings were confirmed with Staff #4.

B. Based on staff interview, review of facility policy and procedure, and review of six (6) medical records of patients in restraints, it was determined that the facility failed to ensure that the restraint assessment and flowsheet was completed by the RN in two (2) out of six (6) medical records.

Findings include:

Reference: Policy titled "Restraints" states, "...MONITORING RESTRAINTS FOR NON-VIOLENT, NON-SELF DESTRUCTIVE BEHAVIOR The RN assesses the patient upon initiation of restraints and at least every two (2) hours thereafter... DOCUMENTATION RESTRAINTS FOR NON-VIOLENT, NON-SELF DESTRUCTIVE BEHAVIOR... ...2. Clinical notes will provide additional supporting documentation about the restraint episode, including patient and family education provided by the RN. 3. All documentation must be done as soon as possible after the assessment/reassessment occurred to ensure the accuracy of the information and to reflect ongoing care....."

1. The medical record of Patient #5 was reviewed and the following was identified:

a. An order for restraints was placed by Staff #24 on 5/16/2020 at 6:10 PM.

b. The restraint flow sheet was not completed on the following dates and time: 5/16/2020 at 8:00 PM; 5/16/2020 at 10:00 PM, and 5/17/2020 at 12:00 AM.

(i) The medical record contained evidence that the restraints were continued during the above dates and times.

2. The medical record of Patient #6 was reviewed and the following was identified:

a. An order for restraints was placed by Staff #25 on 4/7/2020 at 10:13 AM.

b. The restraint flow sheet was not completed on the following dates and time: 4/7/2020 at 12:00 PM; 4/7/2020 at 2:00 PM; 4/7/2020 at 4:00 PM; and 4/7/2020 at 6:00 PM.

(i) The medical record contained evidence that the restraints were continued during the above dates and times.

3. The above findings were confirmed by Staff #4.

Based on staff interview, review of policy and procedure, and the review of six (6) medical records of patient's with restraints, it was determined that the facility failed to ensure that the patient's plan of care was modified per facility policy in one (1) out of six (6) medical records.

Findings include:

Reference: Policy titled "Restraints" states, "...Interdisciplinary Plan of Care Restraints for Non-Violent, Non-Self Destructive Behavior Restraints for Violent of Self Destructive Behavior 1. The Interdisciplinary Plan of Care (IPOC) for restraints is initiated at the start of a restraint episode...".

1. A review of the medical record of Patient #1 revealed the following:

a. A restraint order was placed by Staff #20 on 5/29/2020 at 11:07 AM.

b. The restraint care plan was initiated on 5/30/2020 at 7:20 PM by Staff #26.

(i) The plan of care was modified to include restraints thirty-two (32) hours and thirteen (13) minutes after the restraints were initiated.

2. The above findings were confirmed by Staff #4.

Based on staff interview, review of policy and procedure, and review of six (6) medical records of patients that were restrained, it was determined that the facility failed to ensure that the documentation of the restraints were in accordance with an LIP's (Licensed Independent Practitioner) order in two (2) out of six (6) medical records.

Findings include:

Reference: Policy titled "Restraints" states, "...LIP ORDERS RESTRAINTS FOR NON-VIOLENT, NON-SELF DESTRUCTIVE BEHAVIOR 1. Restraints require an LIP order. a. Except in emergent circumstances, the attending physician or other designated LIP must evaluate the patient, and document the assessment in the physician's progress notes, prior to the initiation of restraints.....
DOCUMENTATION RESTRAINTS FOR NON-VIOLENT, NON-SELF DESTRUCTIVE BEHAVIOR 1. Both the electronic medical record documentation and the downtime paper documentation must reflect: ...c. Restraint Initiation... d. Restraint Maintenance of RN (Registered Nurse) assessments/reassessments... documented at least every two (2) hours... Restraint Discontinuation...".

1. A review of the medical record of Patient #1 revealed the following:

a. An order was placed by Staff #20 on 5/29/2020 at 11:07 AM for, "Restraint Initiate Non-Violent". Further details for the restraint order included "Pulling at tubes and lines, Mittens, Wrist-Bilateral...".

b. The restraint flowsheet on 5/29/2020 at the following times for the Restraint Episode Activity Type indicated that the restraint activity type was "Initiated: 12:00 PM, 2:00 PM, 4:00 PM , and 6:00 PM."

(i) There was no evidence in the medical record to indicate changes were made to the physician's order to corroborate an RN having to initiate restraints on date at the above noted times.

2. Staff #4 confirmed the above findings and stated that the RN should have documented on the restraint flowsheet, the Restraint Episode Activity Type as "Ongoing Assessment" and not as "Initiated" on 5/29/2020 at the following times: 12:00 PM, 2:00 PM, 4:00 PM , and 6:00 PM.

3. A review of the medical record of Patient #3 revealed the following:

a. An order was placed by Staff #23 on 2/6/2020 at 3:16 PM for "Restraint Initiate Non-Violent". Further details for the restraint order included "Pulling at tubes and lines, Soft limb, Wrist-Bilateral...".

b. The restraint flowsheet contained documentation of the initiation of restraints on 2/6/2020 at 2:00 PM by Staff #27.

(i) The order to initiate the restraints was placed by Staff #23 on 2/6/2020 at 3:16 PM. This was one (1) hour and sixteen (16) minutes after Staff #27 documented the initiation of the application of restraints on Patient #3.

4. Staff #4 confirmed the above findings.

Based on staff interview, review of policy and procedure, and review of six (6) medical records of patients in restraints, it was determined that the facility failed to ensure that the order to continue restraints was in adherence to facility policy in one (1) out of six (6) medical records.

Findings include:

Reference: Policy titled "Restraints" states, "...LIP (Licensed Independent Practitioner) ORDERS... 6. If the restraint is to be continued, a new restraint order is required every 24 hours....."

1. The medical record of Patient #4 was reviewed and the following was identified:

a. An order to initiate restraints was placed by Staff #20 on 3/15/2020 at 1:29 PM. The next order to continue restraints was placed on 3/16/2020 at 4:59 PM by Staff #22.

(i) The nursing restraint flowsheet indicated that the restraints were continued on 3/16/2020 at 2:00 PM and 4:00 PM.

(ii) The patient was in restraints without an order for three (3) hours and thirty (30) minutes.

b. The next order to continue the restraints was on 3/17/2020 at 6:49 PM by Staff #20. This was one (1) hour and fifty (50) minutes after the previous restraint order would have expired.

(i) The nursing restraint flowsheet for 3/17/2020 indicated that the restraints were continued during the above time frame.

c. An order to continue restraints was placed on 3/20/2020 at 3:51 PM. The next order to continue restraints was on 3/21/2020 at 6:43 PM by Staff #28. This was two (2) hours and fifty-two (52) minutes after the previous order would have expired.

(i) The nursing flowsheet indicated that the restraints were continued on 3/21/2020 during the above timeframe.

d. An order to continue restraints was placed on 3/22/2020 at 3:10 PM. The next order to continue restraints was on 3/23/2020 at 5:54 PM by Staff #20. This was two (2) hours and forty-four (44) minutes after the previous order would have expired.

(i) The nursing flowsheet indicated that the restraints were continued on 3/23/2020 during the above timeframe.

2. Staff #4 confirmed the above findings.

Based on staff interview, review of medical staff bylaws, rule and regulations, and review of medical records, it was determined that the facility failed to ensure that providers assess their patients daily in one (1) out of eleven (11) closed medical records.

Findings include:

Reference: Document titled, "Rules and Regulations of the Medical Staff - St. Joseph's Healthcare System" states, "...Physician of Record... 1. The physician of record must see the patient on a daily basis during the patient's hospital stay... 5. The daily progress notes of the physician of record should reflect the changes in the patient's status and care plan...".

1. Review of the medical record of Patient #1 revealed the following:

a. The patient was admitted to the facility on 5/16/2020 and was discharged from the facility on 6/2/2020.

b. The medical record lacked evidence that the physician on record or designee visited the patient on the following dates: 5/20/2020, 5/21/2020, 5/25/2020, 5/27/2020, 5/28/2020, 5/30/2020, 5/31/2020, and 6/1/2020.

2. The above was confirmed with Staff #4.

A. Based on observation, staff interview, and document review, it was determined that the facility failed to ensure the development and implementation of policies and procedures that the manufacturer's instructions for use for disinfectant wipes are followed for cleaning of respiratory equipment during the Coronavirus Disease (COVID-19) Pandemic.

Findings include:

Reference #1: Facility policy titled "Cleaning and Disinfecting Procedures for Patient Environment/Patient Care Equipment" states, "... Policy: Patient Care Equipment - ... If a speciality area uses a specific patient monitoring device on multiple patients, the staff person trained in the use of the device is responsible for cleaning the device after each patient use following manufacturer's directions for cleaning. ..."

Reference #2: Maquet Getinge Group SERVO-i/s Ventilator cassette manufacturer's instructions for use (IFU's) states,"2.4.4 Drying alternatives ... The expiratory cassette must be dried before use .... - Drying cabinet 1 hour in maximum 70 degrees Celsius (158 degrees Fahrenheit); ..."

1. On 7/1/2020 at 10:50 AM, on 3 South in the "supply clean utility room" in the critical care building (CCB), in presence of Staff #29, Staff #43 and Staff #44, the following was observed:

a. Staff #43 and Staff #44, respiratory staff, confirmed the respiratory ventilator cassettes are the only accessory devices from the ventilator machine(s) that are multiple-patient use and are dismantled from the ventilator and are cleaned, disinfected and dried between patient use.

(i) The facility has a drying cabinet for the drying process after cleaning and disinfecting has been completed.

(ii) A timer is located on top of the drying cabinet, however there was no documentation to indicate the time cassettes were placed into the drying cabinet and when they were taken out to ensure it does not exceed the 1 hour maximum time.

2. At 11:00 AM Staff #29, Staff #43 and Staff #44 confirmed the above findings.

B. Based on observation, staff interview and review of facility documents, it was determined that the facility failed to ensure implementation of policies, procedures and protocols addressing the management of the Coronavirus Disease (COVID-19) Pandemic.

Findings include:

Reference: Facility policy titled, "Updated Visitor Policy" states, "... Potential visitors will be screened at the hospital entrances. Once a visitor is approved, they will undergo a temperature screening. ..."

1. On 6/30/2020 at 9:30 AM, upon entrance to the facility, Surveyor #1 and Surveyor #2 were greeted by Staff #10. The names of the surveyors and forehead temperatures were obtained and documented on a log.

a. There were no screening questions asked to Surveyor #1 or Surveyor #2 upon the arrival screening.

2. On 6/30/2020 at 10:55 AM, while conducting an observation at the main lobby entrance of the screening process for visitors and/or patients, in the presence of Staff #7, Staff #9 and Staff #29, the following was observed:

a. Staff #9 explained that on arrival, Staff #10, an information desk facilitator screens visitors using a written questionnaire. Staff #9 provided the facility document titled, "Screening Questions for Patients" which includes nine (9) screening questions and includes a temperature range of 100.4 degrees Fahrenheit/38 degrees Celsius or greater as indicators for a possible fever.

b. Staff #9 also confirmed that Staff #30, an educator, trained the desk staff for monitoring visitors/patients on arrival at the facility's non-clinical entrances and provided them with the written questionnaire and written instructions for use (IFU's) to correctly take temperatures using the "TemporalScanner."

c. At 11:00 AM, upon interview, Staff #10 confirmed the designated lowest temperature number for fever screening the facility has chosen was 100.1 degrees Fahrenheit.

d. At 11:01 AM, Staff #9 confirmed the designated lowest temperature number for fever screening the facility has chosen was 100.4 degrees Fahrenheit/38 degrees Celsius as indicated on the written screening instructions provided for staff to use.

(i) Upon request at 11:03 AM, Staff #10 could not provide his/her written questionnaire and/or temporal scanner IFU's.

3. At 11:10 AM, Staff #7, Staff #9 and Staff #29 confirmed the above findings.

4. On 7/1/2020 at 9:13 AM, Staff #48 approached Surveyor #1 and obtained his/her temperature and name and these were documented on a log.

a. Staff #48 did not ask COVID-19 related screening questions upon the arrival screening.

5. Staff #1 and Staff #7 agreed with the above findings.


















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