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Based on observations, interviews and facility document reviews, it was determined the facility's staff failed to obtain informed consents to allow patients to make informed decisions effecting their privacy and personal dignity for five (5) of five (5) in-patients included in the survey sample (Patient #15, #16, #17, #18, and #19).

The findings include:

On 01/31/18 at 3:30 p.m., the surveyor toured the Neurology and Oncology units. On the neurology unit, Patients #15 and #16 had continuous visual monitoring. On the Oncology unit Patients #17, #18, and #19 had continuous visual monitoring.

The surveyor interviewed Patient #15's family. The family member stated he/she was aware the TeleSitter (continuous visual monitoring) was used the previous night.

The surveyor was unable to speak with Patient #16. Staff Member (SM) #5 reviewed the clinical record and was unable to find any documentation that the patient/family had been educated about the TeleSitter.

On the afternoon of 01/31/18, the surveyor conducted an interview with SM #12. The surveyor asked if the patient or family was aware or had been educated about the use of the TeleSitter. SM #12 stated, "I haven't had time to document."

On the afternoon of 01/31/18, a review of the clinical record for Patients #15, #16, #17, #18 and #19 was conducted with SM #5. The clinical record contained no written education or any account of when the TeleSitter was monitoring.

On 02/01/18 at 10:47 a.m., Staff Member (SM) #5 gave the surveyor a Progress Note from Patient #16's clinical record, written by SM #12, on 01/31/18 at 9:00 a.m. "Pt [Patient] informed that [he/she] would be under video surveillance per tele monitor. RN [Registered Nurse] explained to patient that [he/she] was confused last night and picking at [his/her] port dressing along with trying to get out of bed and that for [his/her] safety we needed to have the monitor in the room to inform RN of any unsafe activity that he may do."

"1100- pt [patient] family arrived and informed of situation and reasoning behind tele monitor."

The following information found in the facility's policy and procedure titled, "TeleSitter, Continuous Visual Monitoring" (revision date 09/16) read in part as follows:

"Purpose
A. To provide guidelines for continuous visual monitoring of patients using TeleSitter monitoring including criteria selection.
B. Initiation of continuous visual monitoring is a nursing intervention. It can be utilized to ensure patient safety as an additional tool in the plan of care for patients at high risk for falls. Confusion, impaired mobility, etc."

"C. RN Responsibility:
3. Notify patient and family that continuous visual monitoring will be implemented to promote patient
safety.
4. Document patient/family education and plan of care in EMR.
8. Document nursing interventions to include safety measures:
a. TeleSitter Monitoring - Continuous (video monitoring for safety) and other appropriate safety
interventions
b. Reason for monitoring
10. Reassess patient at least every eight (8) hours for the need to continue visual monitoring."

"PATIENT TEACHING

The patient and family will be informed that continuous visual monitoring will be utilized to ensure patient safety and educated on the intervention and criteria for initiation and discontinuation. The patient or family will receive a written copy of the educational material. This education shall be documented in patient education in the EMR."

"DOCUMENTATION
C. Nurse should document in a Progress Note the reason and patient activity throughout the shift."

On the evening of 01/31/18, the survey team meet with the Director of Quality. The survey team shared the following information regarding the lack of education and documentation in the clinical records, prior to the surveyor staff about patient/family knowledge and documentation of education. of patient monitored with the Telesitter. No further information provided.

Based on interviews, and document reviews, it was determined the facility staff failed, to ensure appropriate use of restraints for the management of violent and/or aggressive behavior; failed to ensure an order was written for restraints and/or the appropriate type of restraints, for two (2) of seven (7) patients selected for restraint review (Patients #9 and #12).

The findings include:

On 01/31/18 at 1:30 p.m., the surveyor reviewed Patient #9's clinical record. Staff Member (SM) #4 assisted the surveyor with navigating the clinical record.

Patient #9's clinical record contained an order dated 11/16/17 at 3:46 p.m. for a vest restraint and bilateral wrist and ankle restraints; documentation included an order for non-violent/non-behavior restraints. The patient's behavior documented on the restraint order was "Agitated Encephalopathy".

On 11/16/17, the following nursing documentation read in part as follows:

-3:00 p.m., the patient arrived back to the room with supervisor and security, after a code Atlas was call in CT (Computed Tomography).
-3:08 p.m., the nurse documented the physician was at the bedside and gave a verbal order to give the patient "2mg IV (intravenous) Ativan (Anxiety medication)".
-3:20 p.m., Patient is attempting to break 4 point restraints and is shaking the bed. The physician continued to be at bedside and ordered "50mg IV Benadryl (an antihistamine. Can induce sleep)."
-3:24 p.m., "Benadryl 50mg IV given over 3 minutes". Physician at bedside.
-3:45 p.m., Patient somewhat less agitated, but is still attempting to sit and pull on restraints at times. The physician informed the family of the day's events and the reason for the vest and 4-point restraints. "Sitter at bedside." The [physician] remains on the unit and stated to keep patient NPO (nothing by mouth) for now.

The following information documented in the Physicians Progress Note on 11/16/17 at 3:54 p.m., read in part as follows:

-Patient was given "7.5mg Haldol (antipsychotic medication) IM (Intramuscular)" and sent to CT, [patient] became very agitated and combative, returned to floor without study completed.

The following information found in the facility's policy and procedure titled, "Restraints and Seclusion" (revision date 07/17) read in part as follows:

"10.1 Definition
- Use for the management of violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, staff member or others and when non-physical interventions would not be effective.

10.2 Purpose
- The use of a physical or chemical restrain (medication), or seclusion to manage behavior in an emergency situation or crisis and only for the duration of that situation.
- This measure is reserved for those occasions when unanticipated, severely aggressive, violent or destructive behavior places the patient, staff, or others in imminent danger.

10.6 Continuous
-Each patient with Violent or Self-Destructive behavior and restrained with be observed Monitoring continuously 1:1 and their care documented as frequently as their condition warrants and every 15 minutes for the Management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member or others.

10.20 Chemical Restraints
- A drug or medication that is not being used as a standard treatment for the patient's medical or psychiatric condition, and that results in restricting the patient's freedom of movement would be a drug used as a restraint.
- For example, STAT medications given by order of a physician to control behavior in emergency situations are considered a Chemical restraint if these medications are not part of the patient's normal Plan of Care.
- All Violent or Self Destructive Behavior standards would apply."

On 01/31/18 at 4:45 p.m., the survey team met with the facility's Director of Quality to discuss Patient #9's non-violent, non-behavioral restraint orders, though aggressive behaviors were documented. No additional information was provided.

On 02/01/18 at 9:58 a.m., the surveyor reviewed Patient #12's clinical record. SM #5 assisted the surveyor with navigating the clinical record.

Patient #12's clinical record contained an order dated 10/07/17 at 9:45 p.m. for "soft restraints: Right ankle, right wrist, left ankle and left wrist. Reason for restraints: Danger to self and danger to others." On 10/07/17 at 7:38 p.m. the nurse documented, "Apply soft wrist restraints per [physician]."

Documentation in the clinical record revealed a restraint order was written two (2) hours after the restraints were applied.

Based on interviews and clinical record reviews, it was determined facility staff members failed to ensure a timely assessment by care/case management for 1 of 6 patients selected for discharge planning review (Patient #8).

The findings included:

The facility staff failed to ensure care/case management responded to Patient #8's case management consults in the time frame detailed in the facility's policy/procedure.

The following information was found in a facility policy/procedure entitled "Discharge Planning and Process" (last reviewed 12/6/16): "Discharge planning for all patients shall be initiated on admission by the admitting RN utilizing the Admission Database (specifically the functional assessment, discharge planning, and care management screen sections). Based on the RN's assessment and completion of the admission navigator, appropriate referrals are made in conjunction with the attending physician. Care Managers are to respond to referrals for discharge planning within 24 hours of the referral being completed. The following list (nonexclusive) should be considered in identifying patients at high risk if discharged without adequate interdisciplinary planning: ... Impaired ambulation, balance problems or fall within past 12 months ..."

Patient #8's clinical documentation included an order dated 11/19/17 at 9:43 p.m. for a case management consult for discharge planning for possible placement in a skilled nursing facility or a rehabilitation facility.

Patient #8's clinical documentation included another order dated 11/20/17 at 10:03 p.m. for a case management consult for "(d)ischarge planning postoperative fracture repair"; comments included in the order indicated it should be implemented on post-operative day #1 and include assessment for "Home Health for rehab, labs and wound management; SNF (skilled nursing facility); DME (durable medical equipment) for ambulatory aid, bedside commode as recommended by therapy". The patient's surgery was for a hip fracture resulting from a fall.

The first case/care management documentation found in Patient #8's clinical record was documented on 11/24/17. This case/care management note stated a physician had contacted case/care management to make discharge arrangements for the patient.

On the afternoon of 1/31/18, the failure of the facility's staff to ensure case/care management assessed patient #8 within 24 hours of having a consult ordered was discussed with the facility's Director of Quality/Clinical Management (Staff Member (SM) #4) and a Clinical Care Leader (SM #5). This was also discussed with the facility's Director of Care Management (SM #3) on 1/31/18. No additional information related to this issue was provided to the survey team prior to the conclusion of the survey.

Based on interviews, clinical record reviews, and the review of facility documents, it was determined the facility staff failed to ensure documentation indicated the patient and/or patient's family were provided options of rehabilitation facilities during discharge planning for 1 of 6 patients selected for discharge planning review (Patient #8).

The findings included:

Review of Patient #8's clinical record failed to provide evidence that the patient and/or the patient's family were provided options of rehabilitation facilities in preparation for the patient being discharged.

The following information was found in a facility policy/procedure entitled "Patient Choice for Community Referral" (last reviewed 10/3/17): "The patient and family will be offered a clear explanation of the recommended service, and of their right to choose a service provider. a) Care will be arranged with the preferred provider as long as the provider is able to and agrees to provide the services. b) List of providers are to be given to patient/family for referrals to a Skilled Nursing Facility, Rehab Hospital, Home Health or Hospice program. A listing of agencies from Care Management staff. [sic] Staff may offer (facility's corporate name omitted) agencies as a choice."

The first case/care management documentation found in Patient #8's clinical record was documented on 11/24/17. This case/care management note stated a physician had contacted case/care management asking someone to make discharge arrangements for the patient. This note indicated the patient's family was aware to which facility the patient was being transferred but there was no documentation to indicate the patient and/or patient's family was involved in selecting the facility. This documentation did not state which family member was informed of the transfer.

Patient #8's clinical documentation was reviewed with Staff Member (SM) #5 (a clinical care leader) on 1/3/18. SM #5 reported he/she was unable to find evidence of a choice of provider for discharge being offered to Patient #8.

During an interview on the afternoon of 1/31/18, the failure of clinical documentation to evidence that the facility's staff provided options to Patient #8 and/or the patient's family, to which rehabilitation facility the patient was to be discharged, was discussed with the facility's Director of Quality/Clinical Management (Staff Member (SM) #4) and a Clinical Care Leader (SM #5). This was also discussed with the facility's Director of Care Management (SM #3) on 1/31/18. No additional information related to this issue was provided to the survey team prior to the conclusion of the survey.

Based on interviews and the review of facility documents, it was determined the facility staff failed to ensure the reassessment of the facility's discharge planning process included an analysis of previous discharge plans for potentially preventable readmissions.

The findings included:

The facility staff failed to evaluate discharge planning interventions/care from the prior stay when patients were readmitted to the facility.

Interviews were conducted on the afternoon of 1/31/18 with Director of Quality/Clinical Management (Staff Member (SM) #4), a Clinical Care Leader (SM #5), and the facility's Director of Care Management (SM #3). During these interviews, the surveyor reported still needing to be provided details of the review of the facility's discharge planning process related to readmissions.

On 2/1/18 at 9:50 a.m., the Director of Care Management (Staff Member (SM) #3 and a corporate Director of Care Management (SM #11) were interviewed about the facility staff's evaluation of the facility's discharge planning program. SM #11 reported that case/care management processes were currently being revised. It was explained to the surveyor that, as of January 22, 2018, changes had been implemented related to the case/care management process. SM #11 also reported the way that the facility's readmissions are to be monitored/reviewed is also being changed; SM #11 reported the monitoring/review tool for readmissions had not yet been completed.

On the morning of 2/1/18, the surveyor reviewed facility data collected on recent facility readmissions with SM #3 and SM #11. The data included if case/care management had been involved in the discharge prior to the readmission; the data also included if a 48-hour follow-up appointment had been scheduled. (Data collected also included information related to care the patient did or did not receive between discharge and readmission.) SM #3 was asked if the readmission review looked at: (a) was case/care management involved as needed/expected in the prior discharge planning process of readmitted patients and (b) was 48-hour follow-up appointments made as required as part of the prior discharge planning process of readmitted patients. SM #3 reported that the data just shows whether the aforementioned events occurred not if what occurred or did not occur was appropriate. SM #3 reported when reviewing the previous discharge planning process for readmissions, if concerns were identified then the concerns were addressed with the individuals involved; SM #3 acknowledged the data collected as part of the facility's discharge planning program review does not include information related to when any such concerns have been addressed.