HospitalInspections.org

Based on policy and procedure review, clinical records review and staff interviews, it was determined that the hospital failed to meet the requirements of the Medicare Condition of Participation for 42 CFR 482.13 Patient Rights, as evidenced by:

a. failure to respond in writing to all grievances in a timely manner. See A Tag 0122.

b. failure to provide a written response to grievances that included all the required elements. See A Tag 0123.

c. failure to ensure patients received care in a safe setting. See A Tag 0144.

d. failure to ensure patients were free from abuse and harassment. See A Tag 0145.

e. failure to develop and implement policies, procedures and training to address the use of all devices that could be used to restrain patients and failure to implement safe restraint policies and procedures when those devices were used. See A Tag 0154.

f. failure to identify all restraint devices used within the hospital. See A Tag 0159.

g. failure to apply it's definition of a restraint to the use of geri-chairs, lap buddies, merrywalkers and side rails. The hospital's policy limited the use of restraints only to the management of violent or self-destructive behavior and did not allow for use for other medical reasons. See A Tag 0161.

h. failure to assess patients for the appropriate use of restraint devices after less restrictive interventions had been determined ineffective. See A Tag 0164.

i. failure to determine that the use of a mechanical restraint was not the least restrictive alternative necessary to meet the patient's clinical needs. See A Tag 0165.

j. failure to modify the patients' treatment plans to include the use of restraint devices. See A Tag 0166.

k. failure to ensure that restraint devices were used in a safe and appropriate manner. See A Tag 0167.

l. failure to ensure that a physician's order was obtained prior to, or immediately after, the initiation of a restraint. See A Tag 0168.

m. failure to ensure that physician's orders for the use of restraint devices were not written "as needed" basis. See A Tag 0169.

n. failure to have a policy that addressed the use of restraints for non-violent, non-self-destructive patients. See A Tag 0173.

o. failure to ensure that restrained patients were assessed and monitored on an ongoing basis to determine if restraints could be safely discontinued at the earliest possible time. See A Tag 0174.

p. failure to ensure that restrained patients were monitored according to the hospital's policy and were offered fluids, nourishment, toileting, range of motion and/or exercise and the systematic release of restraints at intervals defined in policy. See A Tag 0175.

q. failure to ensure that the staff clearly documented the patient's behavior that warranted the use of restraints. See A Tag 0185.

r. failure to ensure less restrictive or alternatives to restraint application were documented in the clinical record. See A Tag 0186.

s. failure to ensure that staff documented a description of the patient's condition or symptom that warranted the use of restraints. See A Tag 0187.

t. failure to document the patient's response to the application of restraints. See A Tag 0188.

u. failure to ensure that staff were adequately trained in the application of all restraint devices used in the hospital. See A Tag 0194.

v. failure to train staff and verify competency for the use of all restraint devices within the hospital. See A Tag 0196.

w. failure to ensure that staff caring for all patient populations within the hospital were trained to appropriately and safely manage the use of restraints. See A Tag 0199.

x. failure to ensure that the staff were trained and were determined to be competent to identify signs of physical and psychological distress during the use of restraint devices. See A Tag 0202.

y. failure to ensure that staff were trained to identify behaviors that may indicate when restraint is no longer necessary. See A Tag 0204; and failed to:

z. failure to ensure that patients were adequately monitored while restrained. See A Tag 0205.

Based on policy and procedure review, documents review and staff interviews, it was determined that the hospital failed to respond in writing to all grievances in a timely manner.

Findings:

A hospital policy titled "Grievance - Patient," documented "......Patients will receive a written response with steps taken to resolve the grievance within seven (7) days......"

Patient grievances were reviewed. Two written grievances in October 2012 had no written response from the hospital to the complainant. Four written grievances in November 2012 had no written response from the hospital.

On 12/05/12, staff A and B stated they were not aware of the lack of written responses to complainants.

Based on policy and procedure review, documents review and staff interviews, it was determined that the hospital failed to provide a written response to grievances that included all the required elements.

Findings:

A hospital policy titled "Grievance - Patient," documented ".......Patients will receive a written response with steps taken to resolve the grievance within seven (7) days....... Report to patient should contain the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance and the date of completion......."

Patient grievances were reviewed. Two written grievances in October 2012 had no written response from the hospital to the complainant to indicate the resolution of the grievances. Four written grievances in November 2012 had no written response from the hospital to indicate the resolution of the grievances.

On 12/05/12, staff A and B stated they were not aware of the lack of written responses to complainants.

Based on documents review, policy and procedure review and staff interviews, it was determined that the hospital failed to ensure that patients received care in a safe setting.

Findings:

A hospital document titled "Patient Rights," documented "...... The patient has the right to a humane treatment environment that affords reasonable protection from harm..."

A grievance form written by patient #4 dated 11/01/12, was also signed by eight other patients. Among other issues, the grievance alleged that the patients were exposed to mold on the walls and safety hazards from construction going on inside the hospital.

There was no documentation the patients' grievance was responded to by the hospital. There was no documentation the hospital investigated the allegations of safety hazards and responded in writing to the patients.

Staff A and B stated they were not aware of the grievance and were not aware appropriate actions had been taken.

A grievance form written by patient #5 dated 10/07/12, alleged that a nurse was rude and acted indifferently to her complaints of pain and did not act when the she requested a different pain medication.

There was no documentation that the hospital investigated the allegations to ensure a humane care environment.

Based on records review, policy and procedure review and staff interviews, it was determined that the hospital failed to ensure that patients were free from abuse and harassment.

Findings:

A hospital document titled "Patient Rights," failed to include that patients have the right to be free from various forms of abuse and harassment.

A hospital policy titled "Abuse: Patient," documented "...... Reports of Abuse or Neglect that occur while the patient is hospitalized will be thoroughly investigated......"

On 11/17/12, a family member for patient #2 wrote a grievance alleging that the patient was being physically harmed (excessive bruising) and was verbally abused by staff. There was no documentation that the hospital responded to the allegations and completed an abuse investigation.

On 11/17/12, patient #3 wrote a grievance alleging that a staff member was sexually harassing her and had touched her inappropriately.

On 11/14/12, patient #2 wrote a grievance alleging a staff member was sexually harassing her with inappropriate comments.

On 12/05/12, staff A and staff B stated they were not aware of the allegations and were not aware that the allegations had been investigated and acted upon.

Based on clinical records review, policy and procedure review and staff interviews, it was determined that the hospital failed to develop and implement policies, procedures and training to address the use of all devices that could be used to restrain patients, and failed to implement safe restraint policies and procedures when those devices were used.

Findings:

A hospital policy titled "Restraints," documented "...... A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move... freely...... Restraint may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others after less restrictive interventions are ineffective or ruled-out....."

The policy did not identify all possible types of restraints used in the hospital.

Nurses' notes for patient #1 documented that the staff used a geri-chair, a merry-walker and a wheelchair lap buddy at various times during the patient's hospitalization.

The patient fell out of the geri-chair twice, one time sustaining a head injury. Staff B stated that the patient was confused and crawled over the arm of the geri-chair falling to the floor.

Nurses' notes for patient #6 documented that the staff used a geri-chair and a wheelchair with a lap buddy during the care of the patient.

The clinical records for both patients did not document why this equipment was used. There were no physician's orders for the use of the equipment.

On 12/05/12, staff A and B were asked why the equipment was used on the patients. They stated it was used to prevent falls. They were asked if the equipment was to be considered a restraint. They stated they were not. They were asked if the patients could freely get out of those devices or remove them without assistance. They stated they were not sure.

Staff A and B stated that they had not considered those items to be restraint devices and restraint policies and procedures were not implemented when they were used.

Staff A and B stated that the staff had not been trained to treat these devices as restraints.

Based on clinical records review, policy and procedure review and staff interviews, it was determined that the hospital failed to identify all restraint devices used within the hospital.

Findings:

A hospital policy titled "Restraints," did not document all possible restraint devices that were used within the hospital. The policy only referred to "bed restraints."

On 12/05/12, staff A and B stated geri-chairs, merrywalkers, lap buddies, and side rails were used in the hospital. They stated that those items were used primarily to prevent falls.

The staff had not determined that these pieces of equipment could be used as restraints. They stated that they had never applied the restraint policy to these, or other devices that may be used to restrict patients.

Based on policy and procedure review and staff interviews, it was determined that the hospital failed to apply it's definition of a restraint to the use of geri-chairs, lap buddies, merrywalkers and side rails. The hospital policy limited the use of restraints only to the management of violent or self-destructive behavior and did not allow for use for other medical reasons.

Findings:

The hospital policy on restraints gave an appropriate definition of a restraint. However, the hospital had not identified various equipment used in the hospital that should be considered a restraint if used according to the restraint definition. The hospital policy did not identify when and how geri-chairs, lap buddies, merrywalkers and side rails could be used.

Clinical records indicated that geri-chairs, lap buddies, merrywalkers and side rails were used by staff during the care of patients. The clinical records did not document how and why these devices were used.

When staff were interviewed, they stated that the devices were used to prevent falls. The staff were asked if the use of the devices had been evaluated according to the definition of a restraint. They stated they had not.

They were asked if the patients who used the devices could easily remove them or get out of them without assistance. They stated the devices were used on patients who were confused and were unlikely to understand what the devices were used for. They stated they usually did not follow commands.

The clinical record for patient #1 documented that the patient was placed in a geri-chair. The record documented that the patient fell out of the geri-chair on 07/23/12 and sustained a head injury. On 07/27/12, the patient again fell out of the geri-chair, this time with no apparent injury.

Staff B was asked how the patient fell out of the geri-chair. She stated the patient was confused and crawled out (over the side) of the geri-chair. She was asked why the patient was placed in the geri-chair. She stated that it was a way to keep her from getting up from a chair and falling.

The clinical record documented that the patient also used a merrywalker and a lap buddy at various times. Staff stated these were also used to prevent a patient from falling due to the patient's debility and confusion.

The clinical record did not document that the patient could safely remove herself, unassisted, from these devices.

There was no documentation that an evaluation of the use of these devices determined they were not used as restraints.

Based on policy and procedure review, clinical records review and staff interviews, it was determined the hospital failed to assess patients for the appropriate use of restraint devices after less restrictive interventions had been determined ineffective.

Findings:

A hospital policy titled "Restraint," documented "...... The registered nurse will document behaviors which led to the need for the use of restraint....... The attending/covering practitioner will be contacted...... The order shall indicate the reason and maximum duration of restraint......."

The hospital policy did not require documentation to include:
~ a physician's order for the specific type of restraint;
~ consideration of other possible factors (other than the patient) in determining a cause for restraint; and
~ the use of less restrictive interventions prior to the application of a restraint device or to determine why less restrictive measures would be insufficient.

The clinical records for patient #1 and #6 documented that geri-chairs, lap buddies, merrywalkers and side rails were used during the patients' hospitalization. There was no documentation that the patients could remove or get out of them unassisted.

There was no documentation of the patients' behaviors or other factors that warranted the use of the devices. There was no documentation of less restrictive measures attempted or considered prior to the application of the devices.

There was no documentation of physician's orders for their use.

There was no documentation of patient assessment and revision of the plan of care.

On 12/05/12, staff A and B stated that since the hospital had not considered these devices could be restraints, the restraint procedures had not been implemented.

Based on clinical records review and staff interview, it was determined the hospital failed to use the least restrictive measures necessary to meet the patient's clinical needs before the use of mechanical restraints.

Findings:

The clinical records for patient #1 and #6 documented geri-chairs, lap buddies, merrywalkers and side rails were used at various times during the patients' hospitalization. There was no documentation that the patients could remove or get out of them without assistance.

The records did not document a comprehensive assessment prior to the use of the restraints and further assessment after they were applied.

There was no documentation of interventions used prior to the use of the mechanical restraints.

The clinical record did not document if attempts were made to release the patients from the restaint devices at the earliest possible time.

On 12/05/12, staff A and B stated they did not know these devices could be considered restraints.

Based on policy and procedure review, clinical records review and staff interviews, it was determined that the hospital failed to modify the patients' treatment plans to include the use of restraint devices.

Findings:

A hospital policy titled "Restraint," documented "....... The treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent recurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is restrained on more than one occasion....."

The clinical records for patient #1 and #6 documented geri-chairs, lap buddies, merrywalkers and side rails were used at various times during the patients' hospitalization. There was no documentation that the patients could remove or get out of them on their own.

There was no documentation in the patients' treatment plans that indicated how and why geri-chairs, lap buddies, merrywalkers and side rails were used. The treatment plans did not identify this equipment was used as a restraint.

On 12/05/12, staff A and B stated that if the staff had identified these devices as restraints, they would be required to modify the treatment plans. They stated all devices used on patients should be included in the treatment plans.

Based on policy and procedure review and staff interviews, it was determined the hospital failed to ensure that restraint devices were used in a safe and appropriate manner.

Findings:

A hospital policy for restraints did not identify all possible types of mechanical restraints found within the hospital, to include side rails, geri-chairs, wheelchair seatbelts, lap buddies, merry walkers and others. There was no instruction on the safe and appropriate use of these devices.

The policy only allowed for the use of physical and mechanical restraints for the management of violent or self-destructive behavior that jeopardized the immediate physical safety of the patient or others.

The policy did not allow for the use of certain devices for the physical safety of a patient for medical reasons when there was no other successful less restrictive intervention available.

The hospital restraint policy documented "........ (when a patient is restrained) the patient shall be monitored and reassessed through continuous in-person observation. The nurse in charge will assign trained staff to continuously monitor the patient during the restraint event. Continuous means ongoing without interruption........"

Clinical records review indicated that various devices were used to keep patients physically restrained in chairs or in bed. The records did not document why the devices were used and if they achieved an intended purpose.

Patient #1 was placed in a geri-chair. Staff stated that she could not manipulate the chair herself to get out of it on her own, and that it was used to prevent her from getting up and falling.

The clinical record documented that the patient fell out of the geri-chair twice, when she climbed over the arm of the chair. One fall resulted in a head injury. The record did not document that the patient was monitored continuously while in the geri-chair or when other devices such as a wheelchair with a lap buddy and a merrywalker were used.

Based on clinical records review, policy and procedure review and staff interviews, it was determined that the hospital failed to ensure that a physician's order was obtained prior to, or immediately after, the initiation of a restraint.

Findings:

A hospital policy titled "Restraint," documented "...... The attending/covering practitioner will be contacted during the initiation of restraint or immediately after......"

Clinical records for patients #1 and #6 documented that the patients were placed in restraint devices they could not remove or get out of without assistance.

There were no physician's orders for the devices found in the clinical record.

On 12/05/12, staff A and B stated that since the staff did not recognize the devices as restraints, orders were not obtained.

Based on clinical records review and staff interviews, it was determined that the hospital failed to ensure that physician's orders for the use of restraint devices were not written "as needed" basis.

Findings:

The clinical records for patients #1 and #6 documented the periodic use of geri-chairs, side rails and wheelchairs with lap buddies. There was no documentation that the staff secured an appropriate physician's order to use these devices for specific medical reasons.

On 12/05/12, staff A and B stated it was a common practice to use these devices "as needed" and without a physician's order.

Based on policy and procedure review and staff interviews, it was determined that the hospital failed to have a policy that addressed the use of restraints for non-violent, non-self-destructive patients.

Findings:

A review of the hospital policy for restraints indicated that there was no guidance for staff to obtain appropriate orders for restraints used for non-violent, non-self-destructive patients.

On 12/05/12, staff A and B stated that there was no policy to address restraints used in this manner. They stated geri-chairs, merrywalkers, side rails and lap buddies were used to treat patients who were confused and unsafe if they tried to stand alone.

They stated they did not know these devices could be considered restraints and subject to compliance with regulation.

Based on clinical records review and staff interviews, it was determined that the hospital failed to ensure restrained patients were assessed and monitored on an ongoing basis to determine if restraints could be safely discontinued at the earliest possible time.

Findings:

The clinical records for patients #1 and #6 indicated that restraint devices were used periodically throughout the hospitalization. There was no documentation found that indicated the decision to continue or discontinue the use of the restraints.

There was no documentation to indicate when the patients were placed in restraints and when they were released.

On 12/05/12, staff B stated the assessment and evaluation of the patients' restraints had not been done.

Based on policy and procedure review, clinical records review and staff interviews, it was determined that the hospital failed to ensure restrained patients were monitored according to policy and were offered fluids, nourishment, toileting, range of motion and/or exercise and the systematic release of restraints at intervals defined in policy.

Findings:

A hospital restraint policy documented that restrained patients would be monitored in person and continuously while restraints were being used. The policy had no provision for monitoring patients restrained with geri-chairs, lap buddies, merrywalkers, side rails or other medical devices.

The policy did not define established intervals for offering fluids, nourishment, toileting, range of motion and/or exercise and the systematic release of any type of restraint.

The clinical records for patients #1 and #6 had no documentation of continuous monitoring while the patients were restrained in geri-chairs, lap buddies or merrywalkers. There was no documentation fluids, nourishment, toileting, range of motion and/or exercise and the systematic release of restraints were offered while the patients were restrained.

On 12/05/12, staff B stated there was no other hospital policy that addressed the care of patients in restraints.

Based on clinical records review and staff interviews, it was determined that the hospital failed to ensure that the staff clearly documented the patient's behavior that warranted the use of restraints.

Findings:

Clinical records for patients #1 and #6 documented that the patients were placed in geri-chairs, lap buddies, merrywalkers and in bed with side rails up. Staff stated these devices were used to restrict the patients from getting up unassisted and to prevent falls.

There was no documentation in the clinical record regarding the patients' behaviors or what had happened to determine whether less restrictive measures were necessary to prevent serious injury rather than the use of physical restraints.

There was no documentation that indicated when the patients were placed in the restraint devices, and there was no documentation of the patients' clinical response to the restraints.

On 12/05/12, staff B stated the restraint policy had not been followed in these cases.

Based on clinical records review, policy and procedure review and staff interviews, it was determined that the hospital failed to ensure less restrictive or alternatives to restraint application were documented in the clinical record.

Findings:

The hospital restraint policy did not instruct staff to document attempts at alternatives or less restrictive interventions prior to the application of mechanical restraint devices.

The clinical records for patients #1 and #6 had no documentation of interventions attempted before the patients were placed in geri-chairs, lap buddies, merrywalkers and side rails.

There was no documentation that indicated the use of those devices was evaluated for appropriate use.

On 12/05/12, staff A was asked if the staff should document less restrictive interventions attempted before restraints were used. She stated they should.

Based on clinical record review and staff interview, it was determined that the hospital failed to ensure staff documented a description of the patient's condition or symptom that warranted the use of restraints.

Findings:

The clinical records for patients #1 and #6 documented that geri-chairs, lap buddies, merrywalkers and side rails were used during the patient's hospitalization.

There was no documentation to describe the patients' condition or other symptoms that warranted the use of the restraints. Since there was no documentation of dates and times when the various restraints were applied, it could not be determined that a condition or symptom was present that warranted the use of restraints.

On 12/05/12, staff A and B stated the restraint policy was not followed for these devices used on the patients.

Based on clinical records review and staff interviews, it was determined that the hospital failed to document the patient's response to the application of restraints.

Findings:

The clinical records for patients #1 and #6 documented that geri-chairs, lap buddies, merrywalkers and side rails were used during the patient's hospitalization.

There was no documentation of when the restraints were applied and therefore no clear documentation of the patients' response to it.

On 12/05/12, staff A and B stated the restraint policy was not followed for these devices used on the patients.

Based on records review, policy and procedure review and staff interviews, it was determined that the hospital failed to ensure that staff were adequately trained in the application of all restraint devices used in the hospital.

Findings:

The hospital restraint policy did not specify what training would be provided and how often staff would be trained on the various types of restraints. The policy did not specify what types of restraints could be used in the hospital.

The clinical records for patients #1 and #6 documented that geri-chairs, lap buddies, merrywalkers and side rails were used to restrain the patients during their hospitalization.

On 12/05/12, staff A stated the use of these devices were not included in the staff restraint training.

Based on records review and staff interviews, it was determined that the hospital failed to train staff and verify competency for the use of all restraint devices within the hospital.

Findings:

On 12/05/12, staff A stated that because the hospital did not identify that geri-chairs, lap buddies, merrywalkers, side rails and other devices could be used as restraints, staff were not trained to implement the restraint policy and procedure for their use.

Staff B stated there was no competency verified for their use.

Based on records review and staff interviews, it was determined that the hospital failed to ensure that staff caring for all patient population within the hospital were trained to appropriately and safely manage the use of restraints used with each population.

Findings:

On 12/05/12, staff A stated that because the hospital did not identify that geri-chairs, lap buddies, merrywalkers, side rails and other devices could be used as restraints, staff were not trained to implement the restraint policy and procedure for their use.

She stated these devices were most often used on the geriatric psychiatric unit.

Based on clinical records review and staff interviews, it was determined that the hospital failed to ensure that the staff were trained and were determined to be competent to identify signs of physical and psychological distress during the use of restraint devices.

Findings:

The clinical record for patient #1 documented that the patient fell out of a geri-chair twice. One fall resulted in a head injury.

On 12/05/12, staff B stated that the patient crawled over the arm of the geri-chair and fell. She stated the chair was being used to prevent the patient from getting out of the chair without assistance because she was at risk for falls.

She stated the hospital did not recognize the use of the geri-chair as a restraint and did not monitor the patient continuously while she was in it.

Based on clinical records review and staff interviews, it was determined that the hospital failed to ensure that staff were trained to identify behaviors that may indicate when restraint is no longer necessary.

Findings:

On 12/05/12, staff A stated the staff were not trained to identify the use of geri-chairs, lap buddies, merrywalkers, side rails and other devices as potential restraints.

Clinical records indicated patients were placed in and out of these devices during the course of hospitalization without documentation of an assessment for discontinuation of them.

Based on policy and procedure review, clinical records review and staff interviews, it was determined that the hospital failed to ensure patients were adequately monitored while restrained.

Findings:

The hospital restraint policy documented "........The patient shall be monitored and reassessed through continuous in-person observation......."

The policy did not specify what physical and psychological parameters would be assessed and how often.

The clinical records for patients #1 and #6 documented the use of restraint devices. There was no documentation of physical and psychological monitoring provided while the restraints were used.

On 12/05/12, staff A stated the staff were not trained to identify the use of geri-chairs, lap buddies, merrywalkers, side rails and other devices as potential restraints, and therefore did not treat them as restraints.