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Based on review of facility documents and interview with staff (EMP), it was determined that Altoona Regional Health System failed to track restraint use in the Emergency Department as a quality assurance monitor according to their adopted Standard of Practice.

Findings include:

Review of "Altoona Regional Health System, Standard of Practice R14. Subject: Restraint/Seclusion .... Revised 7/21/11 ... H. Monitoring of Restraints. The hospital collects data on the use of restraints and seclusion in order to monitor and improve its performance of processes that involves risks or may result in sentinel events. It analyzes the data to: Ascertain the restraint and seclusion are used only as emergency interventions and are not related to staffing levels, ect.; Identify opportunities for incrementally improving the rate and safety of restraint and seclusion use; and identify any need to redesign care processes. Using a patient identifier, data on all restraint and seclusion episodes are collected from and classified for all settings/units/locations by: Shift; Staff who initiated the process; The length of each episode; Date and time each episode was initiated; Day of the week each episode was initiated; The type of restraint used; Whether injuries were sustained by the patient or staff; Age of the patient; and Gender of the patient. ... ".

1. Review of "Continuous Performance Improvement, Annual Report to the Board and President/CEO's Review For the Calendar Year 2010, May 2011 ... Selected examples of system-wide clinical and non-clinical data use: ... Patient Restraints - Compliance with policies to ensure patient safety ... Patient Safety... to ensure that procedures established to prevent harm to the patient are followed and documented when patients are restrained for their own safety and/or safety of others. ... Aggregated restraint monitoring was started in April 2009 to measure performance against established protocol and to identify trends and areas for improvement. ... Monitoring will continue throughout 2011. "

Review of "Restraint Log" dated September 2010 to September 2011 revealed 127 restraints were utilized in the Emergency Department.

1. An interview was conducted with EMP13 on September 29, 2011 at approximately 1:40 PM. "Historically, we have not been doing any quality tracking on restraint use in the Emergency Department. I did not realize that we used that many restraints in our department."

Based on facility documents and interview with staff (EMP), it was determined that Altoona Regional Health System failed to promptly complete medical records after discharge in accordance with State law and hospital policy within 30 days after discharge.

Findings Include:

Review of "Medical Staff Bylaws, Altoona Regional Health System" revised May 17, 2011, revealed, " ... ARTICLE IV. CORRECTIVE ACTION ... 4.6 Medical Records Suspension. Altoona Regional Health System may adopt rules, regulations, policies, and procedures relating to the completion of medical records. If any practitioner fails to complete medical records in accordance with the policies and procedures adopted by Altoona Regional Health System, the clinical privileges of the practitioner may be suspended pursuant to the policy as long as the practitioner is in violation of the Altoona Regional Health System's policies and procedures. ... ."

Review of "Practitioner Incomplete Record Count List (IRC List)" policy and procedure revised January 2011, revealed, "Policy: The Department of Health stipulates that medical records of discharged patients shall be completed in their entirety within 30 days of the date of discharge/treatment. Physician Obligation and Responsibility: It is the physician's responsibility to dictate reports, sign orders, sign dictations, sign other documents, complete transcription blanks, respond to coding & CDS queries/clarifications, etc. within 30 days of discharge. The Health Information Department (HIM) analyzes records after discharge/treatment. Some physician deficiencies are noted during this process. However, this does not extend the 30 day from discharge requirement for completion of the record. ... ."

Review of "ARHS CPI [Continuous Performance Improvement] Data Analysis & Reporting System" dated June-August 2011, revealed, the total number of patient medical records that were incomplete 30 days after discharge was: 1463 in June 2011, 1503 in July 2011, and 1307 in August 2011.

1) An interview was conducted with EMP4 on September 30, 2011, at approximately 12:00 PM. "We don't have any physicians suspended at this time. We have a high percentage of deficiencies for telephone orders and most of them are missing signatures. Our goal is to have zero."