HospitalInspections.org

The hospital reported a census of 25 patients. Based on observation, document review and staff interview the governing body failed to protect and promote each patient's rights with physical restraints.

Findings include:

- The governing body failed to protect and promote each patient's rights related to the use of physical restraints. See further evidence at A-0115, CFR 482.13.

- The governing body failed to ensure the hospital had an effective ongoing Quality Assurance Program. See further evidence at A-0263, CFR 482.21.

- The governing body failed to ensure the hospital had an effective pharmacy department to meet the needs of the hospital patients. See further evidence at A-0490, CFR 482.25.

- The Governing Body failed to ensure all physicians were granted priviledges prior to directing patient care. See further evidence at A-045, CFR 482.12 (a)(1).
The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

The hospital reported a census of 25 patients. Based on observation, document review and staff interview the hospital failed to protect and promote each patient's rights with physical restraints, failed to develop a comprehensive policy to direct staff on the use of restraints, failed to ensure staff included restraints in the patient's plans of care, failed to ensure staff obtained restraint orders, properly assessed, monitored and removed restraints when no longer warranted and failed to appoint a qualified trainer to train physicians and staff for the use of restraints and failed to ensure all direct care staff were provided training for safe implementation of restraints.

On 2/28/11 a finding of Immediate Jeopardy, a situation which is likely to cause serious injury, harm, impairment or death to a patient, was identified from the hospital's failure to protect and promote patient rights when altered/modified physical restraints were applied by untrained staff.

On 3/1/11, the hospital abated the Immediate Jeopardy by removal and disposing of all hospital manufactured/customized non-releasing seatbelt restraints, provided restraint education for all hospital staff, reassessment of current restrained patients with removed of their restraints, and completed education for maintenance department staff regarding no future manufacturing/customizing seatbelt restraints.

Findings include:

- The hospital failed to protect the patient's right to be free from restraints, imposed as a means of convenience for staff. See further evidence at A-0154, CFR 482.13(e).

- The hospital failed to ensure the staff had an ongoing process to assess the patient need for restraint use. See further evidence at A-0164, CFR 482.13(e)(3).

- The hospital failed to ensure the patient's plan of care was updated to include to use of restraints. See further evidence at A-0166, CFR 482.13(e)(4).

- The hospital failed to ensure the staff obtained physician orders for the use of restraints. See further evidence at A-0168, CFR 482.13(e)(5).

- The hospital failed to ensure the staff discontinued the patient restraint at the earliest possible time, regardless of the length of time identified in the order. See further evidence at A-0174, CFR 482.13(e)(9).

- The hospital failed to ensure the physician properly assessed the patients for the need of the restraint and monitor the patients while in restraints. See further evidence at A-0175, CFR 482.13(e)(10).

- The hospital failed to ensure the medical staff had proper training for the use of restraints. See further evidence at A-0176, CFR 482.13(e)(11).

- The hospital failed to ensure the staff had training for safe application of restraints. See further evidence at A-0194, CFR 482.13(f).

- The hospital failed to provide a qualified trainer evidenced by education, training, and experience in techniques to train hospital staff. See further evidence at A-207, CFR 482.13(f)(3).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on document review and staff interview the hospital failed to implement an effective on-going hospital wide Quality Assurance program and performance improvement program with data collection, measurable goals, improvement indicators to ensure positive patient outcomes for all hospital departments.

Findings include:

- The hospital failed to implement an ongoing Quality Assurance program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes. See further evidence at A-0265, CFR 482.21(a).

- The hospital failed to ensure the Quality Assurance program had measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital services and operations. See further evidence at A-0267, CFR 482.21(b).

- The hospital failed to ensure the Quality Assurance program frequency and detail of data collection was specified by the hospital's governing body. See further evidence at A-0277, CFR 482.21(c).

- The hospital failed to ensure the Quality Assurance program conducted performance improvement projects. See further evidence at A-0297, CFR 482.21(d).

- The hospital's governing body failed to demonstrate responsible and accountability for the hospital wide Quality Assurance program. See further evidence at A-0309, CFR 482.21(e).

The hospital reported a census of 25 patients. Based on document review and staff interview the hospital failed to ensure 16 of 16 radiology physicians (physicians BB, CC, DD, EE, FF, GG, HH, II, JJ, KK, LL, MM, NN, OO, PP, QQ) were credentialed and failed to ensure 4 of 4 physicians and 1 mid level (physicians RR, SS, TT, VV and Advanced Registered Nurse Practitioner Z) were credentialed to order outpatient services.

Findings include:

- Review of the hospital's radiology contract on 2/23/11 and multiple patient records revealed the hospital allowed 16 radiology physicians to read patient x-rays.

Medical Staff By-laws reviewed on 2/18/10 revealed the hospital must privilege physicians through the credentialing process and grant permission to render diagnostic patient services for inpatients and outpatients.

Credentialing staff G interviewed on 3/2/11 at 9:45am reported the hospital lacked evidence of any credentialing for radiology physicians BB, CC, DD, EE, FF, GG, HH, II, JJ, KK, LL, MM, NN, OO, PP, QQ and lacked a credentialing process for radiology physicians.

- Patient #31's medical record, reviewed on 2/24/11, revealed Advanced Registered Nurse Practitioner Z completed an order for outpatient physical therapy evaluation and treat on 12/24/10. Review of the medical record revealed physician VV signed the physical therapy evaluation/certification form on 1/4/11 and physician TT signed the second physical therapy treatment form on 2/4/11.

- Patient #34's medical record, reviewed on 2/24/11, revealed physician RR admitted them to outpatient services on 7/27/10. Review of the medical record revealed a physical therapy evaluation/certification form and an additional order to continue outpatient services dated 11/1/10 was signed by physician RR who lacked clinical privileges.

Review of the medical record revealed a speech evaluation/certification signed by physician SS who lacked clinical privileges.

- Administrative therapy staff H interviewed on 2/24/11 at 10:00am reported they lacked knowledge if physician RR had hospital granted privileges and stated they "never check to ensure the physician was granted privileges by the hospital to admit patients to outpatients services."
- Credentialing staff G interviewed on 3/2/11 at 9:45am verified the hospital lacked credentialing for physicians RR, SS, TT AND VV and Advanced Registered Nurse Practitioner Z and lacked a credentialing process for outpatient physicians.

The Hospital reported a census of 25 patients. Based on document review and staff interview, the Hospital Governing Body failed to ensure they reviewed and approved all medical staff bylaws.

Findings include:

- Review of the Hospital Governing Body bylaws revealed a plan to meet quarterly to "...discharge its duties." The bylaws also documented a required Quorum of "at least two members of the Governing Body must be present...Minutes of the meetings of the Governing Body are maintained by the Medical Records Director..."

- Hospital policy 100.020.032, reviewed on 3/2/11, documented the responsibility of the Governing Body to include-"...d) The Governing Body will assure that the Medical Staff has bylaws and will approve those bylaws and all other medical staff rules and regulations..."

The Hospital Medical Staff By-Laws/Rules and Regulations, reviewed on 3/2/11, section 12.3.1 documented the medical staff maintained a By-Laws Committee which was to conduct annual reviews of the by-laws/rules and regulations and submit changes to the General Medical Staff for review.

This document stated the meetings shall be held yearly and as necessary. Section 13.4-2 of this document stated that "not less than two (2) voting members who are also members of the Medical Staff shall constitute a quorum at Committee meetings..."

The Hospital Staff by-laws/rules and regulations, reviewed on 3/2/11 documented the last review and revision on 2/18/10 with only physician AA present.

Staff G interviewed on 3/2/11 at 9:45am., verified the Hospital has never had a Quorum of two physician's for the approval of the bylaws/rules and regulations.

The Governing Body failed to ensure that the required Quorum of physician's approved the medical staff bylaws/rules and regulations prior to Governing Body review and approval.

- Review of the Governing Body bylaws, on 3/2/11, revealed the plan to review the "client care policies and by-laws governing the operation of the facility"... "at least on an annual basis..." The bylaws documented that at least 2 members of the Governing Body must be present for a Quorum.

Documentation by the Governing Body of their last review revealed the Hospital documented one Governing body member approved the By-laws on 12/18/08, another on 12/30/08 , and one physician member on 1/8/09.

The Hospital Governing Body failed to have the required Quorum of two as required for proper approval of the by-laws.

The hospital reported a census of 25 patients. Based on document review and staff interview the hospital failed to ensure they included contracted services within the hospital wide Quality Assurance program.

Findings include:

- Hospital policy #100.020.032 for governing body responsibilities reviewed on 3/1/11, indicated the governing body were responsible for contracted services to ensure services were provided in a safe and effective manner.

- Review of the hospital contracts on 2/23/11 revealed the had contracted services for pharmacy, therapy services, outpatient therapy services, and radiology utilization review.

-The hospital failed to ensure the contracted pharmacy met the needs of patient #12.

Patient #12's medical record reviewed on 2/28/11 revealed the pharmacy failed to provide nicotine patches for three days as ordered by the physician.

The Hospital failed to ensure the pharmacy contracted services meet the needs of the patients.

Administrative staff C failed to provide the requested Quality Assurance data showing how they monitored the contracted services.

- Review of the hospital's Quality Assurance documentation lacked evidence of their contracted therapy services, radiology services and organ procurement documentation.

Quality Assurance staff E interviewed on 3/1/11 at 10:00am reported the hospital failed to include their contracted services within their hospital wide quality assurance program.

The Hospital's Governing Body did not identify the need to incorporate contracted services within their QA Program.

The hospital reported a census of 25 patients with three outpatients records reviewed. Based on document review and staff interview the hospital failed to ensure 3 of 3 outpatients received notices of their patient rights at admission (patient #'s 31, 33 and 34).

Findings include:

- Patient #31's medical record, reviewed on 2/24/11, revealed they began outpatient therapy services on 12/24/10. The medical record lacked evidence of any patient rights acknowledgement.

- Patient #33's medical record, reviewed on 2/28/11, revealed they began outpatient therapy services on 9/8/10. The medical record lacked evidence of any patient rights acknowledgement.

- Patient #34's medical record, reviewed on 2/24/11, revealed they began outpatient therapy services on 7/27/10. The medical record lacked evidence of any patient rights acknowledgement.

- Administrative staff V interviewed on 2/24/11 at 9:00am reported they were responsible for outpatient admission paperwork and stated the hospital "only provides patient rights to their inpatients not their outpatients".

The hospital reported a census of 25 patients with three outpatients records reviewed. Based on document review and staff interview the hospital failed to ensure 3 of 3 outpatients exercised their right for informed consents for treatment at admission (patient #'s 31, 33 and 34).

Findings include:

- Patient #31's medical record, reviewed on 2/24/11, revealed they began outpatient therapy services on 12/24/10. The medical record lacked evidence of any informed consent for treatment.

- Patient #33's medical record, reviewed on 2/28/11, revealed they began outpatient therapy services on 9/8/10. The medical record lacked evidence of any informed consent for treatment.

- Patient #34's medical record, reviewed on 2/24/11, revealed they began outpatient therapy services on 7/27/10. The medical record lacked evidence of any informed consent for treatment.

- Administrative staff V interviewed on 2/24/11 at 9:00am reported they were responsible for outpatient admission paperwork. Staff V stated the hospital does not obtain informed consent forms for outpatients.

The hospital reported a census of 25 patients with 30 medical records reviewed. Based on observation, document review and staff interview the hospital failed to provide 10 of 10 patients their right to be free from physical restraints used for staff convenience (patient #'s 1, 2, 4, 6, 7, 8, 12, 15, 16 and 26).

Findings include:

- The Hospital policy for Mechanical Restraint Number 825.020.092, reviewed on 2/22/11, documented "...Mechanical Restraint is defined as the use of a devise to suppress or restrict physical actions/movements as needed to maintain the patient's safety. The use of a mechanical restraint will only be implemented when all other procedures are deemed ineffective in situations where personal injury is eminent...3. Anytime mechanical restraint is deemed medically warranted a plan will be designed to closely monitor and safe guard the patients health and mental status. The staff will document the activities as well as the outcome...5. justification for continued use will be documented in the Treatment Care Plan..."

- Patient #2 was observed restrained in a wheelchair with a seatbelt on 2/21/11 at 2:00pm seated near the nurse's station. Observation of the restraint buckle revealed a hole near the buckle release button. The hole was approximately 1 centimeter in diameter and exposed a silver metal bar inside the buckle.

Licensed staff M and K interviewed on 2/21/11 at 4:09pm reported they lacked knowledge of the "device" the staff used to release the locked restraint and stated they would need to check the hospital policies to obtain an answer. Administrative nurse B on 2/21/11 at 4:10pm stated they did not know what the staff used to release the locked restraint but thought "some of the staff had a metal silver tool". Staff B accompanied survey staff to the patient restrained in their wheelchair at the dinner table. Staff B stated they did not know how to open the locked restraint and asked Certified staff Q how they released the restraint.

Certified staff Q quietly explained they discovered they could use a writing pen to release the lock. Staff Q demonstrated by putting their writing pen into the hole on the buckle and released the locked restraint. Administrative Nurse B asked Certified staff Q who instructed them to release the lock with a writing pen? Staff Q replied "we all just figured it out on our own". Staff Q reported they have not received any restraint education from the hospital.

Corporate nurse C observed patient #2 on 2/22/11 at 8:10am seated in their wheelchair with the locked restraint across their lap. Staff C reported the hospital did not use non-releasing seatbelts and lacked knowledge where it came from.

Maintenance staff J interviewed on 2/22/11 at 11:00am reported they drilled the clasp of the self releasing seatbelts to make them a non-releasing seat belt in the hospital's maintenance shop. Staff J stated the nursing staff requested a non-releasing seatbelt and they did not have any available. Staff J reported they decided to drill the face of the clasp after they assessed how the clasp worked, but lacked any manufacturer directions to do so. Staff J reported they lacked knowledge if the modified restraint had the ability to be released consistently in case of emergencies.

Administrative staff A and C interviewed on 2/23/11 at 8:00am reported all seatbelts were removed from all patients on 2/22/11 and that the hospital had begun training staff on the use of restraints.

- Patient #1's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 10/21/11 with diagnosis of a skull fracture with traumatic brain injury and impulsive behavior.

Patient #1 was observed restrained in a wheelchair with a seatbelt on 2/21/11 at 2:00pm seated near the nurse's station. Patient #1 was also observed with the seatbelt restraint applied on 2/22/11 at 7:35am, 8:00am and at 9:00am.

Licensed staff K interviewed on 2/21/11 at 3:00pm reported the patient could not release the self releasing seatbelt. Certified staff W on 2/21/11 at 3:00pm, requested the patient to release the seatbelt. The patient did not attempt to remove the restraint or follow the staff command. Certified staff Q at 4:45pm, requested the patient to release the seatbelt restraint, and the patient could not perform this task when requested to do so.

On 2/22/11 (time undocumented) Hospital Administration requested Physical Therapy to assess this patient regarding the need for the restraint. Physical Therapist N completed this assessment and recommended the hospital try to manage the patient without the restraint.

Director of therapy staff H, interviewed on 2/22/11 at 2:45pm stated they assessed and determined the patient no longer needed the restraint.

Patient #1 was observed on 2/22/11 at 3:00pm and 5:00pm, on 2/23/10 at 8:00am and on 3/1/11 at 11:40am, in their wheelchair without any restraint and patient did not attempt to rise from chair.

The medical record lacked evidence of an accurate assessment of the need for the restraint, including daily monitoring and assessments by the nursing staff.. The medical record failed to demonstrate consistent restraint documentation.

- Patient #6's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/27/11 and diagnosis of head trauma with subarachnoid hemorrhage.

Patient #6 was observed restrained in a wheelchair with a seatbelt on 2/21/11 at 3:30pm propelling self down the hallway. Patient #6 was also observed with the seatbelt restraint applied on 2/22/11 at 7:40am, 11:45am and at 12:38pm.

Certified staff W on 2/21/11 at 4:45pm requested the patient #6 to release their seatbelt. The patient attempted to manipulate the belt but was not successful in releasing the belt.

Patient #6's medical record revealed a printed physician order dated 1/31/11, with an additional handwritten notation by a staff (not signed, timed or dated) indicating the patient had a self releasing seatbelt. Review of the nursing notes between 2/1/11 to 2/22/11 revealed the nursing staff failed to consistently document the use of the restraint. The nursing staff failed to document the presence of the restraint on 2/21/11 and 2/22/11 when they were observed using the restraint. The medical record lacked evidence of an accurate assessment of the need for the restraint.

On 2/22/11 (time undocumented) Hospital Administration requested Physical Therapy to assess this patient regarding the need for the restraint. Physical Therapist N completed this assessment and recommended the hospital try to manage the patient without the restraint.

Director of Therapy staff H, interviewed on 2/22/11 at 2:45pm stated they assessed and determined the patient no longer needed the restraint.

Patient #6 was observed on 2/22/11 at 2:55pm and 5:00pm, on 2/23/10 at 8:00am and on 3/1/11 at 11:40am, in their wheelchair without any restraint and patient did not attempt to rise from chair.



12674

- Patient #16's medical record reviewed on 2/22/11 revealed the patient was admitted to the Hospital on 12/30/10 with traumatic brain injury with right sided hemiparesis. A physician's order, dated 1/5/11, instructed hospital staff to place an alarmed self releasing seat belt on this patient for safety related to impulsivity.

Patient #16 was observed restrained in a wheelchair with a seat belt on 2/21/11 at 2:25pm and wheeled themselves. Patient #16 interacted frequently with staff, mumbling to themselves and to the staff, which consisted mostly of unintelligible conversation and repeated number sequences. This patient was also observed with the seat belt restraint applied on 2/22/11 at 7:40am, 2/22/11 at 8:16am, and 2/22/11 at 8:36am.

Licensed nurse K interviewed on 2/22/11 at 10:00am verified this patient could not release the self releasing seat belt on request. Licensed nurse K, at that time, requested the patient to release the seat belt. The patient was observed fumbling with the seat belt restraint straps for over five minutes and could not release the restraint. Certified staff O, interviewed on 2/21/11 at 2:35pm asked patient #16 to release the seat belt restraint, and the patient could not perform this task when requested to do so.

On 2/22/11 (time undocumented) Hospital Administration requested Physical Therapy to assess this patient regarding the need for the restraint. Physical Therapist N completed this assessment and recommended the hospital try to manage the patient without the restraint.

Director of Therapy staff H, interviewed on 2/22/11 at 12:45pm stated they assessed and determined the patient no longer needed the restraint.

Patient #16 was observed on 2/23/11 at 12:50pm, 2/28/11 at 9:47 and 3/1/11 at 12:55pm, in their wheelchair without any restraint and the patient did not attempt to rise from the chair.

The medical record failed to provide an accurate assessment of the need for the restraint. The medical record documented patient #16 was restrained from 1/15/11 to 2/22/11, a total of 38 days, for staff convenience.

- Non-compliance of the facility to provide an accurate assessment of the need for a restraint prior to application of the restraint also affected patients #4, 7, 8, 12, 15, and 26.

The hospital reported a census of 25 patients with 30 medical records reviewed. Based on observation, document review and staff interview the hospital failed to ensure staff assessed 10 of 10 patients (#'s 1, 2, 4, 6, 7, 8, 12, 15, 16 and 26) for the on-going need for the use of restraints.

Findings include:

- Patient #2's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/21/11 and diagnosis of traumatic head injury with subarachnoid hemorrhage.

Patient #2 was observed restrained with a non-releasing seatbelt on 2/21/11 at 2:00pm in a wheelchair near the nurse's station.

Patient #2's medical record revealed a phone order dated 2/7/11 that directed the staff to discontinue the self releasing seatbelt restraint and apply a non-releasing seatbelt restraint.

On 2/22/11 (time undocumented) Hospital Administration requested Physical Therapy to assess this patient regarding the need for the restraint. Physical Therapist N completed this assessment and recommended the hospital try to manage the patient without the restraint.

Director of Therapy staff H, interviewed on 2/22/11 at 2:45pm stated they assessed and determined the patients no longer needed the restraint.

- Patient #6's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/27/11 and diagnosis of head trauma with subarachnoid hemorrhage.

Patient #6 was observed restrained in a wheelchair with a seatbelt on 2/21/11 at 3:30pm propelling self down the hallway. Patient was also observed with the seatbelt restraint applied on 2/22/11 at 7:40am, 11:45am and at 12:38pm.

Certified staff W interviewed on 2/21/11 at 4:45pm requested the patient to release their seatbelt. The patient attempted to manipulate the beat but was not successful in releasing the belt.

Patient #6's medical record revealed a printed physician order dated 1/31/11, with an additional handwritten notation by a staff (not signed, timed or dated) indicating the patient had a self releasing seatbelt. Review of the nursing notes between 2/1/11 to 2/22/11 revealed the nursing staff failed to consistently document the use of the restraint. The nursing staff failed to document the presence of the restraint on 2/21/11 and 2/22/11 when they were observed using the restraint. The medical record lacked evidence of an accurate assessment of the need for the restraint.

On 2/22/11 (time undocumented) Hospital Administration requested Physical Therapy to assess this patient regarding the need for the restraint. Physical Therapist N completed this assessment and recommended the hospital try to manage the patient without the restraint.

Director of Therapy staff H, interviewed on 2/22/11 at 2:45pm stated they assessed and determined the patient no longer needed the restraint.

Patient #6 was observed on 2/22/11 at 2:55pm and 5:00pm, on 2/23/11 at 8:00am and on 3/1/11 at 11:40am, in their wheelchair without any restraint and patient #6 did not attempt to rise from chair.



12674

- Patient #16's medical record reviewed on 2/22/11 revealed the patient was admitted to the Hospital on 12/30/10 with traumatic brain injury with right sided hemiparesis. A physician's order, dated 1/5/11, instructed hospital staff to place an alarmed self releasing seat belt on this patient for safety related to impulsivity.

Patient #16 was observed restrained in a wheelchair with a seat belt on 2/21/11 at 2:25pm and wheeled themselves. Patient #16 interacted frequently with staff, mumbling to themselves and to the staff, which consisted mostly of unintelligible conversation and repeated number sequences. This patient was also observed with the seat belt restraint applied on 2/22/11 at 7:40am, 2/22/11 at 8:16am, and 2/22/11 at 8:36am.

Licensed nurse K interviewed on 2/22/11 at 10:00am verified this patient could not release the self releasing seat belt on request. Licensed nurse K requested the patient to release the seat belt. The patient was observed fumbling with the seat belt restraint straps for over five minutes and could not release the restraint. Certified staff O, interviewed on 2/21/11 at 2:35pm asked patient #16 to release the seat belt restraint, and the patient could not perform this task when requested to do so.

On 2/22/11 (time undocumented) Hospital Administration requested Physical Therapy to assess this patient regarding the need for the restraint. Physical Therapist N completed this assessment and recommended the hospital try to manage the patient without the restraint.

Director of Therapy staff H, interviewed on 2/22/11 at 12:45pm stated they assessed and determined the patient no longer needed the restraint.

Patient #16 was observed on 2/23/11 at 12:50pm, 2/28/11 at 9:47 and 3/1/11 at 12:55pm, in their wheelchair without any restraint and the patient did not attempt to rise from the chair.

- Non compliance of the facility to ensure only least restrictive restraints also affected patients #4, 7, 8, 12, 15, and 26.

The hospital reported a census of 25 patients with 30 medical records reviewed. Based on observation, document review and staff interview the hospital failed to ensure the staff updated 10 of 10 (patient #'s 1, 2, 4, 6, 7, 8, 12, 15, 16 and 26) patient's plan of care after the application of physical restraints.

Findings include:

- Hospital policy number 825.020.092 for Mechanical Restraints, reviewed on 2/22/11, documented "....1. The procedure may only be implemented for those patients with an authorized plan for mechanical restraint in their plan..."

- Patient #1's medical record reviewed on 2/21/11, revealed the patient was admitted on 10/12/10 with a diagnosis of closed head injury with traumatic brain injury (TBI).

Patient #1 was observed restrained with a self-releasing seatbelt on 2/21/11 at 2:00pm in a wheelchair at the nurses station.

Licensed Staff K interviewed on 2/21/11 at 2:30pm verified patient #1 could not remove the restraint.

Patient #1's plan of care lacked evidence of the patients restraint and failed to document this patient's inability to release the restraint, failed to include required nursing cares which included every 30 minute checks, release of the restraint every two hours, and to provide range of motion for 10 minutes.

Phone order dated 10/27/10 directed staff to place patient #1 in a self-releasing seatbelt. Staff applied the self-releasing seatbelt on 10/27/10 per physician order and then failed to obtain a new physician order every 24 hours. Nursing staff continued to restrain the patient for an additional 87 days without a physician order.

- Patient #2's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/21/11 with a diagnosis of traumatic head injury with subarachnoid hemorrhage.

Patient #2 was observed restrained with a non-releasing seatbelt on 2/21/11 at 2:00pm in a wheelchair near the nurse's station.

Patient #2's plan of care failed to document this patient's inability to release the restraint, failed to include required nursing cares which included every 30 minutes checks, release of the restraint every two hours, and to provide range of motion for 10 minutes.

Corporate Nurse C on 2/22/11 at 10:15am verified the staff failed to modify patient #2's plan of care following the application of the restraint.

- Patient #4's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 12/10/10 with a diagnosis of brain damage.

Patient #4's physician orders dated 1/6/11 directed staff to apply a non-releasing seatbelt restraint when the patient was in the wheelchair.

Patient #4's plan of care lacked evidence of the patients restraint and failed to document this patient's inability to release the restraint, failed to include required nursing cares which included every 30 minutes checks, release of the restraint every two hours, and to provide range of motion for 10 minutes.

- Patient #6's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/27/11 and diagnosis of head trauma with subarachnoid hemorrhage.

Patient #6 was observed restrained in a wheelchair with a seatbelt on 2/21/11 at 3:30pm propelling self down the hallway. Patient was also observed with the seatbelt restraint applied on 2/22/11 at 7:40am, 11:45am and at 12:45pm.

Patient #6's plan of care failed to document this patient's inability to release the restraint, failed to include required nursing cares which included every 30 minutes checks, release of the restraint every two hours, and to provide rage of motion for 10 minutes.

Corporate Nurse C on 2/22/11 at 10:15am verified the staff failed to modify patient #6's plan of care following the application of the restraint.

- Patient #7's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 12/20/10 with a diagnosis of TBI, memory defect, obesity and schizophrenia.

Patient #7's phone order dated 1/12/11 directed staff to apply a right hand mitt and a self-releasing seatbelt.

Patient #7's plan of care lacked evidence of the patients restraint and failed to document this patient's inability to release the restraint, failed to include required nursing cares which included every 30 minutes checks, release of the restraint every two hours, and to provide range of motion for 10 minutes.

- Patient #8's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 8/20/10 with a diagnosis of TBI, craniotomy, hypertension (HTN) and GERD.

Corporate Nurse C interviewed on 2/21/11 verified patient #8 was restrained between 8/20/10 to 2/22/11 (186 days) without physician orders.

Patient #8's plan of care lacked evidence of the patients restraint and failed to document this patient's inability to release the restraint, failed to include required nursing cares which included every 30 minutes checks, release of the restraint every two hours, and to provide range of motion for 10 minutes.

- Patient #12's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 8/26/10 with the diagnosis of TBI, encephalopathy, dysphasia and peg tube and discharged on 9/30/10.

Nursing staff applied the self-releasing seatbelt and net bed to patient #12 on 8/26/10. Nurse staff continued to restrain patient #12 for 34 additional days without evidence the physician renewed the order every 24 hours.

Patient #12's plan of care lacked evidence of the patient's restraint, failed to document this patient's inability to release the restraint, failed to include required nursing cares which included every 30 minutes checks, release of the restraint every two hours, and to provide range of motion for 10 minutes.



12674

- Patient # 15's medical record reviewed on 2/22/11 revealed the patient was admitted to the hospital 6/11/08 and readmitted on 8/12/09 with the diagnosis of traumatic brain injury.

The medical record revealed a physician's order on 12/13/10 for an alarmed self-releasing seatbelt for safety secondary to impulsivity for patient #15.

Patient #15 was observed on 2/21/11 at 1:10pm and 2/22/11 at 7:58am in a wheelchair with the alarmed self-releasing seatbelt on.

Patient #15's plan of care failed to include required nursing cares which included every 30 minutes checks, release of the restraint every two hours, and to provide range of motion for 10 minutes.

- Patient #16's medical record reviewed on 2/22/11 revealed the patient was admitted to the Hospital on 12/30/10 with traumatic brain injury with right sided hemiparesis. A physician's order, dated 1/5/11, instructed hospital staff to place an alarmed self releasing seat belt on this patient for safety related to impulsivity.

Patient #16 was observed restrained in a wheelchair with a seat belt on 2/21/11 at 2:25pm and wheeled themselves. Patient #16 interacted frequently with staff, mumbling to themselves and to the staff, which consisted mostly of unintelligible conversation and repeated number sequences. This patient was also observed with the seat belt restraint applied on 2/22/11 at 7:40am, 2/22/11 at 8:16am, and 2/22/11 at 8:36am

Patient #16's plan of care failed to document this patient's inability to release the restraint, failed to include required nursing cares which included every 30 minutes checks, release of the restraint every two hours, and to provide range of motion for 10 minutes.

- Patient #26's medical record reviewed on 3/1/11 revealed the patient was admitted on 11/10/10 with a diagnosis of traumatic brain injury and schizophrenia.

Review of nursing documentation on 3/1/11 revealed nursing applied an alarmed self-releasing seatbelt on 11/13/10 to patient #26. The medical record lacked evidence of a physician's order for this restraint until 11/30/10; 17 days later. Nursing staff removed the restraint on 12/5/10 without a physician's order to remove it.

Patient #26's plan of care lacked evidence of staff application of an alarmed self release seat belt restraint, lacked documentation of when nursing discontinued the restraint, failed to document this patient's inability to release the restraint, failed to include required nursing cares which included every 30 minutes checks, release of the restraint every two hours, and to provide range of motion for 10 minutes.

- Nursing staff failed to perform these needed patient cares which had the potiential to lead to negative patient outcomes such as; skin breakdown, lack of ability to ambulate and loss of patient strength.

The hospital reported a census of 25 patients with 30 medical records reviewed. Based on observation, document review and staff interview the hospital failed to ensure the staff obtained physician orders for restraints for 10 of 10 patients (patient #'s 1, 2, 4, 6, 7, 8, 12, 15, 16 and 26).

Findings include:

- Hospital policy # 850.020.097 regarding physical restraints, reviewed on 2/22/11, documented the Procedure of "...5. Physical restraints shall be used only when it is part of the treatment plan and approved by the attending physician..." Hospital policy #082.020.092, reviewed on 2/22/11, documented the implementation of a mechanical restraint required a physician's order and would be time limited..."

- Preprinted restraint orders used by the hospital stated, "4) time limit for restraints 24 hours, maximum allowed is 24 hours."

- Patient #1's medical reviewed on 2/21/11 revealed the patient was admitted on 10/12/10 with a diagnosis of closed head injury with traumatic brain injury (TBI).

Patient #1 was observed restrained with a self-releasing seatbelt on 2/21/11 at 2:00pm in a wheelchair at the nurses station.

Licensed Staff K interviewed on 2/21/11 at 2:30pm verified patient #1 could not remove the restraint.

Phone order dated 10/27/10 directed staff to place patient #1 in a self-releasing seatbelt. Staff applied the self-releasing seatbelt on 10/27/10 per physician order and then failed to obtain a new physician order every 24 hours. Nursing staff continued to restrain the patient for an additional 87 days without a physician order.

- Patient #2's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/21/11 and diagnosis of traumatic brain injury with subarachnoid hemorrhage.

Patient #2 was observed restrained with a non-releasing seatbelt on 2/21/11 at 2:00pm in a wheelchair near the nurse's station.

Patient #2's medical record revealed a phone order dated 2/7/11 that directed the staff to discontinue the self releasing seatbelt restraint and apply a non-releasing seatbelt restraint. Review of the signed restraint orders lacked evidence of any completed orders from 2/9/11 and between 2/16/11 to 2/21/11. Review of the signed restraint orders between 2/8/11 to 2/15/11 lacked evidence of the time the physician signed the orders.

The medical record documented the physician failed to assess and complete orders prior to nursing staff application of the mechanical restraints every 24 hours as follows:

Restraint orders dated by nursing staff on 2/8/11 not reviewed and signed until 2/10/11.
Restraint orders dated by nursing staff on 2/12/11, 2/13/11, 2/14/11 and 2/15/11 not reviewed and signed until 2/16/11.

Review of the medical record from 1/27/11 to 2/21/11 lacked evidence of a signed physician order for the seatbelt restraint. Corporate nurse C on 2/22/11 at 10:15am verified the medical record lacked complete orders for the restraint.

- Patient #4's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 12/10/10 with a diagnosis of brain damage.

Patient #4's physician orders dated 1/6/11 directed staff to apply a non-releasing seatbelt restraint when patient was in the wheelchair.

Nursing staff continued to restrain patient #4 for 39 additional days without evidence the physician renewed the order every 24 hours.

Patient #4's plan of care lacked evidence of the patients restraint and failed to document this patient's inability to release the restraint, failed to include required nursing cares which included every 30 minutes checks, release of the restraint every two hours, and to provide range of motion for 10 minutes.

- Patient #6's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/27/10 and diagnosis of head trauma with subarachnoid hemorrhage.

Patient #6 was observed restrained in a wheelchair with a seatbelt on 2/21/11 at 3:30pm propelling self down the hallway. Patient was also observed with the seatbelt restraint applied on 2/22/11 at 7:40am, 11:45am and at 12:38pm.

Patient #6's medical record revealed a printed physician order dated 1/31/11, with an additional handwritten notation by a staff (not signed, timed or dated) indicating the patient had a self releasing seatbelt.

Review of the medical record from 1/27/11 to 2/21/11 lacked evidence of a signed physician order for the seatbelt restraint. Corporate nurse C on 2/22/11 at 10:15am verified the medical record lacked an order for the restraint.

- Patient #7's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 12/20/10 with a diagnosis of TBI, memory defect, obesity and schizophrenia.

Patient #7's phone order dated 1/12/11 directed staff to apply a right hand mitt and a self-releasing seatbelt.

Nursing staff continued to restrain patient #7 for an additional 41 days without evidence the physician renewed the order every 24 hours.

- Patient #8's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 8/20/10 with a diagnosis of TBI, craniotomy, hypertension (HTN) and GERD.

Corporate Nurse C interviewed on 2/21/11 verified patient #8 was restrained between 8/20/10 to 2/22/11 (186 days) without physician orders

- Patient #12's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 8/26/10 with the diagnosis of TBI, encephalopathy, dysphasia and peg tube and discharged on 9/30/10.

Nursing staff applied the self-releasing seatbelt and net bed to patient #12 on 8/26/10. Nursing staff continued to restrain patient #12 for 34 additional days without evidence the physician renewed the order every 24 hours.


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- Patient # 15's medical record reviewed on 2/22/11 revealed the patient was admitted to the hospital 6/11/08 and readmitted on 8/12/09 with the diagnosis of traumatic brain injury.

The medical record revealed a physician's order on 12/13/10 for an alarmed self-releasing seatbelt for safety secondary to impulsivity for patient #15.

Patient #15 was observed on 2/21/11 at 1:10pm and 2/22/11 at 7:58am in a wheelchair with the alarmed self-releasing seatbelt on.

Review of the signed restraint orders between 12/13/10 to 2/21/11 lacked evidence of the time the physician signed the orders.

- Patient #16's medical record reviewed on 2/22/11 revealed the patient was admitted to the hospital on 12/30/10 with traumatic brain injury with right sided hemiparesis. A physician's order, dated 1/5/11, instructed hospital staff to place an alarmed self releasing seat belt on this patient for safety related to impulsivity.

Patient #16 was observed restrained in a wheelchair with a seat belt on 2/21/11 at 2:25pm and wheeled themselves. This patient was also observed with the seat belt restraint applied on 2/22/11 at 7:40am, 2/22/11 at 8:16am, and 2/22/11 at 8:36am.

The physician's signed orders, reviewed on 2/21/11 failed to contain physician orders for the restraint on 1/5/11,1/7/11, 1/9/11, 1/17/11, 1/21/11,1/30/11, 2/4/11, 2/6/11, 2/13/11, 2/18/11 and 2/21/11.

The physician's restraint orders dated by nursing staff on 1/6/11, 1/8/11, 1/10/11, 1/22/11, 1/24/11, 2/1/11 and 2/2/11, failed to document the date and time the physician verified the need for the restraint.

The medical record documented the physician failed to assess and complete orders prior to nursing staff application of the mechanical restraint every 24 hours as follows:
Restraint orders dated by nursing staff on 1/11/11 and 1/12/11 not reviewed and signed until 1/13/11. Restraint orders dated by nursing staff on 1/13/11, 1/14/11, 1/15/11 and 1/16/11 not reviewed and signed until 1/17/11.
Restraints orders dated by nursing staff on 1/18/11 and 1/19/11 not reviewed and signed until 1/20/11. Restraint orders dated by nursing staff on 1/25/11 and 1/26/11 not reviewed and signed until 1/27/11.
Restraint orders dated by nursing staff on 1/28/11 and 1/29/11 not reviewed and signed until 1/31/11. Restraint orders dated by nursing staff on 2/3/11 not reviewed and signed until 2/6/11.
Restraint orders dated by nursing staff on 2/5/11 and 2/6/11 not reviewed and signed until 2/7/11. Restraint orders dated by nursing staff on 2/19/11 and 2/20/11 not reviewed and signed until 2/21/11.

- The Hospital failed to ensure physician review and proper completion of orders every 24 hours for the seat belt restraint applied to patient #16. The Hospital staff restrained patient #16 from 1/5/11 until 2/22/11 until assessment by Physical Therapy which documented the lack of need for the restraint.

- Patient #26's medical record reviewed on 3/1/11 revealed the patient was admitted on 11/10/10 with a diagnosis of traumatic brain injury and schizophrenia.

Review of nursing documentation on 3/1/11 revealed nursing applied an alarmed self-releasing seatbelt on 11/13/10 to patient #26. The medical record lacked evidence of the physician ordered restraint until 11/30/10; 17 days later. Nursing staff removed the non-releasing seatbelt restraint on 12/5/10, also without a physician's order to do so.

- Physician AA interviewed on 2/21/11 at 4:03pm verified nursing staff filled out the restraint orders and put in their box for signature. Physician AA stated they signed the restraint orders when they are here a couple of days per week.

The hospital reported a census of 25 patients with 30 medical records reviewed. Based on observation, document review and staff interview the hospital failed to ensure patient restraints were assessed and discontinued at earliest time possible for 10 of 10 patients (patient #'s 1, 2, 4, 6, 7, 8, 12, 15, 16 and 26).

Findings include:

- Patient #2's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/21/11 and diagnosis of traumatic head injury with subarachnoid hemorrhage.

Patient #2 was observed restrained with a non-releasing seatbelt on 2/21/11 at 2:00pm in a wheelchair near the nurse's station.

Patient #2's medical record revealed a phone order dated 2/7/11 that directed the staff to discontinue the self releasing seatbelt restraint and apply a non-releasing seatbelt restraint.

On 2/22/11 (time undocumented) Hospital Administration requested Physical Therapy to assess this patient regarding the need for the restraint. Physical Therapist N completed this assessment and recommended the hospital try to manage the patient without the restraint.

Director of Therapy staff H, interviewed on 2/22/11 at 2:45pm stated they assessed and determined the patient no longer needed the restraint.

- Patient #6's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/27/10 and diagnosis of head trauma with subarachnoid hemorrhage.

Patient #6 was observed restrained in a wheelchair with a seatbelt on 2/21/11 at 3:30pm propelling self down the hallway. Patient was also observed with the seatbelt restraint applied on 2/22/11 at 7:40am, 11:45am and at 12:38pm.

Patient #6's medical record revealed a printed physician order dated 1/31/11, with an additional handwritten notation by a staff (not signed, timed or dated) indicating the patient had a self releasing seatbelt.

Review of the nursing notes between 2/1/11 to 2/22/11 revealed the nursing staff failed to consistently document the use of the restraint. The nursing staff failed to document the presence of the the restraint on 2/21/11 and 2/22/11 when the patient was observed using the restraint. The medical record lacked evidence of an accurate assessment of the need for the restraint to determine if the restraint could be discontinued.

On 2/22/11 (time undocumented) Hospital Administration requested Physical Therapy to assess this patient regarding the need for the restraint. Physical Therapist N completed this assessment and recommended the hospital try to manage the patient without the restraint.

Director of Therapy staff H, interviewed on 2/22/11 at 2:45pm stated they assessed and determined the patient no longer needed the restraint.

Patient #6 was observed on 2/22/11 at 2:55pm and 5:00pm, on 2/23/10 at 8:00am and on 3/1/11 at 11:40am, in their wheelchair without any restraint and patient #6 did not attempt to rise from chair.



12674

- Patient #16's medical record reviewed on 2/22/11 revealed the patient was admitted to the Hospital on 12/30/10 with traumatic brain injury with right sided hemiparesis. A physician's order, dated 1/5/11, instructed hospital staff to place an alarmed self releasing seat belt on this patient for safety related to impulsivity.

Patient #16 was observed restrained in a wheelchair with a seat belt on 2/21/11 at 2:25pm and wheeled themselves. This patient was also observed with the seat belt restraint applied on 2/22/11 at 7:40am, 2/22/11 at 8:16am, and 2/22/11 at 8:36am.

On 2/22/11 (time undocumented) Hospital Administration requested Physical Therapy to assess this patient regarding the need for the restraint. Physical Therapist N completed this assessment and recommended the hospital try to manage the patient without the restraint.

Director of Therapy staff, interviewed on 2/22/11 at 12:45pm stated they assessed and determined the patient no longer needed the restraint.

Patient #16 was observed on 2/28/11 at 9:47, 2/23/11 at 12:50pm, and 3/1/11 at 12:55pm, in their wheelchair without any restraint and the patient did not attempt to rise from the chair.

The medical record failed to provide evidence of an accurate assessment of the continued need for and assessment of the potential to discontinue the restraint. The medical record documented patient #16 was restrained from 1/15/11 to 2/22/11, a total of 38 days, for staff convenience.

- Administrative staff A, interviewed on 2/22/11 at 2:30 pm., verified the Hospital lacked policies directing staff to perform an accurate and continued assessment of the patient's need for the restraint.

The hospital reported a census of 25 patients with 30 medical records reviewed. Based on observation, document review and staff interview the hospital failed to ensure staff followed the physician orders for monitoring patients in restraints for 10 of 10 patients (patient #'s 1, 2, 4, 6, 7, 8, 12, 15, 16 and 26).

Findings include:

- Patient #1's medical reviewed on 2/21/11 revealed the patient was admitted on 10/12/10 with a diagnosis of closed head injury with traumatic brain injury (TBI).

Patient #1 was observed with a self-releasing seatbelt on 2/21/11 at 2:00pm in a wheelchair at the nurses station.

The medical record lacked evidence of an accurate assessment for the need of a restraint, lacked evidence staff observed the patient every 30 minutes and performed range of motion (ROM) every 2 hours when they released the restraint.

- Patient #2's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/21/11 and diagnosis of traumatic head injury with subarachnoid hemorrhage.

Patient #2 was observed restrained with a non-releasing seatbelt on 2/21/11 at 2:00pm in a wheelchair near the nurse's station.

Patient #2's medical record revealed a phone order dated 2/7/11 that directed the staff to discontinue the self releasing seatbelt restraint and apply a non-releasing seatbelt restraint. The printed form directed staff to check the patient every 30 minutes, release the restraint every 2 hours and perform Range of Motion (ROM) for ten minutes.

The nursing staff failed to document the presence of the restraint on 2/21/11 and 2/22/11 when they were observed using the restraint.

The medical record lacked evidence of an accurate assessment of the need for the restraint, lacked evidence staff observed the patient every 30 minutes and performed ROM every 2 hours with the release of the restraint.

- Patient #4's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 12/10/10 with a diagnosis of brain damage.

The printed form directed staff to check the patient every 30 minutes, release the restraint every 2 hours and perform Range of Motion (ROM) for ten minutes and perform Range of Motion (ROM) for ten minutes.
.

- Patient #6's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/27/11 and diagnosis of head trauma with subarachnoid hemorrhage.

Patient #6 was observed restrained in a wheelchair with a seatbelt on 2/21/11 at 3:30pm propelling self down the hallway. Patient was also observed with the seatbelt restraint applied on 2/22/11 at 7:40am, 11:45am and at 12:38pm.

Patient #6's printed physician order dated 1/31/11, revealed an additional handwritten notation by a staff (not signed, timed or dated) indicating the patient had a self releasing seatbelt.

Review of the nursing notes between 2/1/11 to 2/22/11 revealed the nursing staff failed to consistently document the use of the restraint. The printed form directed staff to check the patient every 30 minutes, release the restraint every 2 hours and perform Range of Motion (ROM) for ten minutes.

The nursing staff failed to document the presence of the the restraint on 2/21/11 and 2/22/11 when they were observed using the restraint. The medical record lacked evidence of an accurate assessment of the need for the restraint, lacked evidence staff observed the patient every 30 minutes and performed ROM every 2 hours with the release of the restraint.

- Patient #7's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 12/20/10 with a diagnosis of TBI, memory defect, obesity and schizophrenia.

The medical record lacked evidence of an accurate assessment for the need of a restraint, lacked evidence staff observed the patient every 30 minutes and performed range of motion (ROM) every 2 hours when they released the restraint and perform Range of Motion (ROM) for ten minutes.

- Patient #8's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 8/20/10 with a diagnosis of TBI, craniotomy, hypertension (HTN) and GERD.

The medical record lacked evidence of an accurate assessment for the need of a restraint, lacked evidence staff observed the patient every 30 minutes and performed range of motion (ROM) every 2 hours when they released the restraint.

- Patient #12's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 8/26/10 with the diagnosis of TBI, encephalopathy, dysphasia and peg tube.

The medical record lacked evidence of an accurate assessment for the need of a restraint, lacked evidence staff observed the patient every 30 minutes and performed range of motion (ROM) every 2 hours when they released the restraint and perform Range of Motion (ROM) for ten minutes.

- Patient # 15's medical record reviewed on 2/22/11 revealed the patient was admitted to the hospital 6/11/08 and readmitted on 8/12/09 with the diagnosis of traumatic brain injury.

The medical record lacked evidence of an accurate assessment for the need of a restraint, lacked evidence staff observed the patient every 30 minutes and performed range of motion (ROM) every 2 hours when they released the restraint and perform Range of Motion (ROM) for ten minutes.

- Patient #16's medical record reviewed on 2/22/11 revealed the patient was admitted to the hospital on 12/30/10 with traumatic brain injury with right sided hemiparesis. A physician's order, dated 1/5/11, instructed hospital staff to place an alarmed self releasing seat belt on this patient for safety related to impulsivity.

- Patient #26's medical record reviewed on 3/1/11 revealed the patient was admitted on 11/10/10 with a diagnosis of traumatic brain injury and schizophrenia.

The medical record lacked evidence of an accurate assessment for the need of a restraint, lacked evidence staff observed the patient every 30 minutes and performed range of motion (ROM) every 2 hours when they released the restraint.



12674

The Hospital identified a census of 25 patients with 30 medical records reviewed. Based on document review and staff interview the hospital failed to ensure 9 of 9 Physician's, 2 of 2 Licensed Independent Practitioners, and 2 of 2 Licensed physician's private nurses had the required restraint training per hospital policy and a working knowledge of the hospital's policy regarding specified requirements for the use of restraints.

Findings include:

- Hospital policy number 825.020.092 for Mechanical Restraint, reviewed on 2/22/11, failed to document the requirement that physicians and other Licensed Independent practitioners would be trained in the safe implementation of restraints.

Staff G interviewed on 3/2/11 at 9:45am, verified the Hospital failed to train Physician and other Licensed Independent practitioners regarding restraint use.

Licensed Administrative Nurse C interviewed on 2/22/11 at 2:30pm verified "our policies and procedures are lacking and [the] system is broken." Nurse C stated the Hospital's policy did not meet the regulatory requirement.

The Hospital identified a census of 25 patients with 30 medical records reviewed. Based on document review and staff interview the hospital failed to ensure 9 of 104 licensed or certified direct care staff, 19 of 19 direct care therapy staff, and 4 of 4 direct care therapy students had the required restraint training per hospital policy and a working knowledge of the hospital's policy regarding specified requirements for the use of restraints.

Findings include:

- Hospital policy number 825.020.092 for Mechanical Restraint, reviewed on 2/22/11, failed to document the requirement that all direct care staff would be trained in the safe implementation of restraints.

- Review of the nursing and safety employee training information on 2/22/11 between 1:03pm and 4:28pm revealed multiple direct care staff who lacked documentation of training for safe implementation of restraints with return demonstration on the date of review (2/22/11) as follows:

1. Certified Nurse Aide CCC, hired on 7/14/10.
2. Licensed staff EEE, hired on 8/25/10.
3. Licensed staff DDD, hired on 9/8/10.
4. Certified Nurse Aide FFF, hired on 9/29/10.
5. Certified Nurse Aide GGG, hired on 9/22/10.
6. Certified Nurse Aide Y, hired on 10/27/10.
7. Certified Nurse Aide XX, hired on 6/30/10.
8. Certified Nurse Aide BBB, hired on 8/25/10.
9. Certified Nurse Aide ZZ, hired 9/8/10.

Licensed Administrative Nurse C, interviewed on 2/22/11 at 2:30pm verified the Hospital policies for mechanical restraints lacked the requirement that all direct care staff be trained in the safe implementation of restraints.

- Therapy direct care staff training information, reviewed on 2/22/11 failed to evidence training provided to any Therapy staff member on the safe implementation and handling of restraints. This staff included:

1. Registered Physical Therapists- N and HHH.
2. Physical Therapy Aides- III, JJJ, KKK and LLL.
3. Registered Occupational Therapists-MMM, NNN and H.
4. Certified Occupational Therapy Aides-OOO, PPP and D.
5. Speech Language Pathologists-QQQ, RRR, SSS, TTT, and UUU.
6. Rehabilitation Technician VVV.
7. Therapy Students R, S, T, and U.

Registered Administrative Occupational Therapist H, interviewed on 2/22/11 at 4:00pm. verified all staff were employed by a new contracted therapy company on 11/1/10. Staff H verified the hospital lacked training for any therapy staff or students in the safe implementation of restraints.

The Hospital identified a census of 25 patients with 30 medical records reviewed. Based on document review and staff interview the hospital failed to ensure only a qualified trainer provided training for the safe implementation of restraints to other direct care staff.

Findings include:

- The Hospital policy for Mechanical Restraints number 825.020.092, reviewed on 2/22/11 failed to document the requirement for the restraint trainer's education, training and experience in restraint techniques.

Licensed Administrative Nurse C interviewed on 2/22/11 at 2:30pm verified "our policies and procedures are lacking and [the] system is broken." Nurse C stated the Hospital's policy did not meet the regulatory requirement and verified they lacked a designated trainer.

The hospital reported a census of 25 patients. Based on document review and staff interview the hospital failed to ensure all departments had meaningful quality assurance/performance improvement project.

Findings include:

- The hospitals Medical Staff By-Laws and Rules and Regulations, reviewed on 3/1/11, section 12.3.6 directed the medical staff to establish and organize a Continuous Quality Improvement (CQI) system to analyze the care of patients in the hospital, establish priorities, measure performance and monitor the effectiveness of corrective action with documentation of results. The by laws stated the committee would meet quarterly to accomplish this.

The Governing body rules and regulations, section XI, reviewed on 3/1/11, directed the governing body to annually review and approve the Hospitals CQI to ensure acceptable care standards. The Scope of Continuous Quality Improvement stated the program at the Hospital will encompass all departments and correlate the activities of administrative, medical and nursing staff, contract and all other support services.

Hospital policy #100.020.032, reviewed on 3/1/11, indicated the Governing Body as responsible to ensure an effective, hospital wide, on-going, CQI program existed with a written plan of implementation. This policy stated all services related to patient care, including contracted services would be evaluated.

Review of the Hospitals CQI, with Administrative staff member A, on 3/2/11 at 12:00pm, revealed the Hospital lacked any Quality Assurance projects performed for Nursing, Social Work, and Respiratory Therapy since 3/14/10, and all other patient care departments failed to perform any CQI for 2010 and failed to develop any projects so far for 2011.

Review of the CQI on 3/2/11 at 12:00pm failed to include the identification of multiple concerns with restraints including application, training, assessment prior to implementation, and monitoring for adverse effects as well as for potential for earliest release as indicated at tag A-0115.

Administrative Staff A, on 3/2/11 at 12:00pm verified multiple Hospital departments and contracted services failed to complete CQI, and verified the staff member responsible to ensure all departments identified and performed CQI projects for the last 12 months. Staff A stated the CQI program "fell by the wayside" and the Hospital "just did not do it."

The hospital reported a census of 25 patients. Based on document review and staff interview the governing body failed to demonstrate accountability for the overall Quality Assurance program.

Findings include:

- The hospitals Medical Staff By-laws and Rules and Regulations reviewed on 3/1/11, section 12.3.6 titled "Continuous Quality Improvement" (CQI) committee directed the medical staff to establish and organize a system to analyze the care of patients in the hospital and implement a CQI plan and review it annually. Assure proper review components are utilized for problem identification, establishment of priorities, development of criteria, measurement of performance, demonstration of deficiencies, starting for remedial action, monitoring of effects of the corrective action and documentation of results. The committee will meet quarterly.

- Hospital policy #100.020.032 for governing body responsibilities reviewed on 3/1/11, indicated the governing body were responsible to ensure that there is an effective, hospital wide, quality assurance program to evaluate the provisions of patient care. The quality assurance program will be on-going and have written plan of implementation. All services related to patient care, including services furnished by a contractor will be evaluated.

- The governing body rules, regulations and responsiblity section XI regarding Continuous Quality Improvements, reviewed on 3/1/11 directed the governing body to annually review and approve the hospital's Continuous Quality Improvements to ensure acceptable care standards.

- Review of the hospital contracts on 2/23/11 revealed the hospital had contracted services for pharmacy, therapy services, outpatient therapy services and radiology utilization review.

-The hospital failed to ensure the contracted pharmacy met the needs of patient #12.

Administrative staff C failed to provide the requested Quality Assurance data showing how they monitored the contracted services.

Patient #12's medical record reviewed on 2/28/11 revealed the pharmacy failed to provide nicotine patches for three days as ordered by the physician.

The Hospital failed to ensure the pharmacy contracted services met the needs of the patients.

- Review of the hospital's Quality Assurance documentation lacked evidence of their contracted therapy services, radiology services and organ procurement documentation.

Quality Assurance staff E on 3/1/11 at 10:00am reported the hospital failed to include their contracted services within their hospital wide quality assurance program.

Administrative staff A interviewed on 3/2/11 at 12:00pm reported the hospital failed to implement a Quality Assurance Plan for 2011 and stated the hospital failed to establish indicators, measurable goals and collect any quality assurance data since the 2nd quarter of 2010. Staff A reported the program "fell by the wayside" and the hospital "just did not do it". Staff A reported the nursing, social work and respiratory department failed to report any data since 3/14/10.

The Governing Body of the Hospital contained 5 members. Based on document review and staff interview, the Hospital Medical Staff failed to follow hospital policy to have a quorum of 2 physician's to approve their medical staff bylaws and rules and regulations, as planned, prior to sending to the Governing Body for approval.

Findings include:

- The Hospital Medical Staff By-Laws/Rules and Regulations, reviewed on 3/2/11, section 12.3.1 documented the medical staff maintained a By-Laws Committee which was to conduct annual reviews of the by-laws/rules and regulations and submit changes to the General Medical Staff for review. This document stated the meetings shall be held yearly and as necessary. Section 13.4-2 of this document stated that "not less than two (2) voting members who are also members of the Medical Staff shall constitute a quorum at Committee meetings..."

The Hospital Staff by-laws/rules and regulations were reviewed on 3/2/11 and reported the last review and revision by the medical staff was on 2/18/10, and only one physician AA was present.

Staff G interviewed on 3/2/11 at 9:45am. verified the Hospital has never had a Quorum of two physicians for the approval of the bylaws/rules and regulations.

The hospital had one outpatient department with three outpatient records reviewed. Based on document review and staff interview the hospital failed to ensure 3 of 3 patients had current history and physical examinations before each patient began to receive outpatient services(patient #'s 31, 33 and 34).

Findings include:

- Patient #31's medical record, reviewed on 2/24/11, revealed outpatient therapy services started on 12/24/10. The medical record lacked evidence of a current history and physical examination.

- Patient #33's medical record, reviewed on 2/28/11, revealed outpatient therapy services started on 9/8/10. The medical record lacked evidence of a current history and physical examination.

- Patient #34's medical record, reviewed on 2/24/11, revealed outpatient therapy services started on 7/27/10. The medical record lacked evidence of a current history and physical examination.

- Administrative staff V interviewed on 2/24/11 at 9:00am acknowledged they were responsible for outpatient admission paperwork. Administrative staff V indicated the hospital failed to require the physician to provide a current history and physical for all their outpatients.

The Hospital identified a census of 25 patients with 30 medical records reviewed. Based on document review, record review and staff interview the Hospital nursing staff failed to provide 2 of 30 patients the care needed to prevent the development of a pressure sore, and Methicillin Resistant Staphylococcus Aureus (MRSA); patient #15 & 29.

Finding include:

- Licensed Nurse L was observed on 2/21/11 at 1:10pm applying Lotrimin to the irritated area around Patient #15's peg tube site.

Nurse L interviewed on 2/21/11 at 2:30 pm stated the Hospital used to use Cutivate cream to this area, but now used Lotrimin cream and "had for a while."

Physician progress notes for patient #15, reviewed on 2/21/11, revealed Registered Nurse WWW documented 6 notes between 1/31/11 and 2/21/11 which stated staff used Cutivate cream to the irritated area around patient #15's peg tube site. These progress notes were signed as reviewed and correct by Physician AA.

Physician AA interviewed on 2/21/11 at 4:03pm verified progress notes which stated that staff used Cutivate cream on patient #15's peg insertion site was inaccurate and verified he signed the inaccurate assessments.

- The Hospital policy for Prevention of Decubitus Ulcer, number 325.035.215, reviewed on 3/16/11 directed nursing staff to assess patients on admission for risk of skin breakdown, turn and reposition every 2 hours, and perform a skin assessment every shift. Although the policy directed staff to perform a skin assessment every shift, the policy directed staff to document those findings weekly.

Patient #29's medical record, reviewed on 2/28/11, documented the patient was admitted to the Hospital on 8/11/10 with diagnoses of Traumatic Brain Injury.

Review of the initial nursing assessment, completed on 8/12/10 revealed documentation that patient #29 had a right buttock wound on admission.

On 9/12/10 nursing staff first documented patient #29 with an approximately 0.5 centimeter (cm) scab of the right outer great toe, pink surrounding tissue, and yellow drainage on the bed sheet, but no drainage on the scabbed area. Nursing staff completed a culture of the drainage per physician's order 9/12/10 which documented MRSA infection in this toe area. Nursing staff documented the area was healing and left open to air on 9/17/10.

Licensed Nurses C and E interviewed on 2/28/11 at 4:15pm verified patient #29 developed the open area on the toe and the MRSA infection at this Hospital.

The Hospital identified a census of 25 patients with 30 medical records reviewed. Based on observation, document review, medical record review, and staff interview the Hospital failed to develop a complete plan of care for 3 of 30 records reviewed. (patients #5, #20, #29)

Findings include:

- The Hospital policy for Nursing Care Plans, Policy number 325.015.230, reviewed on 3/2/11, documented Nursing Care Plan procedures which included-"...6. Each nurse assigned to the patient will evaluate the plan of care and when changes are noted, the nurse will document such changes in the care plan..."

- Patient #29's medical record, reviewed on 2/28/11, documented the patient admitted to the Hospital on 8/11/10 with diagnoses of Traumatic Brain Injury.

Review of the initial nursing assessment, completed on 8/12/10 documented patient #29 with a right buttock wound on admission.

On 9/12/10 nursing staff first documented patient #29 with an approximately 0.5 centimeter (cm) scab of the right outer great toe, pink surrounding tissue, and yellow drainage on the bed sheet, but no drainage on the scabbed area. Nursing staff completed a culture of the drainage per physician's order 9/12/10 which documented MRSA infection in this toe area. Nursing staff documented the area healing and left open to air on 9/17/10.

Licensed Nurses C and E interviewed on 2/28/11 at 4:15pm verified patient #29 developed the open area on the toe and the MRSA infection at this Hospital.

The plan of care for patient #29, reviewed on 2/28/11, and dated by nursing staff as completed on 8/11/10 failed to have any documentation of the development of the decubitus ulcer on the patient's toe and the development of MRSA in this ulcer.

Administrative staff A interviewed on 2/28/11 at 5:20pm verified the Plan of Care for patient #29 lacked any documentation of the decubitus ulcer and the MRSA infection.

- Patient #20's medical record, reviewed on 2/18/11, documented the patient admitted to the Hospital on 2/4/09 with a traumatic brain injury. On 12/28/10 Physician AA ordered Ambien 5 milligrams by mouth as needed for the patient's complaint of insomnia.

Review of the Medication Administration Record for patient #20, on 2/18/11, revealed the patient asked for Ambien and received it almost every night since Physician AA ordered the medication.

Nurses notes, dated 2/2/11 documented nursing staff gave the patient Ambien at 9:30pm and nursing staff found patient #20 asleep in the Hospital dining room at 11:00pm. Staff woke up Patient #20 to put to bed and Patient #20 requested another Ambien for sleep. Staff did not give the patient any more Ambien and documented finding the patient behind the nurses station at 11:30pm.

The Plan of Care for patient #20, reviewed on 2/28/11, contained a section for staff to document sleep/rest/activity problems, but nursing staff failed to document patient #20's ongoing sleep/rest problems.

Licensed Nurse M, interviewed on 2/28/11 at 1:15pm verified themselves as the person who updated patient #20's plan of care on 1/11/11 and verified they failed to document the patient's ongoing sleep problems.




19629

- Patient #5 was observed on 2/22/11 at 7:30am with licensed nurse P teaching the patient on self injection of insulin. Review of patient #5's plan of care on 2/22/11 revealed the staff left the endocrine (diabetic) section blank.

Licensed staff P interviewed on 2/22/11 at 10:00am reported "We should have completed that section because the patient is diabetic."

The Hospital identified a census of 25 patients with 30 medical records reviewed. Based on document review, medical record review and staff interview, the Hospital failed to ensure staff properly timed, dated and signed all entries into the medical record for 30 of 30 medical records reviewed. (patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30).

Findings include:

- The Hospital policy for INPATIENT RECORD DOCUMENTATION number 300.020.010, reviewed on 3/2/11, documented the direction for "...All physician's, nursing staff and other health care professionals involved in the client's care will be responsible for making prompt, appropriate and accurate entries in the record and authenticating the entries with date, signature or written initials, and credentials."

Administrative staff member A interviewed on 3/2/11 at 5:24pm verified the lack of a policy which directs staff to time entries in the medical record, but stated-"we told them."

The Hospital Medical Staff Rules and Regulations, reviewed on 2/28/11, instructed physicians to sign, date, and time orders.

Progress notes for patient #19, reviewed on 2/28/11, documented 8 physician progress notes which lacked documentation of the time of the entry, a History and Physical which lacked the time, and an entry into the plan of care which lacked time and date.

Pharmacy Regimen reviews for patient #24, reviewed on 2/23/11, dated 1/31/11 and 2/10/11, failed to document time of the completion of this entry into the medical record.

Social Service progress notes reviewed on 3/1/11 for patient #30 and dated 8/16/10, 8/17/10 and 8/23/10 failed to document the time staff signed the notes.

- Non-compliance with this regulation also affected patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 25, 26, 27, 28, 29.

The hospital reported a census of 25 patients with 30 medical records reviewed. Based on observation, document review and staff interview the hospital failed to ensure all orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner for 10 of 10 patients with restraints (patient #'s 1, 2, 4, 6, 7, 8, 12, 15, 16 and 26).

Findings include:

- Hospital policy # 850.020.097 regarding physical restraints, reviewed on 2/22/11, documented the Procedure of "...5. Physical restraints shall be used only when it is part of the treatment plan and approved by the attending physician..." Hospital policy #082.020.092, reviewed on 2/22/11, documented the implementation of a mechanical restraint required a physician's order and would be time limited..."

- Preprinted restraint orders used by the hospital "4) time limit for restraints 24 hours, maximum allowed is 24 hours."

- Hospital policy for "Inpatient Record Documentation" #300.020.010 stated "... All physicians, nursing staff and other health care professionals involved in the clients care will be responsible for making prompt, appropriate and accurate entries in the record and authenticating the entries. . . "

- Administrative staff A on 3/21/11 at 5:24pm verified the hospital lacked a policy which instructed staff to time entries, but stated, "We told them."

- Patient #1's medical reviewed on 2/21/11 revealed the patient was admitted on 10/12/10 with a diagnosis of closed head injury with traumatic brain injury (TBI).

Patient #1 was observed restrained with a self-releasing seatbelt on 2/21/11 at 2:00pm in a wheelchair at the nurses station.

Licensed Staff K interviewed on 2/21/11 at 2:30pm verified patient #1 could not remove the restraint.

Phone order dated 10/27/10 directed staff to place patient #1 in a self-releasing seatbelt. Staff applied the self-releasing seatbelt on 10/27/10 per physician order and then failed to obtain a new physician order every 24 hours. Nursing staff continued to restraint the patient for an additional 87 days without a physician order.

- Patient #2's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/21/11 and diagnosis of traumatic brain injury with subarachnoid hemorrhage.

Patient #2 was observed restrained with a non-releasing seatbelt on 2/21/11 at 2:00pm in a wheelchair near the nurse's station.

Patient #2's medical record revealed a phone order dated 2/7/11 that directed the staff to discontinue the self releasing seatbelt restraint and apply a non-releasing seatbelt restraint. Review of the signed restraint orders lacked evidence of any completed orders from 2/9/11 and between 2/16/11 to 2/21/11. Review of the signed restraint orders between 2/8/11 to 2/15/11 lacked evidence of the time the physician signed the orders.

The medical record documented the physician failed to assess and complete orders prior to nursing staff application of the mechanical restraints every 24 hours as follows:

Restraint orders dated by nursing staff on 2/8/11 not reviewed and signed until 2/10/11.
Restraint orders dated by nursing staff on 2/12/11, 2/13/11, 2/14/11 and 2/15/11 not reviewed and signed until 2/16/11.

Review of the medical record from 1/27/11 to 2/21/11 lacked evidence of a signed physician order for the seatbelt restraint. Corporate nurse C on 2/22/11 at 10:15am verified the medical record lacked complete orders for the restraint.

- Patient #4's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 12/10/10 with a diagnosis of brain damage.

Patient #4's physician orders dated 1/6/11 directed staff to apply a non-releasing seatbelt restraint when patient was in the wheelchair.

Nursing staff continued to restraint patient #4 for 39 additional days without evidence the physician renewed the order every 24 hours.

- Patient #6's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 1/27/10 and diagnosis of head trauma with subarachnoid hemorrhage.

Patient #6 was observed restrained in a wheelchair with a seatbelt on 2/21/11 at 3:30pm propelling self down the hallway. Patient was also observed with the seatbelt restraint applied on 2/22/11 at 7:40am, 11:45am and at 12:38pm.

Patient #6's medical record revealed a printed physician order dated 1/31/11, with an additional handwritten notation by a staff (not signed, timed or dated) indicating the patient had a self releasing seatbelt.

Review of the medical record from 1/27/11 to 2/21/11 lacked evidence of a signed physician order for the seatbelt restraint. Corporate nurse C on 2/22/11 at 10:15am verified the medical record lacked an order for the restraint.

- Patient #7's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 12/20/10 with a diagnosis of TBI, memory defect, obesity and schizophrenia.

Patient #7's phone order dated 1/12/11 directed staff to apply a right hand mitt and a self-releasing seatbelt.

Nursing staff continued to restraint patient #7 for an additional 41 days without evidence the physician renewed the order every 24 hours.

- Patient #8's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 8/20/10 with a diagnosis of TBI, craniotomy, hypertension (HTN) and GERD.

Corporate Nurse C interviewed on 2/21/11 verified patient #8 was restrained between 8/20/10 to 2/22/11 (186 days) without physician orders.

- Patient #12's medical record reviewed on 2/21/11 revealed the patient was admitted to the hospital on 8/26/10 with the diagnosis of TBI, encephalopathy, dysphasia and peg tube and discharged on 9/30/10.

Nursing staff applied the self-releasing seatbelt and net bed to patient #12 on 8/26/10. Nurse staff continued to restrain patient #12 for 34 additional days without evidence the physician renewed the order every 24 hours.

- Patient # 15's medical record reviewed on 2/22/11 revealed the patient was admitted to the hospital 6/11/08 and readmitted on 8/12/09 with the diagnosis of traumatic brain injury.

The medical record revealed a physician's order on 12/13/10 for an alarmed self-releasing seatbelt for safety secondary to impulsivity for patient #15.

Patient #15 was observed on 2/21/11 at 1:10pm and 2/22/11 at 7:58am in a wheelchair with the alarmed self-releasing seatbelt on.

Review of the signed restraint orders between 12/13/10 to 2/21/11 lacked evidence of the time the physician signed the orders.

- Patient #16's medical record reviewed on 2/22/11 revealed the patient was admitted to the hospital on 12/30/10 with traumatic brain injury with right sided hemiparesis. A physician's order, dated 1/5/11, instructed hospital staff to place an alarmed self releasing seat belt on this patient for safety related to impulsivity.

Patient #16 was observed restrained in a wheelchair with a seat belt on 2/21/11 at 2:25pm and wheeled themselves. This patient was also observed with the seat belt restraint applied on 2/22/11 at 7:40am, 2/22/11 at 8:16am, and 2/22/11 at 8:36am.

The physician's signed orders, reviewed on 2/21/11 failed to contain physician orders for the restraint on 1/5/11,1/7/11, 1/9/11, 1/17/11, 1/21/11,1/30/11, 2/4/11, 2/6/11, 2/13/11, 2/18/11 and 2/21/11.

The physician's restraint orders dated by nursing staff on 1/6/11, 1/8/11, 1/10/11, 1/22/11, 1/24/11, 2/1/11, 2/2/11, failed to document the date and time the physician verified the need for the restraint.

The medical record documented the physician failed to assess and complete orders prior to nursing staff application of the mechanical restraint every 24 hours as follows:
Restraint orders dated by nursing staff on 1/11/11 and 1/12/11 not reviewed and signed until 1/13/11. Restraint orders dated by nursing staff on 1/13/11, 1/14/11, 1/15/11 and 1/16/11 not reviewed and signed until 1/17/11.
Restraints orders dated by nursing staff on 1/18/11 and 1/19/11 not reviewed and signed until 1/20/11. Restraint orders dated by nursing staff on 1/25/11 and 1/26/11 not reviewed and signed until 1/27/11.
Restraint orders dated by nursing staff on 1/28/11 and 1/29/11 not reviewed and signed until 1/31/11. Restraint orders dated by nursing staff on 2/3/11 not reviewed and signed until 2/6/11.
Restraint orders dated by nursing staff on 2/5/11 and 2/6/11 not reviewed and signed until 2/7/11. Restraint orders dated by nursing staff on 2/19/11 and 2/20/11 not reviewed and signed until 2/21/11.

- Physician AA interviewed on 2/21/11 at 4:03pm verified nursing staff filled out the restraint orders and put in their box for signature. Physician AA stated they signed the restraint orders when they are here a couple of days per week.

- The Hospital failed to ensure physician review and proper completion of orders every 24 hours for the seat belt restraint applied to patient #16. The Hospital staff restrained patient #16 from 1/5/11 until 2/22/11 until assessment by Physical Therapy which documented the lack of need for the restraint.

- Patient #26's medical record reviewed on 3/1/11 revealed the patient was admitted on 11/10/10 with a diagnosis of traumatic brain injury and schizophrenia.

Review of nursing documentation on 3/1/11 revealed nursing applied an alarmed self-releasing seatbelt on 11/13/10 to patient #26. The medical record lacked evidence of a physician's order for this restraint until 11/30/10; 17 days later. Nursing staff removed the restraint on 12/5/10 without a physician's order to remove it.

- The Hospital failed to ensure all orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner.

The hospital had one outpatient department with three outpatients records reviewed. Based on document review and staff interview the hospital failed to ensure 3 of 3 outpatients had complete medical records that included history and physical, patient rights acknowledgements and informed consents for outpatient treatment at admission (patient #'s 31, 33 and 34). The hospital failed to ensure Physician AA properly reviewed assessments documented by their private staff to ensure the accuracy of the medical record.

Findings include:

- Patient #31's medical record, reviewed on 2/24/11, revealed outpatient therapy services started on 12/24/10. The medical record lacked evidence of patient rights acknowledgement, a current history and physical and informed consent for treatment.

- Patient #33's medical record, reviewed on 2/28/11, revealed outpatient therapy services started on 9/8/10. The medical record lacked evidence of any patient right acknowledgement, current history and physical and informed consent for treatment.

- Patient #34's medical record, reviewed on 2/24/11, revealed outpatient therapy services started on 7/27/10. The medical record lacked evidence of any patient rights acknowledgement, current history and physical and informed consent for treatment.

- Administrative staff V interviewed on 2/24/11 at 9:00am acknowledged they were responsible for outpatient admission paperwork. Administrative staff V indicated the hospital failed to provide outpatients with notice of patient rights, consent to treat and failed to require the physician to provide a current history and physical for all their outpatients.


12674

The hospital reported a census of 25 patients with three outpatients records reviewed. Based on document review and staff interview the hospital failed to ensure 3 of 3 outpatients had informed consents for treatment at admission (patient #'s 31, 33 and 34).

Findings include:

- Patient #31's medical record, reviewed on 2/24/11, revealed they began outpatient therapy services on 12/24/10. The medical record lacked evidence of any informed consent for treatment.

- Patient #33's medical record, reviewed on 2/28/11, revealed they began outpatient therapy services on 9/8/10. The medical record lacked evidence of any informed consent for treatment.

- Patient #34's medical record, reviewed on 2/24/11, revealed they began outpatient therapy services on 7/27/10. The medical record lacked evidence of any informed consent for treatment.

- Administrative staff V interviewed on 2/24/11 at 9:00am reported they were responsible for outpatient admission paperwork and stated the hospital does not provide informed consent for treatment forms to their outpatients.

The hospital reported a census of 25 patients. Based on observation and staff interview the hospital failed to establish a system to ensure the hospital had a safe and functional pharmacy department that used established policies and procedures that are developed and monitored under the supervision of a professional pharmacist. The hospital failed to designated dedicated pharmacy staff, failed to limit access to the pharmacy area and failed to establish a system to obtain medications after hours.

Findings include:

- The hospital failed to establish policies and procedures to direct staff on drug storage area. See further evidence at A-0491, CFR 482.25.

- The hospital failed to employ a qualified pharmacist with designated pharmacy responsibilities. See further evidence at A-0492, CFR 482.25(a)(1).

- The hospital failed to designate pharmacy staff to respond to the needs of the patients. See further evidence at A-0493, CFR 482.25(a)(3).

- The hospital failed to develop current policies and procedures to provide patient safety, drugs and biologicals in accordance with applicable standards of practice. See further evidence at A-0500, CFR 482.25(b).

- The hospital failed to ensure the hospital had a qualified pharmacist to supervise pharmacy services. See further evidence at A-0501, CFR 482.25(b)(1).

- The hospital failed to limit and restrict access to the hospital's pharmacy area. See further evidence at A-0502, CFR 482.25(b)(2)(i).

- The hospital failed to establish a system to ensure drugs and biologicals must be removed from the pharmacy or storage area only by personnel designated in the policies of the medical staff and pharmaceutical service. See further evidence at A-0506, CFR 482.25(b)(4).

The hospital reported a census of 25 patients. Based on staff interview the hospital failed to establish policies and procedures to direct the staff to follow professional principles for pharmacy services.

Findings include:

- Administrative staff C interviewed on 2/28/11 at 9:45am reported the hospital lacked policies and procedures for their hospital pharmacy services and failed to have a system in place to demonstrate their compliance with this regulatory requirement.

The hospital reported a census of 25 patients. Based on staff interview the hospital failed to ensure the hospital had a qualified pharmacist with designated responsibilities.

Findings include:

- Administrative staff C interviewed on 2/28/11 at 9:45am reported the hospital lacked evidence of a designated pharmacist responsible for establishing pharmacy policies, supervising and coordinating all pharmacy services. Staff C stated the hospital lacked overall administration of the pharmacy services and failed to designate a pharmacist to ensure compliance with this regulatory requirement.

The hospital reported a census of 25 patients. Based on staff interview the hospital failed to ensure the hospital had qualified designated pharmacy staff to respond to pharmaceutical needs of the patient population.

Findings include:

- Administrative staff C interviewed on 2/28/11 at 9:45am reported the hospital lacked evidence of designated pharmacy staff members based on the scope and complexity of the hospital's pharmaceutical services to meet the patients needs. Staff C stated the hospital lacked overall administration of the pharmacy services and failed to designate a pharmacist to ensure compliance with this regulatory requirement.

The hospital reported a census of 25 patients. Based on staff interview the hospital failed to ensure the hospital had current policies and procedures to direct their staff on storage, dispensing and handling the hospital's drugs and biologicals.

Findings include:

- Administrative staff C interviewed on 2/28/11 at 9:45am reported the hospital lacked evidence of specific policies and procedures to manage the hospital's pharmacy services. Staff C stated the hospital lacked overall administration of the pharmacy services and failed to designate a pharmacist to ensure compliance with this regulatory requirement.

The hospital reported a census of 25 patients. Based on staff interview the hospital failed to ensure the hospital had a qualified pharmacist to supervise the dispensing of drugs and biologicals.

Findings include:

- Administrative staff C interviewed on 2/28/11 at 9:45am reported the hospital lacked evidence of a designated pharmacist responsible for establishing pharmacy policies, supervising and coordinating all pharmacy services at the hospital. Staff C stated the hospital lacked overall administration of the pharmacy services and failed to designate a pharmacist to ensure compliance with this regulatory requirement.

The hospital reported a census of 25 patients. Based on observation and staff interview the hospital failed to limit and restrict access to the pharmacy area from unauthorized staff members.

Findings include:

- Licensed Staff K observed on 2/22/11 at 10:20am with an known staff member leaving the pharmacy area of the hospital. Staff K reported the staff member was from their long term care unit. Staff K reported the long term care unit used their medication supplies when they are in need of medications for their residents. Staff K reported both Registered Nurses and Licensed Practical Nurses remove medications from the pharmacy area.

Administrative staff C interviewed on 2/28/11 at 9:45am reported the hospital lacked designated pharmacy staff members and allowed both Licensed Practical Nurses and Registered Nurses from the long term care unit to remove medications. Staff C reported the hospital lacked a pharmacy policies to limit and restrict access to the pharmacy area.

The hospital reported a census of 25 patients. Based on staff interview the hospital failed to ensure the hospital had system to obtain patient medications from the pharmacy after hours.

Findings include:

- Administrative staff C interviewed on 2/28/11 at 9:45am reported the hospital lacked policies and procedures to limit unauthorized staff's access to medications stored in the hospital's pharmacy area. Staff C stated the hospital lacked a system to ensure only qualified and designated Registered Nurses obtained medications from the pharmacy to ensure compliance with this regulatory requirement.

Based on document review and staff interview the hospital failed to implement an effective on-going Quality Assurance program with measurable improvement indicators to ensure positive patient outcomes for all hospital departments and all contractors such as, radiology and pharmacy.

Findings include:

- The hospitals Medical Staff By-laws and Rules and Regulations reviewed on 3/1/11, section 12.3.6 titled "Continuous Quality Improvement" (CQI) committee directed the medical staff to establish and organize a system to analyze the care of patients in the hospital and implement a CQI plan and review it annually. Assure proper review components are utilized for problem identification, establishment of priorities, development of criteria, measurement of performance, demonstration of deficiencies, starting for remedial action, monitoring of effects of the corrective action and documentation of results. The committee will meet quarterly.

Administrative staff A interviewed on 3/2/11 at 12:00pm reported the hospital failed to implement a Quality Assurance Plan for 2011 and stated the hospital failed to establish indicators, measurable goals and collect any quality assurance data since the 2nd quarter of 2010. Staff A reported the program "fell by the wayside" and the hospital "just did not do it". Staff A reported the nursing, social work and respiratory department failed to report any data since 3/14/10.

The hospital reported a census fo 25 patients. Based on document review and staff interview the hospital failed to measure, analyze and track quality indicators to ensure quality care provided by all departments as well as the safe management of patient mechanical restraints.

Findings include:

- The hospitals Medical Staff By-Laws and Rules and Regulations, reviewed on 3/1/11, section 12.3.6 directed the medical staff to establish and organize a Continuous Quality Improvement (CQI) system to analyze the care of patients in the hospital, establish priorities, measure performance and monitor the effectiveness of corrective action with documentation of results. The by laws stated the committee would meet quarterly to accomplish this.

The Governing body rules and regulations, secction XI, reviewed on 3/1/11, directed the governing body to annually review and approve the Hospitals CQI to ensure acceptable care standards. The Scope of Continuous Quality Improvement stated the program at the Hospital will encompass all departments and correlate the activities of administrative, medical and nursing staff, contract and all other support services.

Hospital policy #100.020.032, reviewed on 3/1/11, indicated the Governing Body as responsible to ensure an effective, hospital wide, on-going, CQI program existed with a written plan of implementation. This policy stated all services related to patient care, including contracted services would be evaluated.

Review of the Hospitals CQI, with Administrative staff member A, on 3/2/11 at 12:00pm, revealed the Hospital lacked any Quality Assurance activities performed for Nursing, Social Work, and Respiratory Therapy since 3/14/10, and all other patient care departments failed to report any CQI for 2010 and so far for 2011.

Review of the CQI on 3/2/11 at 12:00pm failed to include the identification of multiple concerns with restraints including application, training, assessment prior to implementation, and monitoring for adverse effects as well as for potential for earliest release as indicated at tag A-0115.

Administrative Staff A, on 3/2/11 at 12:00pm verified multiple Hospital departments and contracted services failed to complete CQI, and verified the staff member responsible to collect, compile, track, analyze and report this information to the Governing body failed to do so, and the Governing Body failed to ensure this information brought to them. Staff A stated the CQI program "fell by the wayside" and the Hospital "just did not do it."

The hospital reported a census of 25 patients. Based on document review and staff interview the hospital Governing Body failed to specify the frequency and detail of the Continuous Quality Improvement (CQI) data collection and presentation to the Governing Body for proper oversight.

Findings include:

- The hospitals Medical Staff By-Laws and Rules and Regulations, reviewed on 3/1/11, section 12.3.6 directed the medical staff to establish and organize a Continuous Quality Improvement (CQI) system to analyze the care of patients in the hospital, establish priorities, measure performance and monitor the effectiveness of corrective action with documentation of results. The by laws stated the committee would meet quarterly to accomplish this.

The Governing body rules and regulations, section XI, reviewed on 3/1/11, directed the governing body to annually review and approve the Hospitals CQI to ensure acceptable care standards. The Scope of Continuous Quality Improvement stated the program at the Hospital will encompass all departments and correlate the activities of administrative, medical and nursing staff, contract and all other support services.

Hospital policy #100.020.032, reviewed on 3/1/11, indicated the Governing Body as responsible to ensure an effective, hospital wide, on-going, CQI program existed with a written plan of implementation. This policy stated all services related to patient care, including contracted services would be evaluated.

A Continuous Quality Improvement document reviewed on 3/1/11 stated the Governing body delegated the responsibility and accountability for the operation of the CQI program to the organized Medical Staff and Hospital Administration. This same document stated the findings of the CQI committee would be taken to Administration, General Medical Staff Committee and the Governing Body.

Review of the Hospitals CQI, with Administrative staff member A, on 3/2/11 at 12:00pm, revealed the Hospital lacked any Quality Assurance activities performed for Nursing, Social Work, and Respiratory Therapy since 3/14/10, and all other patient care departments failed to report any CQI for 2010 and so far for 2011.

Review of the CQI on 3/2/11 at 12:00pm failed to include the identification of multiple concerns with restraints including application, training, assessment prior to implementation, and monitoring for adverse effects as well as for potential for earliest release as indicated at tag A-0115.

Administrative Staff A, on 3/2/11 at 12:00pm verified multiple Hospital departments and contracted services failed to complete CQI, and verified the staff member responsible to collect, compile, track, analyze and report this information to the Governing body failed to do so, and the Governing Body failed to ensure this information brought to them. Staff A stated the CQI program "fell by the wayside" and the Hospital "just did not do it."