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Based on review of facility policy and procedure, and staff interview, the facility failed to follow their own policy of informing patients and/or their representatives of their right to have the facility provide or not allow information to be given interested persons calling to check on a patient's status.


The findings include:

During tour of the facility on 4/27/2010 and 4/28/2010, multiple staff interviews were conducted during the course of the survey regarding how the facility assures patient confidentiality. Per the interviews, staff members are allowed to give out "one word" condition statements to those who ask for the patient by name. The facility offers an "opt-out" program, which allows patients to be taken off the general census, which is given to Operators and Non-Clinical staff. Those patients in the opt-out program have a "&" sign placed next to their names in the computer system, and the clinical facility census which is an alert to the staff to withhold any information from outside parties.

When staff members were asked about this program, three of the six staff members were able to name the program and its intent to protect patient rights. The remaining three staff members were not sure of the specifics of the program. When the staff members were asked who was responsible for offering this information to the patient, one nurse replied administration, one replied he/she could not recall and one replied that registration was responsible. The remaining three employees were not sure of the program. Interview with staff also revealed that some of the staff were unaware where the information was documented in the patient's chart.

The facility policy on Patient Privacy Indicator was reviewed on 4/28/2010 at 1:57pm. Per the policy, in an emergency situation or when a patient cannot reasonably be granted the opportunity to agree or object to uses or disclosures a (U) will be placed in the system. When it becomes practical to do so, the Patient Relations staff will follow-up on the status of the patient so Registration/Admissions can convert the unknown to yes or no.

Interview with the Manager of Admitting on 4/27/2010 at 2:50pm revealed that at registration, the patient is asked whether they would prefer to opt out of the system. If the patient is not able to state their preference, Patient Relations will follow with the patient and will document the patients wishes.

Interview was done with the Supervisor of Patient Relations on 4/28/2010 at 11:00am. Per this staff member, the admission and registration staff offer the patient the opportunity to opt out of the system. If a patient was the victim of a violent crime, the patient is automatically opted out of the system. The admissions staff are responsible for putting this in the computer. The clerical staff on the units are also allowed to place this request in the system. When asked if Patient Relations staff visit patients who are admitted and the opt-out information is not taken by admitting or registration, she stated "No".

Based on observation, clinical record review and facility policy review, the facility failed to renew physician orders per hospital policy for the use of restraints to ensure the physical safety of the non-violent or non-self-destructive patient for three of nine patients (#4,5 &7).

The findings include:

The facility policy on Restraints and Seclusion was reviewed on 4/28/2010 at 3:00pm. Per the policy, for those patients in non-violent or non-self destructive restraints, orders for restraints must be issued a minimum of once each calendar day and is based on examination of the patient by the physician/ARNP/PA. Patients in restraints shall be monitored at least every two hours or more frequently. Monitoring is accomplished by observation, interaction with the patient, or direct examination of the patient. Each episode of restraints is documented in the patient's medical record and shall include: relevant orders for use, alternatives to restraints attempted, type of restraint applied and/or medication given, the plan of care, patient and/or family education, results of patient monitoring and assessment, reassessment, significant changes in the patients condition, a description of the patient's behavior and the intervention used, alternatives or other less restrictive interventions attempted (as applicable), the patients condition or symptoms(s) that warranted the use of restraints and the patients response to the intervention(s) used, including the rationale for continued use of the intervention. Discontinuation of restraints and the patient's behavior reflecting improvement which supports the discontinuation shall be documented and the plan of care revised accordingly.

Patient sample #4
This patient was admitted to the facility on 4/12/2010 with a history of prostate cancer, hypertension, history of clostridium difficile and severe sepsis. Secondary to altered mental status and interfering with medical equipment, the patient was placed on restraints on 4/14/2010. Physician orders were reviewed for restraints and were missing for the dates of 4/21/2010 and 4/23/2010.

Patient sample #5
This patient was admitted to the facility on 4/24/2010 status post gun shot wound under police supervision. The medical record reflects a physician's order for restraints (telephone order read back) and 4 point shackles dated on the same day of admission. This order was not signed by the physician. There was also no nursing monitor sheet for this patient in the medical record.

Patient sample #7
This patient was admitted to the facility on 3/2/2010. Per the medical record, the patient initially began on restraints secondary to interfering with medical care and confusion on 4/24/2010 and continued through 4/27/2010. Per the medical record, the physician's order for restraints were not signed on 4/26/2010.

Based on clinical record review, and facility policy, the facility failed to monitor a patient who is restrained or secluded by a physician, other licensed independent practitioner or trained staff that completed the training criteria, at an interval determined by hospital policy for 1 of 9 patients (Patient #6).

The findings include:

Patient #6 was admitted to the facility on 2/6/2010 with rectal bleeding, nausea and vomiting, past history of pancreatitis and polysubstance abuse. The patient's medical record was reviewed for the physician's orders relevant to the use of restraints, beginning on the date of 4/6/2010. Per the medical record, the patient began on restraints upon admission to the facility and remained on restraints at the time of review. All physician orders were reviewed and confirmed the need for the use of restraints. Nursing monitoring sheets for restraints were also reviewed for the same time period and revealed missing documentation on the following dates: on 4/7/2010, no documentation between 1:00pm and 6:00pm. The narrative nurses or the physician orders on this date do not state the patient was off restraints. Nursing monitoring sheets for the date of 4/21/2010 are missing documentation between the times of 7:00pm through 11:00pm. Nursing narrative notes for this date at 8:00am stated patient restraints were intact. On the same date at 9:00pm, the nurses' narrative notes stated soft wrist and soft ankle restraints continued. On 4/22/2010, the nursing monitoring flow sheet for restraints was not completed between the time frames of 11:00am to 11:00pm. Nurses' narrative notes for the same date at 8:00pm stated the patient continued on 4 point restraints. On 4/23/2010, the nursing monitoring sheet for restraints was not fully completed, missing documentation between 11:00am and 7:00pm. The nurses' narrative notes for the same date and time frame do not state the patient was free from restraint.
The facility policy on Restraints and Seclusion was reviewed on 4/28/2010 at 3:00pm. Per the policy, for those patients on non-violent or non-self destructive restraints, orders for restraints must be issued a minimum of once each calendar day and is based on examination of the patient by the physician/ARNP/PA. Patients in restraints shall be monitored at least every two hours or more frequently. Monitoring is accomplished by observation, interaction with the patient, or direct examination of the patient. Each episode of restraints is documented in the patient medical record and shall include: relevant orders for use, alternatives to restraints attempted, type of restraint applied and/or medication given, the plan of care, patient and/or family education, results of patient monitoring and assessment, reassessment, significant changes in the patient's condition, a description of the patient's behavior and the intervention used, alternatives or other less restrictive interventions attempted (as applicable), the patient's condition or symptoms(s) that warranted the use of restraints and the patient's response to the intervention(s) used, including the rationale for continued use of the intervention. Discontinuation of restraints and the patients behavior reflecting improvement which supports the discontinuation shall be documented and the plan of care.