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PATIENT RIGHTS

Tag No.: A0115

THE CONDTION IS NOT MET:
Based on clinicial record reviews, review of hospital documention and interviews with facility personnel, the facility failed to ensure that one patient in restraints was assessed/monitored and/or a comprehensive care plan was developed when the patient was restrained for an extended period of time. Patient #60 was admitted to the Emergency Department (ED)on 3/7/10 for a psychiatric evaluation. Patient #60 had a history of Williams Syndrome and Mental Retardation. Patient #60 had been experiencing aggressive behaviors, spitting and biting staff. Review of the clinical record on 3/17/10 identified that Patient #60 was physically and chemically restrained in the ED from 3/7/10-3/12/10. Review of the clinical record and interviews with staff identified that although the patient was assessed initially by ED medical staff, the patient was not re-assessed by a physician until admission to the inpatient unit on 3/10/10. Additonally, the clinical record failed to include a nursing care plan to address the patient's extended need for restraints. (See A166, A171, A175, A178)

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0166

Based on clinical record review, review of hospital documentation and interviews with facility personnel for one sampled patient (Patient #60), the facility failed to ensure that a comprehensive care plan was developed to address the use of restraints.

The findings include:

1. Patient #60 was admitted to the Emergency Department (ED)on 3/7/10 for a psychiatric evaluation. Patient #60 had a history of Williams Syndrome and Mental Retardation and had been experiencing assaultive behaviors. Review of the physician orders dated 3/7/10 identified that the patient was to be in four point restraints related to aggressive behaviors. Patient #60 was identified in four point restraints from 3/7/10-3/12/10 (119 hours). Review of the nursing plan of care dated 3/7/10 identified that although a plan of care identified safety issues, the plan of care failed to identify the interventions related to an extended use of restraints. Review of hospital policy identified that the development of each plan of care and treatment is individualized and appropriate to the patient's needs, strengths, limitations and goals and needs to be reassessed at least daily or upon a change in the patient's condition. Interview with the Director of Quality on 3/17/10 identified that the patient's plan of care was not completed.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0171

Based on clinical record reviews, review of hospital documentation and interviews with facility personnel for one sampled patient (Patient #60), the facility failed to ensure that physician orders were obtained for the continuation of restraints.

The findings include:

1. Patient #60 was admitted to the Emergency Department (ED)on 3/7/10 for a psychiatric evaluation. Patient #60 had a history of Williams Syndrome and Mental Retardation and had been experiencing assaultive behaviors. Review of the physician orders dated 3/7/10 identified that the patient was to be in four point restraints related to aggressive behaviors. Patient #60 was identified in four point restraints from 3/7/10-3/12/10 (5 days). Review of physician orders dated 3/7/10-3/10/10 failed to reflect that physician orders for continued restraints were renewed per hospital policy. Review of restraint orders dated 3/7/10 through 3/10/10 identified continuation of restraints up to eight hours without evidence that the patient was evaluated in person prior to renewal and/or that a verbal order was obtained following a report to the physician every four hours. Review of hospital policy identified that a physician order is to be obtained every four hours for adults. Further review identified that after the first four hours, the registered nurse reassesses the patient and obtains a telephone order for another four hours. An in person evaluation by the physician is required every eight hours for continuation of restraints. Interview with the Director of Quality on 3/17/10 identified that the hospital restraint policy was not followed.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0175

Based on clinical record reviews, review of hospital documentation and interviews with facility personnel for one sampled patient (Patient #60), the facility failed to ensure that the patient was monitored consistently while in restraints.

The findings include:

1. Patient #60 was admitted to the Emergency Department (ED)on 3/7/10 for a psychiatric evaluation. Patient #60 had a history of Williams Syndrome and Mental Retardation and had been experiencing aggressive behaviors, including spitting and biting staff. Review of the physician orders dated 3/7/10 identified that the patient was to be in four point restraints related to aggressive behaviors. Patient #60 was identified in four point restraints from 3/7/10-3/12/10 (5 days). Review of nursing documentation dated 3/7/10-3/12/10 identified that although the patient's behavioral symptoms were assessed every hour by staff, the clinical record failed to reflect that the patient's physical condition was assessed and monitored every two hours while in restraints. Review of hospital policy identified that while in restraints, the patient is monitored every two hours while awake and every four hours if asleep. The patient's limbs are released for range of motion, assessment of skin under restraints and fluids/toileting opportunities are offered. In addition, vital signs are assesssed every four hours unless otherwise noted. Documentation failed to reflect that the patient's circulation was assessed, range of motion offered and/or that toileting and fluids were offered in accordance with policy. Interview with the Director of Quality on 3/17/10 identified that the hospital restraint policy was not followed in regard to physical assessment/care of the patient.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0178

Based on clinical record reviews, review of hospital documentation and interviews with facility personnel for one sampled patient (Patient #60), the facility failed to ensure that a face to face evaluation of the patient by a licensed independent practitioner was conducted initially and subsequently in accordance with facility policies.

The findings include:

1. Patient #60 was admitted to the Emergency Department (ED)on 3/7/10 for a psychiatric evaluation. Patient #60 had a history of Williams Syndrome and Mental Retardation and had been experiencing aggressive behaviors, including spitting and biting staff. Review of physician orders dated 3/7/10 identified that the patient was to be in four point restraints related to aggressive behaviors. Patient #60 was identified in four point restraints from 3/7/10-3/12/10 (5 days). Review of the clinical record failed to identify that a face-face re-evaluation of the patient was completed by a licensed independent practitioner every eight hours according to hospital policy for the entire period of time the patient was in restraints. Review of hospital policy identified that adult patients receive an in-person evaluation by the licensed independent practitioner at least every eight hours while in behavior restraints. Interview with the Director of Quality on 3/17/10 identified that the hospital restraint policy in regard to physician assessment of the patient in restraints was not followed.

MEDICAL STAFF

Tag No.: A0338

The CONDITION IS NOT MET:
Based on clinical record reviews, review of hospital documentation and interviews with facility personnel, the facility failed to ensure for 1 of 8 sampled psychiatric patients (Patient #60), that psychiatric and/or medical assessments were performed prior to initiating medical treatment. As a result, medications were ordered by the attending psychiatrist without evaluating the patient. Patient #60 was admitted to the Emergency Department (ED)on 3/7/10 for a psychiatric evaluation. Patient #60 had a history of Williams Syndrome and Mental Retardation and had been experiencing aggressive behaviors, including spitting and biting staff. Review of the clinical record on 3/17/10 identified that Patient #60 remained in restraints in the ED from 3/7/10-3/10/10 and was eventually transferred to Hospital #2 on 3/12/10, where immediately upon admission, he/she experienced cardiac arrest and died. Although the ED physician requested a psychiatric consult on 3/7/10, the patient was seen by non-medical psychiatric clinicians in the ED between 3/7/10 and 3/10/10. During this period the patient received medications ordered by an attending psychiatrist without benefit of a psychiatric assessment. The facility's Medical Staff Rules and Regulations directs that physicians will reassess patients on a daily basis. (See A 347)

MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY

Tag No.: A0347

Based on clinical record reviews, review of hospital documentation and interviews with facility personnel for 1 of 8 sampled patients (Patient #60), the facility failed to ensure that the patient had a psychiatric evaluation in a timely manner by a qualified physician and/or failed to ensure that the patient was medically managed in the Emergency Department.

The findings include:

1. Patient #60 was admitted to the Emergency Department (ED)on 3/7/10 for a psychiatric evaluation. Patient #60 had a history of Williams Syndrome and Mental Retardation and had been experiencing aggressive behaviors, including spitting and biting staff. Review of the clinical record on 3/17/10 identified that Patient #60 remained in restraints from 3/7/10-3/12/10 and was then transferred to Hospital #2, where immediately upon admission, the patient experienced cardiac arrest and died. Review of the ED physician assessment dated 3/7/10 identified that the patient was in four point restraints and had been non compliant with medications. Further review identified that the patient was medically cleared by the ED physician and the patient was referred for a psychiatric consult. Review of the psychiatric consult dated 3/7/10 identified that it was completed by a clinician and the psychiatrist was consulted by telephone. Patient #60 remained in the ED from 3/7/10-3/10/10 (3 1/2 days). Although psychotropic medications and restaints were ordered and administered throughout this time period, review of the ED record dated 3/7/10-3/10/10 failed to identify that an ED physician and/or psychiatrist examined the patient after the initial ED admission. Patient #60 was admitted to the inpatient psychiatric unit on 3/10/10 at which time the attending psychiatrist examined him/her. Patient #60 continued to exhibit aggressive behaviors including spitting and biting of staff and remained in 4 point restraints. On 3/12/10, at 8:00am, Patient #60 was discharged to another facility. Review of hospital medical rules and regulations/bylaws recommend consulatations with a qualified practioner when there is doubt concerning the evaluation, diagnosis or treatment of the patient. A satisfactory consultation includes examination of the patient, review of the medical record, and a signed evaluation by the consulting practitioner must be included in the medical record. Interview with MD # 22 (ED physician) identified that he had initially evaluated the patient on 3/7/10 and ordered medications, however after the second dose the patient had no changes in his behavior and he/she had requested a psychiatric consult. Interview with MD # 23 (psychiatry) identified that he/she went down to the ED and viewed the patient from a distance, however never evaluated/examined the patient. Interview with MD # 21 (Medical Director of Psychiatry) on 3/17/10 identified that he also had viewed the patient in the ED, however never evaluated/examined the patient until 3/10/10 when the patient was admitted to the psychiatric unit.


Based on clinical record reviews, review of hospital documentation and interviews with facility personnel for one sampled patient (Patient #60), the facility failed to ensure that an accurate assessment of the patient was conducted.

The findings include:

1. Patient #60 was admitted to the Emergency Department (ED)on 3/7/10 for a psychiatric evaluation. Patient #60 had a history of Williams Syndrome and Mental Retardation and had been experiencing aggressive behaviors, including spitting and biting staff. Review of the clinical record on 3/17/10 identified that Patient #60 remained in restraints in the ED from 3/7/10-3/12/10 (5 days). Although the patient was immobile throughout this period of time, a medical assessment identified as "Prevent VTE [venous thromboembolism] Protocol, " signed by MD #21, and dated 3/11/10 identified the patient as a low risk (ambulatory without risk factors or lengths of stay less than two days) for venous thromboembolism and no prophylaxis was ordered for the patient. Interview with MD #21 (Director of Psychiatry) identfied that he/she did not order any anticoagulation for Patient #60 due to his aggressive behaviors and impulsiveness. Further interview failed to identify that other preventive interventions (venodynes) were considered.

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on clinical record reviews, review of hospital documentation and interviews with facility personnel for one sampled patient (Patient #60), the facility failed to ensure that the physician's order was completed.

The findings include:

1. Patient #60 was admitted to the Emergency Department (ED)on 3/7/10 for a psychiatric evaluation. Patient #60 had a history of Williams Syndrome and Mental Retardation. Review of the hospitalist consultation dated 3/11/10 identified that the patient had a urinary tract infection and ordered a urine culture and sensitivity. Further review failed to identify that the urine culture was obtained prior to the patient being discharged. Interview with the Director of Quality on 3/17/10 identified that the physician's order was not followed.

NURSING CARE PLAN

Tag No.: A0396

Based on clinical record reviews, review of hospital documentation and interviews with facility personnel for one sampled patient (Patient #60), the facility failed to ensure that a comprehensive care plan was developed while the patient remained in restraints for an extended period of time.

The findings include:

1. Patient #60 was admitted to the Emergency Department (ED) on 3/7/10 for a psychiatric evaluation. Patient #60 had a history of Williams Syndrome and Mental Retardation. Patient #60 had been experiencing aggressive behaviors, including spitting and biting staff. Review of the physician orders dated 3/7/10 identified that the patient was to be in four point restraints related to aggressive behaviors. Patient #60 was identified in four point restraints from 3/7/10-3/12/10 (5 days). Review of the nursing plan of care dated 3/7/10 identified that although the plan of care identified safety issues, it failed to identify interventions related to the extended use of restraints. Review of hospital policy identified that the development of each plan of care and treatment is individualized and appropriate to the patient's needs, strengths, limitations and goals and needs to be reassessed at least daily or upon a change in the patient's condition. Interview with the Director of Quality on 3/17/10 identified that the patient's plan of care was not completed.