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Based on document review and interview, the facility failed to protect patient rights for patients admitted to the facility and for patients that require the need for restraints resulting in the loss of patient rights for all patients served by the facility. Findings include:

---the facility failed to provide documentation showing evidence that patients were given the second notice of the Important Medicare Message prior to discharge (See A-117)

---the facility failed to document the use of restraint in the patients plan of care (POC) or treatment plan (See A-166),

---the facility failed to adhere to the maximum 4 hour time limit for restraint orders for patients who are violent or self destructive (See A-171),

---the facility failed to monitor vital signs for patients that had been placed into restraints (See A-175)

---the facility failed to ensure that a physician performed a face to face evaluation for 1 of 4 (#3) patients that required restraints for violent behavior (See A-178).

Based on document review and interview, the facility failed to provide documentation showing evidence that 5 of 11 ( #1, 8, 12, 13, 17) patients were given the second notice of the Important Medicare Message prior to discharge resulting in the loss of the patients' right to appeal their discharge. Findings include:

On 07/07/2015 at 0800, during review of the medical record for patient #1 revealed that the "Facesheet" identified patient #1's insurance as Medicare. The medical record contained a signed Important Message from Medicare dated at the time of the patient's admission 04/21/2015. The medical record lacked documentation that the second notice was given prior to discharge.

On 07/07/2015 at 0830, during review of the medical record for patient #13 revealed that the "Facesheet" identified patient #13's insurance as Medicare. The medical record contained a signed Important Message from Medicare dated at the time of the patient's admission 01/24/2015. The medical record lacked documentation that the second notice was given prior to discharge.

On 07/07/2015 at 0915, during review of the medical record for patient #12 revealed that the "Facesheet" identified patient #12's insurance as Medicare. The medical record contained a signed Important Message from Medicare dated at the time of the patient's admission 02/20/2015. The medical record lacked documentation that the second notice was given prior to discharge.

On 07/07/2015 at 1000, during review of the medical record for patient #8 revealed that the "Facesheet" identified patient #8's insurance as Medicare. The medical record contained an unsigned first notice of the Important Message from Medicare for the 01/27/2015 admission. The medical record also lacked documentation that the second Important Message from Medicare notice was given prior to discharge.

In an interview with staff A on 07/07/2015 at 1315, when queried about documentation in the patient's records of the second notice being given, she stated, "I have not found that in any of the records that we have looked at."


30988

On 07/07/2015 at 1000, during review of the medical record for patient #17 revealed that the "Facesheet" identified patient #17's insurance as Medicare. The medical record contained a signed Important Message from Medicare dated at the time of the patient's admission 02/20/2015. The medical record lacked documentation that the second notice was given prior to discharge.

Based on document review and interview, the facility failed to document the use of restraint in the patients plan of care (POC) or treatment plan for 7 of 7 (#1, #3, #4, #17, #18, #19, & #20) patients records reviewed with ordered and documented use of restraints in progress notes and on flow sheets, resulting in the potential for a loss of the patients rights.

On 7/6/2015 at 1230 during tour of the ICU staff A was asked to show the plan of care for patient #20 that included the soft restraints she was currently wearing. Staff A stated, "I cannot find the restraints included in the POC."

On 7/6/2015 at 1430 during tour of the geropsych unit (5 north) staff A was asked to show the POC for patients #18 and #19 that included the current use of restraint observed in use on both patients. Staff A stated, "I cannot find Restraints documented on the the POC."

On 7/7/2015 at 1000 during review of a closed record for patient #20 who was documented to be restrained for violent behavior beginning on 2/20/2015 , did not have the use of restraints documented in his plan of care.

On 7/7/2015 at 1300 staff A stated, "Restraint's are to be a part of the POC, we are getting a new computer system and we will make sure that it is included."


28273

On 07/06/2015 at 1300, during review of the medical record for current inpatient, patient #3, revealed that the patient was placed into restraints for violent behavior on 06/23/2015 at 1615 and on 06/24/2015 at 1100.

In an interview and review of the electronic medical record (EMR)on 07/06/2015 at 1315 with staff A, when queried if the use of restraints had been addressed in the patient's plan of care (POC), she stated, "I don't believe so, it has not been in the other ones we looked at." Review of the EMR revealed that the POC lacked modifications/updates related to the use of restraints for violent behavior. Staff A stated, "There is not anything in there."

On 07/06/2015 at 1320, during review of the medical record for current inpatient, patient #4, revealed that the patient was placed into medical restraints on 06/24/2015 for "protection of medical ventilation tube." During review of the EMR on 07/06/2015 at 1325 with staff A, revealed that there was no modification/update to the patient's POC related to the use of restraints. Staff A stated, "We have some work to do on this."

On 07/07/2015 at 0800, during review of the closed medical record for patient #1 revealed that the patient had required the use of medical restraints on 04/29/2015 at 1900 due to "Agitation/medical problem, protection of invasive lines, cannot follow safe instruction/danger to self." Review of the medical record revealed a POC that lacked modification /update related to the use of restraints.

Review of the closed medical record for patient #13 on 07/07/2015 at 0830, revealed that the patient required the use of restraints for violent behavior on 01/25/2015 at 0210 thru 01/28/2015 at 2130. Review of the POC revealed a lack of modification/updates addressing the use of restraints.

In an interview with staff F on 07/07/2015 at 0900, she confirmed that the medical records for both patient #1 and patient #13 lacked documentation in the POC related to the need for restraints.

Based on document review and interview, the facility failed to adhere to the maximum 4 hour time limit for restraint orders for patients who are violent or self destructive [patient #20] and 277 patients in April, 237 patients in May, and 248 patients in June) resulting in the loss of the patient's rights. Findings include:

On 7/7/2015 at 1000 during review of the closed record for patient #20, 9 of 20 restraint orders-"Violent Management" exceeded the 4 hour maximum time frame for the requirement for reordering of the the restraints. On 2/21/2015 at 0015 restraints were initiated, the physician did a face to face assessment at 0105, the next order was written at 0500 (4 hours 45 minutes after the initial order). On 2/21/2015 at 1300 restraints were initiated, the physician did a face to face assessment at 1320, the next order was not written until 1800 (5 hours after the initial order). On 2/22/2015 at 0000 restraints were initiated, the physician did a face to face assessment at 0005, the restraints were not discontinued until 0700. On 2/22/2015 at 1130 restraints were initiated, the physician did the face to face assessment at 1144, the next order was written at 1630 (5 hours after the initial). On 2/23/2015 at 0130 restraints were initiated, the physician did the face to face assessment at 0230, the restraints were discontinued at 0615 (5 hours after the initial). On 2/23/2015 at 1615 restraints were initiated, the physician did the face to face assessment at 1630, the next order was written at 2115 (5 hours after the initial). On 2/24/2015 at 1630 restraints were initiated, the physician did the face to face assessment at 1645, the next order is at 2130 (5 hours after the initial.) On 3/6/2015 at 1200 restraints were initiated, the physician did the face to face assessment at 1253, the next order was written at 1700 (5 hours after the initial.) On 3/7/2015 at 0900 restraints were initiated, the physician did the face to face assessment at 0925, the next order was written at 1400 (5 hours after the initial).

On 7/7/2015 at 1400 staff A Director or Nursing and staff B Chief Nursing Officer were asked about the practice of exceeding the 4 hour maximum time frame for restraint reorder for violent management, They stated, "We are aware of the 4 hour maximum, we did not realize that the staff are not counting the first hour as part of the physicians 4 hour order." They also stated, "We do not track restraint times in our quality program."

On 7/7/2015 at 1430 the policy titled, "Restraints, Seclusion and Death reporting" effective date March 13, 2015 # R100P was reviewed, page 4 of 17 states "E. Orders for Violent restraints.....i. Restraint of patients for behavior management requires a Physician's order prior to the initiation of a restraint or immediately thereafter if restraint is applied in an emergency.....ii. a face to face assessment must be performed by the physician within 1 hour of the initial use.....v...Once a physician personally examines the patient an order must be renewed on the flow sheet......vi....The restraint order may continue for the specified time and not to exceed: 4 hours for adults.........


28273

On 07/06/2015 at 1600, during review of documentation provided by staff L titled, "Important Aspects of Care Seclusion and Restraint Monthly Report" for the months of April 2015, May 2015 and June 2015 for the Gero-psychiatric unit revealed the following:

During the month of April 2015, the facility had 314 incidents of behavioral restraints. On 277 occasions of restraints, the patient was placed into restraints for the first hour by a telephone order from a physician. Once the physician came to the unit he would complete the form titled, "Restraint Order-Violent Management." Near the bottom of the document was a statement that read, "Restrain patient for up to ____ hours . (Not to exceed 4 hours.) The staff on the Gero-psychiatric unit would then continue the restraints for four more hours resulting in the patient being in restraints for 5 hours on a four hour order.
Another document titled, "Daily Restraint Log" contained a column area that read "One Hour Order" and next it was another column that read "# Ext (Extended) Hours." The columns contained documentation that supported that the 277 patients were placed into restraints for more than the four hour order.

During the month of May 2015, the facility had 255 incidents of behavioral restraints. The above actions continued for 237 patients that required restraints.

During the month of June 2015, the facility had 269 incidents of behavioral restraints. The above actions continued for 248 patients that required restraints.

Based on document review and interview, the facility failed to monitor vital signs for 4 of 7 (#3, #8, #17, #20) patients that had been placed into restraints, resulting in the potential for unidentified medical problems and patient harm. Findings include:

On 07/06/2015 at 1300, during review of the restraint documentation of the open medical record for patient #3 revealed a document titled, "Restraint Order-Violent Management." The document contains an area titled, "1 Hour Telephone Order" and contains a place for the the RN's (registered nurse) signature, the physician's name who gave the order, time of the order and a place for the physician to sign the order at a later time. The 1 Hour Telephone Order also contains a section for the RN to document the patient's vital signs (VS) - Blood Pressure, Temperature, Pulse, Respirations, and Pulse ox {oxygen level in the blood}) or if they were "Unable to obtain VS." The restraint order documentation for patient #3 on 06/23/2015 at 1615 revealed a lack of documentation of vital signs. A second order obtained on 06/24/2015 at 0000 contained a check box in the area of "Unable to obtain VS." Another order for 06/24/2015 at 1100, revealed a lack of documentation of VS or explanation of staff's inability to obtain them.

In an interview with staff A on 07/06/2015 at 1300 when queried if the Restraint Order document should contain the patients VS, she stated, "If they are able to take them." When queried as to why staff are not able to at least count the patient's respirations, she stated, "That is a good point."

On 07/07/2015 at 1000, review of the closed medical record for patient #8 revealed that he had been placed into restraints for management of violent behavior with the following documentation:
01/27/2015 at 0015, the RN charted in the VS section "Unable to obtain VS."
01/27/2015 at 1530-no documentation of VS or staff's inability to obtain them.
01/28/2015 1300-no documentation of VS or staff's inability to obtain them.
01/28/2015 at 2400-no documentation of VS or staff's inability to obtain them.
01/29/2015 at 1655-no documentation of VS or staff's inability to obtain them.

In an interview with staff F on 07/07/2015 at 1015, she confirmed that the restraint order documents lacked at least documentation of the patient's respirations.


30988

On 7/7/2015 at 1000 during review of the closed record of patient #20 the document titled "Restraint Order-Violent Management" was found used 19 times between 2/20/2015 and 3/7/2015. The RN charted in the VS section "Unable to obtain VS" 14 times, and no documentation of VS or staff's inability to obtain them 5 times.

On 7/6/2015 at 1600 during review of the open record of patient
#19 the document titled "Restraint Order-Violent Management" was found used 15 times between 6/17/2015 and 6/29/2015. The RN charted in the VS section "Unable to obtain VS" 9 times, and no documentation of VS or staff's inability to obtain them 5 times, the RN charted VS 1 time.

Based on document review and interview, the facility failed to ensure that a physician performed a face to face evaluation for 1 of 4 (#3) patients that required violent restraints application resulting in the potential for a loss of the patients' right to be free from restraints. Findings include:

On 07/06/2015 at 1350, during review of the medical record for patient #3 revealed that the patient was placed into restraints on 06/24/2015 at 1100. The document titled, "Restraint Order-Violent Management, contains a physician note and assessment documented at 1230, one and one-half hour after the patient went into the restraints.

In an interview with staff A on 07/06/2015 at 1355, when queried about the face to face evaluation for patient #3 not being performed within the hour, she stated, "The order is only good for an hour so if it was not done then the patient should have been taken out of the restraints. The documentation revealed that the patient was not removed from the restraints until 2000 on 6/24/2015.