HospitalInspections.org

Based on document review and interview, the facility failed to protect patient's rights in regards to the use of restraints for violent or self-destructive behaviors placing all patients at risk for a loss of their rights. Findings include:

---the facility failed to ensure that 1 of 3 patients (#4) (who presented to the emergency department (ED) and required restraints due to violent behavior) was not restrained for staff/facility convenience (See A-154),
---the facility failed to ensure that it obtained additional physician orders for continued restraints use after four (4) hours, the facility also failed to ensure that a physician's order was placed into the electronic health record (EHR) for all restraint use (See A-168),
---the facility failed to discontinue restraints used to manage violent behavior at the earliest possible time (See A-174).

Based on document review and interview, the facility failed to ensure that 1 of 3 patients (#4) (who presented to the emergency department (ED) and required restraints due to violent behavior) was not restrained for staff/facility convenience. A total of 5 patients were reviewed that required restraints for either medical devices or violent behaviors with a total universe of 13 (thirteen) patient records reviewed. This has the potential to infringe on patient rights not to be restrained unnecessarily for all patients restrained in the facility. Findings include:

On 02/25/2015 at 0830, review of the medical record for patient # 4 revealed that the patient was brought to the ED on 02/17/2015 at 1756 by the police after "Attempting suicide by dunking his head in the toilet." A physician's order was placed at 1813 for "Suicide Precautions and Sitter at beside. Reason for a Sitter? Suicide Precautions." The patient was seen by an RN at 1820 and an assessment was completed. At 1822, restraints were applied, per the RN (registered nurse). On 2/17/15 at 1824 an order was placed by a physician for "Violent or Self Destructive Restraints ." The every fifteen (15) minute monitoring documentation at 1841 and 1900 refers to the patient's Psychological Status as "Tearful." Then between the time frames of 1915 thru 2045, 2115 thru 2235 and 2300 until 2345 the patient's Psychological Status was documented as "Subdued." The patient remained in restraints on 02/18/2015 at 0001. Review of the every fifteen (15) minute documentation from 0015 thru 0200 revealed that the patient's Psychological Status remained "Subdued." The patient remained in restraints and a note entered into the record at 0138 by an RN stated the following: "Spoke with staff at placing (recipient) agency, pt (patient ) will not be accepted until he has been out of restraints X 2 hours. However, unable to remove restraints due to patient being a flight risk and no sitter available. Placing agency informed that pt is NOT in restraints for violence but only for flight risk. Informed that pt must be held in ED until sitter is available and pt can be out of restraints for minimum of two hours." At 0215 the patient's Psychological Status was changed to "Patient asleep." The patient's Psychological Status continued to be documented as "Patient asleep" until 0420 when the documentation changed to "Sleeping, easily arousable." At 0440 the patient is again documented as asleep and the documentation supports that he stayed asleep until 0545. At 0543 there was another physician's order placed for restraints. At 0600 a "ED Note" entered by an RN (registered Nurse) read "After discussion with SW (Social Worker), MD (Medical Doctor) and day shift nursing staff, pt (patient) spoken with, verbal contract for safety and restraints removed. two hour time frame started for psy (psychiatric) admission. Pt up to use bathroom and provided toothbrush and toothpaste. Pt remains very cooperative." The patient was discharged at 1111.

In an interview on 02/25/2015 at 0845 with staff E when queried if the facility provided a sitter for the patient as per the physician's order, staff E replied, "It does not look like they did." When staff E was queried if the use of the sitter that was ordered by the physician would be considered a least restrictive alternative to the restraints, staff E replied, "It could have been, it would depend on how he did once the sitter was there."

On 02/25/2015 at 1000 a review of the facility's policy titled, "Restraint, #EHR010, with a revision Date: 3/12/2013", revealed "Restraint is not to be used as a means of coercion, discipline, convenience, or staff retaliation."

Based on document review and interview, the facility failed to ensure that it obtained additional physician orders for continued restraints after four (4) hours for 2 of 3 patients (#4, #5). The facility also failed to ensure that a physician's order was placed into the electronic health record (EHR) for 1 of 3 patients (#6). All three (3) patients were placed into restraints due to behaviors. A total of 5 patients were reviewed that required restraints for either medical devices or violent behaviors with a total universe of 13 (thirteen) patient records reviewed. These findings have the potential for patients who are restrained, the loss of their rights to be free of restraints. Findings include:

On 02/25/2015 at 0830, review of the medical record for patient # 4 revealed that the patient presented to the ED (emergency department) on 02/17/2015 at 1756 with the police after "Attempting suicide by dunking his head in the toilet." The patient was placed into "Violent or Self-Destructive Restraints" at 1822 with a documented duration of four (4) hours. The next physician's order for restraints was on 02/18/2015 at 0543. The documentation supports that the patient remained in restraints until 02/18/2015 at 0600 a total of 11 (eleven) hours and fifty-seven (57) minutes.

In an interview with staff E on 02/25/2015 at 0845 when queried if there were any restraint orders for the patient between 2218 (4 hours after first order) and 0543. Staff E replied, "No, there are no other orders for restraints except the first one on the 17 th at 1822 and then the second one on the 18 th at 0543. When staff E was queried as to how frequently behavioral restraints are supposed to be renewed, staff E replied, "For behavioral, at least every four (4) hours."

On 02/25/2015 at 0900 during review of the medical record for patient #5, revealed that the patient presented to the ED on 02/23/2015 at 1512 after seeing his PCP (primary care physician). At 1519, the documentation stated, "Patient unable to answer questions 'like I'm going through, I'm crazy, I'm tired of talking.'" The documentation supports that at 1650 a physician's order was placed a for "Restraints violent or self-destructive adult (age 18 and older) with a duration documented as four (4) hours. At 1711 restraints were applied. Per the documentation the patient remained in the restraints until 2250 for a total of 5 (five) hours and 29 (twenty-nine minutes).

In an interview with staff E on 02/25/2015 at 0930 when queried if there was a second restraint order obtained for the patient, staff E replied, "I don't see one."

On 02/25/2015 at 0945, during review of the medical record for patient #6 revealed that the patient arrived at the ED (emergency department) on 02/05/2015 at 1310. The patient arrived via EMS (Emergency Medical Services) after being found outside naked. At 1314, the RN (Registered Nurse) documented, "Patient was reported to be combative and arrived handcuffed. Placed into restraints by ED staff and security." Then at 1325 the RN documented that a "verbal" order was obtained from the attending physician.

In an interview with staff E on 02/25/2015 at 0955, when queried if she could locate the afore mentioned attending physician's order for restraints in the patient's (#6) medical record, staff E replied, "I don't see one in there."

Based on document review and interview, the facility failed to discontinue restraints used to manage violent behavior at the earliest possible time for 2 of 3 patients (#4, #5). A total of 5 patients were reviewed that required restraints for either medical devices or violent behaviors with a total universe of 13 (thirteen) patient records reviewed. This practice has the potential for all patients in restraints to be held in restraints for prolonged periods of time and beyond their need. Findings include:

On 02/25/2015 at 0830, during review of the medical record for patient #4 revealed that the patient was placed into "Violent or Self-Destructive Restraints" on 02/17/2015 at 1824. From 1915 on 02/17/2015 thru 02/18/2015 at 0209 the RN (Registered the Nurse) documents the patient's psychological status as "Subdued." At 0215 the RN documented under the Psychological Status as "Patient asleep." Documentation shows that the patient was asleep in restraints until 0545. A note entered earlier into the record at 0138 by an RN stated the following: "Spoke with staff at placing agency, pt (patient ) will not be accepted until he has been out of restraints X 2 hours. However, unable to remove restraints due to patient being a flight risk and no sitter available. Placing agency informed that pt is NOT in restraints for violence but only for flight risk. Informed that pt must be held in ED until sitter is available and pt can be out of restraints for minimum of two hours."

On 02/25/2015 at 0900, during review of the medical record for patient #5 revealed that the patient was placed into "Violent or Self-Destructive Restraints" on 02/23/2015 at 1711. The record documentation entered at 1828 by the RN showed that the patient was asleep. According to documentation, the patient remained asleep in the restraints until 2240. Restraints were discontinued at 2250.

In an interview with staff E on 02/25/2015 at 0915, when queried if patients #4 and #5 would still be considered violent or self-destructive if they were sleeping, staff E replied, "I guess not if their asleep."

On 02/25/2015 at 1000 a review of the facility's policy titled, "Restraint, #EHR010, Revision Date: 3/12/2013" revealed, "D. Observation, Monitoring and Documentation of Restrained Patients: V. i. A provider or RN will re-assess the patient and determine whether the restraint can be removed. This occurs when the patient's safety is no longer a threat to self or others, or when the patient is compliant with safety measures/medication and/or treatment plan."

Based on document review and interview, the facility failed to ensure that in-patient medical records were completed within thirty (30) days of the patient's discharge resulting in the potential for poor quality of care for all patients with delinquent medical records. Findings include:

On 02/25/2015 at 1100, during review of the medical record deficiency report revealed that the facility had 394 (three-hundred- ninety-four) opened medical records greater than 30 (thirty) days post discharge. The document revealed that the facility had 37 (thirty-seven ) opened records from 2013, 355 (three-hundred-fifty- five) opened records from 2014 and 2 (two) opened records from January 2015. According to the deficiency document, the records were either missing discharge summaries, consults and history & physicals, or were in need of a physician's signature on the documents.

In an interview with staff I on 02/25/2015 at 1200, when queried to explain what steps were being taken to complete the delinquent records, she stated, "A delinquent record report is sent to each department specific chair, the physician with the delinquent record(s) and the Chief Medical Officer (CMO) every 15 (fifteen ) and again every 30 (thirty) days. When staff I was queried as to what steps are taken if the physician does not complete the delinquent records, she stated, "If over 30 (thirty) days staff is suspended and cannot admit patients or board surgeries until records are completed." When staff I was queried if there were currently any physicians on suspension for delinquent medical records, she stated, "No, there are no suspensions at this time."

On 02/25/2015 at 1215, review of the facility's policy/procedure titled, "Medical Record Completion, #EH007, Date: December 1, 2012" revealed "Facility A requires that all medical record documentation be completed and appropriately reviewed, signed and attested timely. Timely, accurate and complete medical record documentation is a key component of patient safety and quality patient care. Timeliness is based on established procedures, including those described below.
The entire inpatient medical record, including signatures, must be completed within 30 (thirty) days of discharge. The entire encounter, visit or service provided record, including signatures, must be completed within 30 (30) days of the encounter. Incomplete documentation is immediately available to owner/author within the EHR (electronic health record).
Incomplete Documentation Notification and Sanction Notification, History and Physical, Operative Note and Discharge Summary. EHR in-basket, e-mail or letter notification of incomplete documentation at 15 (fifteen) days 21 (twenty-one) days after patient discharge. EHR in-basket, e-mail or letter sanction notification at 31 (thirty-one) days after patient discharge. Health System leadership is included in the sanction notification and will initiate the sanction procedure(s)."

In an interview on 02/25/2015 at 1300, with staff H (Chief of Staff) when queried about the delinquent medical records, she stated, "This is an ongoing problem. We are always working on getting them (physicians) to complete their records. Letters are sent out at least twice monthly." When queried if there were any physicians currently suspended for their delinquent medical records, she stated, "No there are not." When queried if the Medical Staff Bylaws or Rules and Regulations speak to completion of the medical records, she stated, "They do."

On 02/25/2015 at 1400, review of the facility's document titled, "Medical Staff Policy Manual, January 2013, Documentation performance will be measured for all Medical Staff Members and when performance falls short of the standards noted, the Medical Staff Member will be notified by phone call, e-mail or in writing. Upon receipt of the notification, the Medical Staff Member will have 15 days to remedy the failed documentation. If the Medical Staff Member fails to remedy the violation within the timeframe, the CMO (Chief Medical Officer) or designated Service Chief is authorized to suspend admission privileges and/or operating room privileges until such time as the medical records are completed."