HospitalInspections.org

Based on interview, document review and medical record review, the facility does not ensure the protection and promotion of rights in the areas of patient grievances, participation in care planning, restraint and seclusion, and visitation rights.

The Condition of Participation is not met due to the following:

1. The facility failed to ensure appropriate policies and procedures are in place for the tracking and notification of the next of kin regarding disposition of the body following autopsy.
Cross refer Tag # 0130.

2. The facility failed to ensure that there is a valid Physician order for non-violent restraints.
Cross refer Tag # 0168.

3. The facility failed to ensure that there is consistent documentation and evidence of ongoing assessment and monitoring of patients who are restrained.
Cross refer Tag # 0175.

4. The facility failed to ensure patients or their representatives are provided with a copy of the facility's visitation policy.
Cross refer Tag # 0216.

Based on document review, interview and policy review the facility failed to ensure appropriate policies and procedures were in place for the tracking and notification of Patient # 1's next of kin regarding disposition of the body following autopsy.

Findings include:

Review on 1/28/14 of the Request for Post-Mortem Examination dated 8/9/13 revealed verbal consent was obtained "over the phone" from the brother, next of kin who is in Florida. The form does not list the next of kin ' s last name.

Review on 1/28/14 of the handwritten autopsy logs revealed the following:
-On 8/10/13 Patient #1 was pending an autopsy.
-On 8/11/13 Patient #1 ' s autopsy was completed.
-On 8/29/13 Patient #1 was unclaimed " u/c " from the Medical Intensive Care Unit and is city case #M13-5003.
-On 8/30/13 Patient #1 is not listed on the log.
This log does not indicate when the body was received for autopsy, when or to who the body is released for burial, or the author of the entries.

Review of an e-mail dated 1/28/14 at 2:56pm revealed a computer screen shot dated 8/22/13 indicating an inability to locate Patient #1's family for funeral arrangements. " The computer entry does not include contact information for the next of kin and/or the date and time contact with the family was attempted.

Review on 1/28/14 of both the emergency department and the inpatient facesheets for Patient #1 revealed the next of kin and emergency contact information is listed as " unknown " despite contact information for Patient #1's brother and nephew listed on the 1/5/10 Health Care proxy form, the 7/12/13 at 6:42pm History & Physical, numerous physician notes and the Discharge Summary dated 8/6/13 at 1:14am.

Review on 1/28/14 of the following post mortem documents revealed the following:
- The initial documented certificate of death dated 8/24/13 indicates the " informant " (next of kin or emergency contact) is unknown. An updated version of the certificate of death (dated unknown) lists Patient #1's brother as the " informant. "
- The City of New York Department of Health and Mental Hygiene death reporting form (no date) revealed Patient #1 died on 8/5/13 at the facility. A private funeral director is listed.
- The Permit to Dispose of or Transport Human Remains document dated 8/26/13 revealed Patient #1 ' s body is to be sent for internment disposal to the City Cemetery.

Review of 2/7/14 e-mail received from Staff #1, Director of Risk Management revealed the following information related to the disposition of the the patient's body:
- After the autopsy was performed (8/10/13), the body remained in our morgue until 8/22/13, where the death certificate was changed to interim disposition for city burial.
- On 8/26/13 a permit for city burial was printed and called into the city.
- On 8/30/13 Patient #1's body was released to the Office of the Chief Medical Examiner (OCME), permit # 156-13-034421 at 4:50am. A funeral home picked up the body from our facility on behalf of the City Mortuary.
- On 8/30/13 at 2:45pm during OCME possession of the body, the death certificate was amended from city burial to a private funeral home indicating the body had been claimed. Name of the informant was changed from unknown to the patient's brother. The private funeral home was contacted, and according to them, the brother contacted them in mid-august giving his contact information and authorization for cremation. The amended death certificate reflects this change from city burial to claimed. In order to proceed with the cremation additional information was needed, however attempts to contact the brother several times were unsuccessful. The death certificate was not changed back to city burial, which is standard practice.

Interview on 1/27/14 at 3:30pm with Staff #1, Director of Risk Management revealed Patient #1's body was released by the morgue to the city cemetery. Morgue staff thought the family would call to make funeral arrangements. No one at the facility has contacted the family regarding the location of Patient #1's body.

Review on 1/27/14 of autopsy/morgue policy "With Next of Kin and Established No Next of Kin " dated 8/26/12 revealed the policy does not address communication and documentation requirements for clinicians and morgue/autopsy staff when consent for an autopsy is given by the next of kin but details of post autopsy body disposition is not received.

Review on 1/29/14 of administrative policy GPP-314 " Disposition of the Deceased Patient " last revised 10/06 revealed upon the death of a patient, the extended care facility must also be notified of a patient ' s death. The clinical nurse informs the next of kin/representative that the body will be taken to the morgue and that they should notify a funeral director and document. The record accompanies the body to the morgue for autopsy. The specialty Services Nursing Office maintains a copy of the Care Center Decedent Log detailing attempts to contact the next of kin and /or significant other/emergency contact. The Nursing Director forwards the completed copy of the Decedent Follow-up form to the Administrator of Pathology. A duplicate copy of the Care Center Decedent log and the completed Decedent Follow-up form is filed in the Pathology department.

Interview on 1/28/14 at 9:15am with Staff #9, Vice President of Pathology and Staff #10, Director of Autopsy Services revealed the current policies do not address the situation where the next of kin has given consent for autopsy and then does not contact us with funeral arrangements. It was also noted the morgue supervisor did not contact the clinical nurse manager to find out the status of the notification process.

Based on policy and medical record review and interview, facility staff failed to ensure that there was a vaild Physician order for non-violent restraints for 2 of 6 patients who had non-violent restraints in place ( Patient #10 and #13).

Findings Include:

Interview on 01/28/14 at 9:49am with Staff #11, Registered Nurse (RN) 5th floor, revealed that there needs to be a Physician ' s order within one hour of initiation. Staff #11 stated that orders are good for 24 hours.

Review on 01/28/14 of Patient #10 ' s medical record from 12/19/13 to 12/27/13 revealed the following:
-There is a lack of a valid Physician/Licensed Independent Practitioner (LIP) order for restraints utilized on 12/20/13 from 8:00pm to 11:00pm.

Review on 01/28/14 of Patient # 13 ' s medical record from 09/12/13 to 11/11/13 revealed the following:
-There is a lack of a valid Physician/LIP order for restraints utilized on 11/03/13 from 7:00am to 10:00pm, 11/05/13 from 7:00am to 10:00am, 11/06/13 from 7:00pm to 10:00pm, 11/07/13 from 12:00am to 7:00am, and 11/08/13 from 7:00am to 6:00pm.

Review on 01/28/14 of policy " Restraint/Seclusion Policy " last facility revision 04/2013 revealed that a written order must be completed at the time of the face to face. A face to face assessment by the Physician/ LIP must be done within one hour after the placement of the restraint.
The maximum duration time for a restraint order for non-violent, non-self-destructive is one day. Subsequent orders must be obtained each day and require a face to face reassessment.

Interview on 01/29/14 at 9:40am with Staff #31, RN 8th floor, revealed that there does need to be a Physician ' s order for restraints and that the order is good for 24 hours.

Interview on 01/29/14 at 10:13am with Staff #35, RN 6th floor, revealed that there has to be a Physician ' s order and the order needs to be updated every 24 hours if the patient still required the restraints.

These findings were confirmed on 01/29/14 at 2:00pm with Staff #1, Director of Risk Management.

Based on record review and interview and document review, the facility failed to ensure that there was consistent documentation and evidence of ongoing assessment and monitoring of patients who are restrained for 4 of 6 patients that had non-violent restraints in place ( Patient #8, #10, 12 and 13 ).


Findings Include:

Interview on 01/28/14 at 9:49am with Staff #11, Registered Nurse (RN) 5th floor, revealed that restraint assessments are to be documented on the restraint form that is in the chart.

Review on 01/28/14 of Patient #8 ' s medical record dated 12/04/13 to 12/10/13 revealed the following:
- There was no evidence in Patient #8 ' s medical record to indicate a Patient Restraint Observation Form was completed while non-violent restraints were utilized on 12/04/13 and 12/05/13.

Review on 01/28/14 of Patient #10 ' s medical record from 12/19/13 to 12/27/13 revealed the following:
- There was no evidence in Patient #10 ' s medical record to indicate a Patient Restraint Observation Form was completed while non-violent restraints were utilized on 12/24/13.
- There was one (1) completed Patient Restraint Observation Form which was undated.

Review on 01/28/14 of Patient #12 ' s medical record from 11/12/13 to 11/29/13 revealed the following:
- There were nine (9) completed Patient Restraint Observation Forms that was undated.
- There was no evidence in Patient #12 ' s medical record to indicate a Patient Restraint Observation Form was completed while non-violent restraints were utilized from 11/17/13 to 11/27/13

Review on 01/28/14 of Patient # 13 ' s medical record from 09/12/13 to 11/11/13 revealed the following:
- There was no evidence in Patient #13 ' s medical record to indicate a Patient Restraint Observation Form was completed while non-violent restraints were utilized from 09/12/13 to 10/31/13 and for 11/09/13.
- There were six (6) completed Patient Restraint Observation Forms that were undated.

Review on 01/28/14 of policy " Restraint/Seclusion Policy " last revised 04/2013 revealed that documentation must be completed on the appropriate restraint or constant observation form.

Interview on 01/29/14 at 9:40am with Staff #31, RN 8th floor, revealed that documentation is done on the restraint form.

These findings were confirmed on 01/29/14 at 2:00pm with Staff #1, Director of Risk Management.

Based on medical record review, documentation review and interview, no evidence was found to indicate patients or their representatives are provided with the facility's visitation policy in 13 of 13 patients (Patient # 2-7 and 18-24).

Findings Include:

Review on 1/28/14 to 1/29/14 of medical records for Patient # 2-7 and 18-24 revealed no evidence they or their representative received written notice of the facility's visitation policy.

Review on 1/29/14 of administrative policy GPP-118 "Patient Visitation Rights" last revised 3/13 revealed prior to care being provided (or as soon as possible), the required written notice of visitation rights will be provided to the patient and the patient's support person if appropriate. The designated admitting staff member must document in the medical record that the patient or support person was provided with the required notice of visitation rights.

Interview on 1/29/14 at 0853 with Staff # 1, Director of Risk Management confirmed that the receipt of visitation rights is not documented in the patient medical record.

Based on record review and policy review, the facility failed to ensure complete documentation for permission for autopsy in 1 out of 5 patients who had autopsies performed (Patient #15).

Findings include:

Review on 1/29/14 of administrative policy GPP-313 " Health Information Management " last revised 3/13 revealed the Health Information Management (HIM) staff screen autopsy consent forms when received and notifies the Morgue/Autopsy suite for follow-up. The autopsy form must be placed in the medical record.

Review of Request for Post-Mortem Examination form dated 1/6/14 for Patient #15 on 1/29/14 revealed the section listing the relationship of the person to the deceased giving consent and the section listing the name of the physician to whom the autopsy report should be sent are blank.