HospitalInspections.org

Complaint #NJ00146586

Based on staff interviews, medical record review, review of facility policies and procedures, and review of other related documentation, it was determined that the facility failed to protect and promote the rights of the patients.

Findings include:

1. It was determined that the facility failed to ensure that all patients, or their designated representative, receive a written notification of their patient rights (Refer to Tag 0117).

2. It was determined that the facility failed to discharge or seek involuntarily commitment within 48 hours after a patient requested to be discharged (Refer to Tag 0129).

3. It was determined that the facility failed to ensure that its policy regarding consent for treatment is implemented (Refer to Tag 0131).

4. It was determined that the facility failed to inquire whether or not patients have an Advanced Directive upon admission (Refer to Tag 0132).

5. It was determined that the facility failed to ensure that the patients care plan is revised when patients are placed in restraints (Refer to Tag 0166).

6. It was determined that the facility failed to ensure that the restraint policy is implemented (Refer to Tag 0168).

7. It was determined that the facility failed to ensure that there is a restraint order for each patient placed in restraints, as per facility policy (Refer to Tag 0168).

8. It was determined that the facility failed to ensure that the restraint orders are renewed as per facility policy (Refer to Tag 0173).

9. It was determined that the facility failed to ensure that all patients are assessed in accordance with facility policy (Refer to Tag 0175).

10. It was determined that the facility failed to ensure that each applicable employee demonstrates restraint competency (Refer to Tag 0208).

Complaint #NJ00146586

Based on review of one (1) of five (5) medical records (#4), staff interview and review of facility policy and procedure, it was determined that the facility failed to ensure that all patients, or their designated representative, receive a written notification of their patient rights.

Findings include:

Reference: Facility policy, "Patient's Bill of Rights/Hospital Patient Rights" states, " ... POLICY ... [Name of Facility] informs each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. ... A copy of Hospital Patient Rights is given to each patient upon admission. ..."

1. Review of Medical Record #4 on 8/12/2021 lacked evidence of a signed copy of the "Patient Rights and Responsibilities" form. The form states, "The undersigned certifies that s/he has read the foregoing, understands it, accepts its terms, has received a copy of it and is the patient or duly authorized by the patient as their agent to execute the above."

2. On 8/12/2021 at 10:15 AM upon interview with Staff #7, he/she explained that the patient rights are reviewed with patients and/or their representative, and the patient or representative can either sign or give verbal consent that a summary of the patient's rights was provided.

a. The medical record lacked evidence of signature or verbal consent on the patient rights form.

3. The above findings were confirmed by Staff #11

Complaint #NJ00146586

Based on staff interview, medical record review, and review of facility documents, it was determined that the facility failed to discharge or seek involuntarily commitment within 48 hours after a patient requested to be discharged.

Findings include:

Reference: Facility policy titled, "Behavioral Health: Against Medical Advice" states, "II. PROCEDURE: When a patient requests to leave treatment, the following procedure will be followed: 1. The patient is presented with a Request to Withdraw from Treatment Form., the patient. 2. Without a temporary or final court order, the patient must be discharged within 48 hours of the discharge request or at the end of the next working day following the request, whichever is longer. N.J.S.A. 30:4-27.20. 3. The patient's physician or designee is contacted immediately after request is signed, to alert the physician. ...6. If the patient is NOT thought to be suicidal or homicidal by the attending physician, yet, the physician feels that continued hospitalization would be beneficial, the physician will allow the patient to discharge against medical advice. ..."

1. Review of Medical Record #15 on 8/13/2021 revealed the following:

a. Patient #15 was admitted to the facility on 6/25/2021 on a voluntary status.

b. A nursing progress note, dated 6/28/2021 at 1600 stated, "... Client spoke to this nurse about desire to be discharged to [his/her] 'own apartment'/"I got people" and getting [his/her] money on 7/1/21 before the payee receives it/" I don't need PACT. ..." A nursing progress note, dated 6/30/21 at 0528 states, "...Pt [patient] stated that [he/she] wanted to get out of here..."

c. A Nursing Progress note, dated 6/30/2021 at 1505 stated, "...pt was asking when [he/she] was going to be d/c [discharged]. SW [Social Worker] informed PT [he/she] was not going to be d/c today and team will re-evaluate tomorrow. ...Pt informed no d/c for today and team will re-evaluate tomorrow. Pt became agitated and aggressive (punching window at nurses station). SW attempted to de-escalate, however, PT was not easily redirected. .."

d. A Nursing Progress note, dated 6/30/2021 at 1758 stated, " ____[name of patient] was verbally hostile this am. [He/She] was focused on [his/her] discharge. Nurse gave [him/her] Haldol 10, Ativan 2 and benadryl. It was somewhat effective for 2 hours. Patient then began to fixate on discharge..."

e. A Case Management note, dated 7/2/2021 at 1128 stated, "Pt being referred to HCI today for evaluation for possible need to be involuntary."

f. A Nursing Progress Note, dated 7/2/2021 at 1829 stated, "...Patient ate [his/her] breakfast and told MHW that [he/she] will tear up this place if [he/she] isn't released today."

g. A Nursing progress note, dated 7/4/2021 at 1041 stated, "...I just want to go."

2. There was no evidence that Patient #15 was presented with a Request to Withdraw from Treatment form.

3. Patient #15 was Involuntarily committed on 7/7/2021 and was transferred to another facility 9 (nine) days after the patient's initial request to be discharged.

4. The above findings were confirmed with Staff #13.

Complaint #NJ00146586

A. Based on review of one (1) of five (5) medical records (#4) and review of facility policy and procedure, it was determined that the facility failed to ensure that its policy regarding consent for treatment is implemented.

Findings include:

Reference: Facility policy, "Consent for Treatment: Emergency Patients" states, "POLICY: To insure that all patients are cared for expediently and in compliance with existing laws. ... PROCEDURE: 1. Patients who are of legal age, conscious and alert will sign consent for treatment. ... An ongoing effort will be made to obtain consent from parent, legal guardian or other responsible for patient. ..."

1. Review of Medical Record #4 on 8/12/2021 lacked evidence of a signed copy of the "Conditions Of Admission and Authorization For Medical Treatment" form. The form states, "I hereby certify and state that I have read, and that I fully and completely understand the above Conditions of Admission and Authorization for Medical Treatment, and that I have signed this Conditions of Admission and Authorization for Medical Treatment knowingly, freely and voluntarily."

a. The medical record lacked evidence of signature or verbal consent on the consent for treatment form.

2. The above findings were confirmed with Staff #11.


Complaint #NJ00146586

B. Based on staff interview, review of one (1) of one (1) medical records (#8) of patients with a current Do Not Resuscitate (DNR) status, and review of facility policy and procedure, it was determined that the facility failed to ensure that facility policy regarding DNR is implemented.

Findings include:

Reference: Facility policy titled, "Resuscitation Status" states, " ... Guidelines ... 2. Alternate Code Status Alert Forms, both written and electronic, are to be completed for all No Code and Partial Code situations. ...d. When completed, the form is placed on the front page of the patient's chart. 3. Two methods are to be practiced to further identify the Code status of patients. a. stickers are placed in the front of the chart binder. - Purple sticker indicates a "do not resuscitate (DNR)" -Orange indicates a "Partial Code" .. c. When notified of a change in the patient's code status, either "DNR" or "Partial Code" is documented in the nurses notes and communicated in nurse to nurse report. ...A. Guidelines for Reaching No Code/Partial Code Decision ... 3. If the patient is capable, the decision for a No Code/Partial Code status shall be made after discussion between that patient and the physician. ..."

1. On 8/12/2021 at 1:23 PM, review of Medical Record #8 with Staff #11 revealed the following:

a. The patient was admitted to the facility from a Subacute Rehab (SAR) on 8/10/2021 with complaints of profound muscle weakness and lethargy, as well as increased lower extremity edema.

b. The patient had an order placed for Do Not Intubate (DNI) on 8/10/2021 at 6:04 PM.

c. The patient had an order placed for Do Not Resuscitate-Allow Natural Death on 8/11/2021 at 11:43 AM.

(i) The medical record lacked documentation that the physician had a discussion with the patient regarding code status.

2. On 8/12/2021 during a tour of 3 North, review of the patient's medical chart revealed the following:

a. The "Alternate Code Status Alert Form" was in the patients chart but was not filled out.

b. The patient had an orange sticker on the front of the chart indicating "Partial Code" instead of a purple sticker which would indicate a "DNR."

(i) The patients chart lacked the necessary identification to identify the patient as a DNR.

3. On 8/13/2021 at 2:12 PM, Staff #11 confirmed that the "Alternate Code Status Form" is not available electronically.

4. The above findings were confirmed with Staff #1, Staff #2 and Staff #3.

Complaint #NJ00146586

Based on review of 5 of 15 medical records (#10, #11, #12, #13 and #14), staff interview, review of facility documents, it was determined that the facility failed to inquire whether or not patients have an Advanced Directive upon admission.

Findings include:

1. Review of Medical Record #10 on 8/13/2021 revealed the following:

a. Patient #10 was admitted on 8/7/2021.

b. The "Condition of Admission and Authorization for Medical Treatment" form, line IV., states, "...Do you have a Living Will? Durable Power of Attorney?" Neither yes or no was checked.

2. Review of Medical Record #11 on 8/13/2021 revealed the following:

a. Patient #11 was admitted on 5/20/2021.

b. The "Condition of Admission and Authorization for Medical Treatment" form, line IV., states, "...Do you have a Living Will? Durable Power of Attorney?" Neither yes or no was checked.

3. Review of Medical Record #12 on 8/13/2021, revealed the following:

a. Patient #12 was admitted on 8/10/2021.

b. The "Condition of Admission and Authorization for Medical Treatment" form, line IV., states, "...Do you have a Living Will? Durable Power of Attorney?" Neither yes or no was checked.

4. Review of Medical Record #13 on 8/13/2021 revealed the following:

a. Patient #13 was admitted on 11/17/20.

b. The "Condition of Admission and Authorization for Medical Treatment" form, line IV., states, "...Do you have a Living Will? Durable Power of Attorney?" Neither yes or no was checked.

5. Review of Medical Record #14 on 8/13/2021 revealed the following:

a. Patient #14 was admitted on 8/11/2021.

b. The "Condition of Admission and Authorization for Medical Treatment" form, line IV., states, "...Do you have a Living Will? Durable Power of Attorney?" Neither yes or no was checked.

6. Upon interview, Staff #3 and Staff #8 confirmed the above findings.

Complaint #NJ00146586

Based on staff interview, review of four (4) of five (5) medical records (#3, #4, #5 and #15) of patients in restraints, and review of facility policy and procedure, it was determined that the facility failed to ensure that the patients care plan is revised when patients are placed in restraints.

Findings include:

Reference: Facility policy titled, "Restraint and Seclusion" states, " ...I. Documentation Each episode of restraint is documented in the patient's medical record, consistent with policies and procedures. ...ix) Revisions to the plan of care. ..."

1. On 8/12/2021 at 11:53 AM, during medical record review, the following was revealed:

a. Review of Medical Record #3 indicated that the patient was placed in bilateral (B/L) soft wrist restraints on 6/12/2021 at 3:08 PM.

(i) The medical record lacked evidence of restraint documentation in the patients care plan.

b. Review of Medical Record #4 indicated that the patient was placed in B/L soft wrist restraints on 7/28/2021 at 12:00 AM.

(i) The medical record lacked evidence of restraint documentation in the patients care plan.

c. Review of Medical Record #5 indicated that the patient was placed in B/L soft wrist restraints on 5/31/2021 at 1:00 PM.

(i) The medical record lacked evidence of restraint documentation in the patients care plan.

d. Review of Medical Record #15 on 8/13/2021, indicated that the patient was placed in 4-point mechanical hard restraints on 7/5/2021 from 0325 to 0900.

(i) The medical record lacked evidence that the Plan of Care was updated post restraints.

2. The above findings were confirmed by Staff #11



43214

Complaint #NJ00146586

A. Based on review of one (1) of one (1) medical record (#15) of patients with violent restraint episodes, staff interview and review of facility documents, it was determined that the facility failed to ensure that the restraint policy is implemented.

Findings include:

Reference: Facility policy titled, "Restraint and Seclusion" states, "...E. ORDERS FOR RESTRAINT...II) In an emergency application situation, a RN [Registered Nurse] who has documented Restraint and Seclusion competency may initiate the application of restraint or seclusion prior to obtaining an order from a LIP [Licensed Independent Practitioner]. In this event the order must be obtained either during the emergency application of the restraint or seclusion or immediately (within a few minutes) after the restraint or seclusion has been applied. ...Each episode of restraint or seclusion must be initiated in accordance with an order by a physician or other LIP. ..."

1. Review of Medical Record #15 on 8/13/2021 revealed the following:

a. Patient #15 was placed in 4-point mechanical hard restraints on 7/5/2021.

b. A Nursing Note, dated 7/5/2021 at 0325 stated, "Has been grossly disruptive to the unit as evidenced by refusing to stay out of patients' rooms, taking items [sic] from other patients' rooms, throwing items in hallway, hanging on glass in nurses' station, verbally threatening staff, posturing as if ready to fight.[name of doctor] was called and orders for 4-point restraints and new medications orders were obtained."

(i) There was no evidence of a restraint order at 0325 when the restraint was initiated or shortly after.

c. Upon interview, Staff #11 stated that the "Provider Restraint/Seclusion Order" form signed on 7/5/2021 at 0900 was the restraint order for the restraint episode initiated at 0325.

d. On the "Provider Restraint/Seclusion Order" form signed on 7/5/2021 at 0900, under the section identified as, Type of Restraint Ordered, it stated, "Restraint: 4-point Mechanical- Hard Date/time: In 7/5/21 0325 Date/Time: out 7/5/21 0900."

(i) Patient #15 was in restraints for five (5) hours and thirty-five (35) minutes before an order for the restraint was obtained.

2. The above findings were confirmed with Staff #11.


43214

Complaint #NJ00146586

B. Based on staff interview, review of two (2) of four (4) medical records (#4 and #6) of patients in non-violent restraints, and review of facility policy and procedure, it was determined that the facility failed to ensure that there is a restraint order for each patient placed in restraints, as per facility policy.

Findings include:

Reference: Facility policy titled, "Restraint and Seclusion" states," ... E. ORDERS FOR RESTRAINT i.) The physician or Licensed Independent Practitioners {LIP} responsible for the care of the patient is authorized to order a restraint. " ... Orders should: a) Be for each use of the restraints and related to a specific episode of the patient's behavior and not for an unspecified future time or episode. b) At [name of facility] the following categories of LIPs are allowed to order restraint or seclusion: 1. Physicians, Nurse Practitioners, Physician's Assistant. ii) In an emergency application situation, a RN who has documented Restraint and Seclusion competency may initiate the application of restraint or seclusion prior to obtaining an order from a LIP. In this event the order must be obtained either during the emergency application of the restraint or seclusion or immediately (within a few minutes) after the restraint or seclusion has been applied. ..."

1. On 8/12/2021 at 11:53 AM, during medical record review, the following was revealed:

a. Review of Medical Record #4 indicated that the patient was placed in B/L (bilateral) soft wrist restraints on 7/28/2021 at 12:00 AM.

b. Documentation in the Nursing Restraint Assessment and Monitoring Flowsheet indicated that restraints were placed on 7/28/2021 at 12:00 AM.

c. The physician order for B/L soft wrist restraints was placed on 7/31/2021 at 12:00 AM.

(i) The medical record lacked evidence that an order was placed when the restraints were initiated.

d. Review of Medical Record #6 indicated that the patient was placed in B/L soft wrist restraints on 7/31/2021 at 9:00 PM.

e. The Nursing Progress note from 8/1/2021 at 8:00 AM states " ... Night shift placed B/L soft wrist restraints during the night with positive results per MD [Medical Doctor] order. ..."

f. The physician order for B/L soft wrist restraints was placed on 8/1/2021 at 9:06 AM.

(i) The medical record lacked evidence that an order was placed when the restraints were initiated.

2. The above findings were confirmed by Staff #11.

Complaint #NJ00146586

Based on staff interview, review of two (2) of four (4) medical records (#5 and #6) of patients in restraints, and review of facility policy and procedure, it was determined that the facility failed to ensure that the restraint orders are renewed as per facility policy.

Findings include:

Reference: Facility policy titled, "Restraint and Seclusion" states, " ... E. Orders For Restraint i.) The physician or Licensed Independent Practitioners {LIP} responsible for the care of the patient is authorized to order a restraint. ... F. NON-VIOLENT/NON SELF DESTRUCTIVE RESTRAINT/SECLUSION RENEWAL ORDERS Each order for restraint to ensure the physical safety of non-violent or non-self destructive patient must be renewed: e.g. Once every 24 hours. ..."

1. On 8/12/2021 at 11:53 AM during medical record review, the following was revealed:

a. Review of Medical Record #5 indicated that the patient was placed in B/L (bilateral) soft wrist restraints from 5/3/2021 until 5/10/2021.

b. Review of the restraint orders revealed that B/L soft wrist restraints were ordered on 5/3/2021, 5/4/2021, 5/9/2021 and 5/10/2021.

(i) The medical record lacked evidence of a new order for restraints every 24 hours as per facility policy.

c. Review of Medical Record #6 indicated that the patient was placed in B/L soft wrist restraints from 7/31/2021 until 8/4/2021.

d. Review of the restraint orders revealed that B/L soft wrist restraints were ordered on 8/1/2021 and 8/3/2021.

(i) The medical record lacked evidence of a new order for restraints every 24 hours as per facility policy.

2. The above findings were confirmed by Staff #11.

Complaint #NJ00146586

Based on review of one (1) of one (1) medical record (#15) pertaining to the use of violent restraints, staff interview, and facility document review, it was determined that the facility failed to ensure that all patients are assessed in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Restraint and Seclusion" states, "...iii) Immediately after restraints are applied, a qualified Registered Nurse makes an assessment to ensure restraints were: -properly applied -applied so as not to cause patient harm or pain. iv) A qualified Registered Nurse must assess the patient at established timeframes. Assessment, as appropriate to the type of restraints or seclusion, includes:
-signs of injury associated with the application
-nutrition/hydration
-circulation and range of motion in the extremities
-vital signs
-hygiene and elimination
-physical and psychological status and comfort
-cognitive functioning
-readiness for discontinuation of restraint or seclusion.
-Ongoing monitoring is performed. Monitoring includes, but is not limited to: the physical and emotional well being of the patient
-that the patient's rights, dignity and safety are maintained
-whether less restrictive methods are possible
-changes in the patient's behavior or clinical condition needed to initiate the removal of restraints
-whether the restraint has been appropriately applied, removed, or reapplied.
v) Care is provided at least every 2 hours to include:
-offer of fluids/nourishment
-hygiene care as required
-toileting as required
-release of extremities and range of motion exercises provided."

1. Review of Medical Record #15 on 8/13/2021 revealed the following:

a. Patient #15 was placed in 4-point mechanical hard restraints on 7/5/2021 from 0325 to 0900 (5 hrs and 35 min).

b. On the Provider Restraint/Seclusion Order, the box marked "other staff-1:1 continuous observation with q [every] 15 min [minute]-care, fluid, toilet, vitals" was checked.

c. There was no evidence that Patient #15 was offered fluid/nourishments, hygiene care, toileting. There was no evidence that vital signs were obtained every 15 minutes.

d. There was no evidence that range of motion was performed while Patient #15 was in restraints.

e. There was no evidence that Patient #15 was assessed to ensure adequate circulation was maintained.

2. Upon interview, Staff #11 confirmed the above findings.

Complaint #NJ00146586

Based on review of (2) two of (2) two employee files (Staff #14 and Staff #16), staff interview and document review, it was determined that the facility failed to ensure that each applicable employee demonstrates restraint competency.

Findings include:

Reference: Facility policy titled, "Restraint and Seclusion" states, "...VI. PROCEDURES: a. STAFF TRAINING AND COMPETENCE Our facility ensures staff, who have direct patient care responsibilities, including contract or agency personnel, receive training and are competent to minimize the use of restraint and seclusion, and to use them safely when their use is indicated. ...Our facility educates and assesses the competence of staff in minimizing the use of restraint and seclusion prior to participation in any use of restraint or seclusion, as part of orientation and on a periodic basis in order to use them safely, including:...vi) the initiation, safe application, and removal of restraints to include monitoring
and reassessment; ..."

1. Staff #14 was assigned to the Behavioral Heath Unit. Upon review of Staff #14's training record on 8/13/2021, there was no evidence that Staff #14 demonstrated competency in the safe application and removal of restraints.

2. Staff #16 was assigned to the Behavioral Health Unit. Upon review of Staff #16's training record on 8/13/2021, there was no evidence that Staff #16 demonstrated competency in the safe application and removal of restraints.

Complaint #NJ00146586

Based on staff interviews and review of facility documents, it was determined the facility failed to ensure an effective infection control program to prevent and control the spread of infectious diseases.

Findings include:

1. It was determined that the facility failed to ensure that a qualified Infection Control Professional (ICP) is designated to oversee the facility's Infection Control Program (Refer to Tag 0748).

Complaint #NJ00146586

Based on staff interviews, review of personnel files and document review, it was determined that the facility failed to ensure that a qualified Infection Control Professional (ICP) is designated to oversee the facility's Infection Control Program.

Findings include:

1. On 9/27/2021 at 10:10 AM, during an interview, Staff #1 and Staff #2 confirmed that the facility's ICP resigned in December 2020, and the facility does not have a current ICP to oversee the facility's Infection Control Program.

a. Staff #1 and Staff #2 stated that until a new ICP is hired, they along with the Infectious Disease Physician are overseeing the facilities Infection Control Program.

b. The job description for the Infection Preventionist was requested and reviewed. The job description indicates that the position qualifications include experience in infection control.

(i) The personnel files for Staff #1 and Staff #2 were requested and reviewed. The personnel files for Staff #1 and Staff #2 lacked evidence of Infection Prevention and Control education and training.

(ii) Upon interview, Staff #1 and Staff #2 confirmed that neither have Infection Prevention and Control education or training.

c. A request was made for the Infection Prevention and Control Committee meeting minutes for the last six months. Staff #1 confirmed that the Infection Prevention and Control Committee had not met between September 2020 and August 2021, and was unable to provide meeting minutes for the 4th quarter of 2020 and the 1st and 2nd quarter of 2021.

d. The facility failed to ensure a qualified individual is designated to oversee the facility's Infection Control Program.

2. The above findings were confirmed by Staff #1 and Staff #2.