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Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure restraint orders were reordered every 24 hours for non-violent or non-self-destructive patient restraint use in two of two applicable medical records reviewed (MR17 and MR18).

Findings include:

Review on March 8, 2018, of the facility's "Patient Rights and Responsibilities" policy, last revised October 2016, revealed "Purpose: It is the purpose of this policy to promote and protect the interest and well being of patients/residents being served by Susquehanna Health, even when the interests of the patient/resident may be in opposition to the interest of the hospital ... Policy: Susquehanna Health has established specific 'listings' of rights and responsibilities. ... Procedure: Susquehanna Health has developed various ways in which to inform patients/residents of their rights and responsibilities. ... 1. Prominent public displays of rights and responsibilities. 2. Susquehanna Health's Patient/Resident Rights and Responsibilities brochure is located in many areas and is available to anyone on request. 3. Each hospital inpatient and skilled nursing resident receives a brochure entitled Patient/Resident Rights and Responsibilities upon admission or as soon as possible after admission. ...".

Review on March 8, 2108 of facility "UPMC Susquehanna Patient Rights and Responsibilities" brochure, last reviewed May 18, 2017, revealed "Our mission is to extend God's healing love by improving the health of those we serve. ... Treatment Your rights are: ... To be free from the use of restraints and/or seclusion unless clinically necessary. ... "

Review on March 8, 2018, of the facility's "Restraint and Seclusion" policy, last revised January 18, 2018, revealed "... Purpose: To assure the right of the patient to be free from restraints or seclusion of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. Hospital Specifics: 1. Definitions A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. ... D. Medical Restraint is all restraint other than Behavioral Restraint ... G. Non-Violent Behavior: Examples - Patient pulling our his/her tubes, trying to disconnect from a ventilator, and is a danger to self. Jeopardizing their immediate physical well-being. ... 9. Medical Restraint ... B. Physician Order ... 6. Continued use is authorized by the ordering physician performing an in-person assessment of the restrained patient at least every 24 hours, at which time restraint will be either reordered or discontinued. ...".

Review on March 8, 2018, of MR17 revealed orders for bilateral wrist restraints on December 16, 2017, at 8:14 AM, December 17, 2017, at 4:00 PM and December 18, 2017 at 10:00 PM. The bilateral wrist restraints were used continually December 16-19, 2017.

Interview with EMP2 and EMP7 on March 8, 2018, at 11:50 AM, confirmed bilateral wrist restraints were ordered for MR17 with orders written on December 16, 2017 at 8:14 AM, December 17, 2017 at 4:00 PM and December 18, 2017 at 10:00 PM. EMP2 and EMP7 confirmed the bilateral wrist restraints were used continually December 16-19, 2017. EMP2 and EMP7 confirmed the orders for December 17 and December 18, 2017, were not within 24 hours of use.

Review on March 8, 2018 of MR18 revealed orders for bilateral wrist restraints on October 13, 2017, at 9:28 PM, October 14, 2017, at 10:34 PM and October 17, 2017, at 5:38 AM and 11:28 AM. The bilateral wrist restraints were used continually October 13-18, 2017. There were no orders for bilateral wrist restraints on October 15 and October 16, 2017.

Interview with EMP2 and EMP7 on March 8, 2018, at 12:15 PM, confirmed bilateral wrist restraints were ordered for MR18 on October 13, 2017, at 9:28 PM, October 14, 2017, at 10:34 PM and October 17, 2017, at 5:38 AM and 11:28 AM. The bilateral wrist restraints were used continually October 13-18, 2017. EMP7 confirmed there were no orders for bilateral wrist restraints on October 15 and October 16, 2017.

Based on review of facility documents, medical records (MR), and staff interview (EMP), is was determined the facility failed to ensure vital signs were obtained as required by facility policy for patients receiving blood transfusions; failed to ensure there was documentation if the blood was infused by pump or gravity; failed to ensure the amount of blood transfused was documented; and failed to ensure there was documentation when the blood transfusion was completed in two of four applicable medical records reviewed (MR1 and MR4).

Findings include:

Review on March 6, 2018, of the facility's "Blood Products Administration Protocol," last revised January 2017, revealed "... Purpose: To safely administer blood and blood products and to outline the responsibilities involved in the area of the patient receiving transfusion therapy. Policy: ... I. General Guidelines ... D. Use volumetric infusion pump to infuse all blood products including Immune Gamma Globulin, except in emergency situations or during procedures, including hemodialysis. ... VII. Transfusion Procedure ... Baseline VS [vital signs] including a temperature are obtained within 15 minutes prior to transfusion. ... B. With each unit: ... 5. Repeat vital signs (TPR-BP) [temperature, pulse, respiration - blood pressure] 15 minutes after initiation of blood product and compare to baseline. C. 1. If there is no sign of a transfusion reaction, adjust flow to prescribed rate. 2. Repeat vital signs at 30 minutes, then every hour throughout the administration, and at the completion of the transfusion. 3. On all inpatients, do vital signs one-hour post transfusion. ... VIII. Documentation A. Guidelines for Use of Blood Bank Form ... 3. Vital signs, assessment and response to transfusion are documented in the patient's electronic medical record. ... 7. The person discontinuing the transfusion records the amount of product infused if the entire product was not used. ... 9. Document VS and I/O [intake/output] on appropriate form. 10. Document administration via volumetric IV [intravenous] infusion pump or gravity and rate on VS form. ...".

Interview on March 6, 2018, with EMP2 revealed facility's electronic medical record (EMR) documented the initiation of blood transfusions as the time the blood transfusion was logged into the EMR.

Review on March 6, 2018 of MR1 revealed a blood transfusion order on January 24, 2018, for two units of blood. VS were obtained at 10:07 AM and 11:41 AM. The blood transfusion was initiated at 11:41 AM. The next VS were documented at 1:29 PM.

VS were obtained at 2:20 PM and a second blood transfusion was initiated at that time. VS were obtained at 2:48 PM. The next set of VS was at 6:41 PM.

There was no documentation if the blood was infused by pump or gravity. There was no documentation of the amount of blood infused. There was no documentation when the blood transfusions were completed.

Interview with EMP2 on March 6, 2018, at 10:20 AM, confirmed MR1 revealed a blood transfusion order on January 24, 2018, for two units of blood. VS were obtained at 10:07 AM and 11:41 AM. The blood transfusion was initiated at 11:41 AM. The next VS were documented at 1:29 PM. EMP2 confirmed VS were obtained at 2:20 PM, and a second blood transfusion was initiated at that time. VS were obtained at 2:48 PM. The next set of VS was at 6:41 PM. EMP2 confirmed there was no documentation if the blood was infused by pump or gravity. There was no documentation of the amount of blood infused. There was no documentation when the blood transfusion was completed.

Review on March 7, 2018, of MR3 revealed a blood transfusion order on February 16, 2018, for two units of blood. VS were obtained on February 17, 2017, at 00:02 AM and 00:58 AM. The blood transfusion was initiated at 00:58 AM.

VS were obtained at 1:13 AM. The second blood transfusion was initiated at that time. VS were obtained at 1:29 AM and next at 5:02 AM.

There was no documentation if the blood was infused by pump or gravity. There was no documentation of the amount of blood infused. There was no documentation when the blood transfusion was completed.

Interview with EMP2 on March 7, 2018, at 8:30 AM, confirmed MR3 revealed a blood transfusion order on February 16, 2018, for two units of blood. VS were obtained on February 17, 2017, at 00:02 AM and 00:58 AM. The blood transfusion was initiated at 00:58 AM. EMP2 confirmed VS were obtained at 1:13 AM. The second blood transfusion was initiated at that time. VS were obtained at 1:29 AM and next at 5:02 AM. EMP2 confirmed there was no documentation if the blood was infused by pump or gravity. There was no documentation of the amount of blood infused. There was no documentation when the blood transfusions were completed.

EMP2 confirmed the VS were not followed as per protocol for MR1 and MR3.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure consent for treatment was completed for four of 20 non-emergent medical records reviewed (MR1, MR5, MR9 and MR13).

Findings include:

Review on March 8, 2018, of the facility's "Patient Rights and Responsibilities" policy, last revised October 2016, revealed "Purpose: It is the purpose of this policy to promote and protect the interest and well being of patients/residents being served by Susquehanna Health, even when the interests of the patient/resident may be in opposition to the interest of the hospital ... Policy: Susquehanna Health has established specific 'listings' of rights and responsibilities. ... Procedure: Susquehanna Health has developed various ways in which to inform patients/residents of their rights and responsibilities. ... 1. Prominent public displays of rights and responsibilities. 2. Susquehanna Health's Patient/Resident Rights and Responsibilities brochure is located in many areas and is available to anyone on request. 3. Each hospital inpatient and skilled nursing resident receives a brochure entitled Patient/resident Rights and Responsibilities upon admission or as soon as possible after admission. ...".

Review on March 8, 2108 of facility "UPMC Susquehanna Patient Rights and Responsibilities" brochure, last reviewed May 18, 2017, revealed "Our mission is to extend God's healing love by improving the health of those we serve. ... Involvement Your rights are: ... To give your consent for any treatment or procedure before the treatment or procedure is started except in emergencies. ...".

Review on March 8, 2018, of the facility's "Informed Consent and General Consent for Treatment" policy, last revised May 2017, revealed "Purpose: To distinguish the difference between informed consent for invasive/surgical procedures and the general consent for medical treatment. To establish guidelines for staff when obtaining consent. Policy: ... It is the policy of UPMC Susquehanna that a general Consent for Treatment is signed at points of entry or admission. The signing of this form also acknowledges the patient or authorized decision-maker received information regarding financial responsibility, release of medical information, personal valuables; and Patient Rights, Grievance and Notice of Privacy Practices brochures. ... General Consent for Treatment: Responsibility- It is the responsibility of every registration clerk at every point of entry to obtain a signed Consent for Treatment form prior to patient services and to provide the brochures Patient Rights and Responsibilities, Patient Complaint/Grievance Process and Notice of Privacy Practices to the patient or authorized decision maker. This includes direct admissions. It is the responsibility of every Emergency Department (ED) registration clerk to obtain a signed consent for treatment form prior to treatment or as soon as possible after the medical screening exam and necessary stabilization and to provide the brochures Patient Rights and Responsibilities, Patient Complaint/Grievance Process and Notice of Privacy Practices to the patient or authorized decision maker. This includes direct admissions. ..."

Review of the facility's "UPMC Susquehanna Health Consent For Treatment" form revealed an area for the Patient Signature, date and time; Patient's Agent, Representative, or Legal Guardian Signature, Relationship to Patient, date and time; and Hospital Witness Signature, date and time, under the Consent for Treatment section.

Review of the facility's "Susquehanna Health Consent For Treatment" form revealed an area for the Patient Signature, date and time; Patient's Agent, Representative, or Legal Guardian Signature, Relationship to Patient, date and time; and Hospital Witness Signature, date and time, under the Consent for Treatment section.

Review on March 6, 2018, of MR1 revealed the patient was admitted on January 7, 2018, from the Emergency Department (ED), for tachycardia and gastrointestinal diagnoses, in stable condition. There was no documentation the "Susquehanna Health Consent For Treatment" or the "UPMC Susquehanna Consent For Treatment" was completed.

Interview with EMP2 on March 6, 2018, at approximately 10:20 AM, confirmed MR1 was admitted on January 7, 2018, from the Emergency Department (ED), for tachycardia and gastrointestinal diagnoses, in stable condition. EMP2 confirmed the was no facility "Susquehanna Health Consent For Treatment" or "UPMC Susquehanna Consent For Treatment" form completed for MR1.

Review on March 7, 2018, of MR5 revealed the patient admitted to the facility on November 12, 2017, to the Joint Unit, as standard of care post procedure. MR5's "Susquehanna Health Consent for Treatment" revealed a verbal/phone consent to treat was obtained from the patient's son. There was no documentation of a second witness for listening and hearing the verbal approval from the patient's son.

Interview with EMP2 on March 7, 2018, at approximately 9:30 AM, confirmed the patient was admitted to the facility on November 12, 2017, to the Joint Unit, as standard of care post procedure. EMP2 confirmed the "Susquehanna Health Consent for Treatment" revealed a verbal/phone consent to treat was obtained from the patient's son, and there was no documentation of a second witness for listening and hearing the verbal approval from the patient's son. EMP2 confirmed it was the facility's standard practice to have two witnesses listen to a verbal approval for treatment or a procedure and document they heard the approval.

Review on March 8, 2018, of MR9 revealed the patient was admitted on November 11, 2017 from the ED, for respiratory diagnoses, in stable condition. MR9 revealed no facility "Susquehanna Health Consent For Treatment" or "UPMC Susquehanna Consent For Treatment" form was completed.

Interview with EMP2 on March 8, 2018, at approximately 9:00 AM, confirmed MR9 was admitted on November 11, 2017, from the ED, for respiratory diagnoses, in stable condition. EMP2 confirmed there was no facility "Susquehanna Health Consent For Treatment" or "UPMC Susquehanna Consent For Treatment" form completed.

Review on March 8, 2018, of MR13 revealed the patient was admitted on December 16, 2017, to the ED for hallucinations and discharged home in stable condition. MR13 revealed the patient signed the "UPMC Consent For Treatment" form. There was no documentation of the time the patient signed the consent. There was no documentation of the time the facility staff witnessed the patient's signature.

Interview with EMP2 on March 8, 2018, at approximately 11:00 AM, confirmed MR13 was admitted on December 16, 2017, to the ED for hallucinations; the patient signed the "UPMC Consent For Treatment" form; there was no documentation of time the patient signed the consent; and there was no documentation of the time the facility staff witnessed the patient's signature.