HospitalInspections.org

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that for 1 of 2 ( Pt. #1) patients under state guardianship, the Hospital failed to ensure the guardian was notified and consented for an invasive procedure.

Findings include:

1. The Hospital policy was reviewed on 9/8/10 at approximately 9:15 AM. The policy required, "RHC will honor the decision of an agent or surrogate decision maker on behalf of a patient who is not capable... Working with the Guardian. RHC staff will cooperate with the court appointed guardian to establish a suitable medical treatment plan and or/discharge plan for the patient."

2. The clinical record of Pt. #1 was reviewed on 9/8/10 at approximately 9:30 AM. Pt. #1 was a 67 year old male who was admitted to the telemetry unit on 8/7/10 at 1:00 AM with diagnosis of Chest Pain and Atrial Fibrillation. A "Family Representative Documentation Form" signed by Pt. #1 on 8/7/10, contained the name of a state guardian with the following written note above the name: "Contact before any procedure." The clinical record contained a "Consent for Surgical, Invasive, Therapeutic or Diagnostic Procedure and Administration of Anesthesia" form signed by Pt. #1 on 8/10/10. The consent form and the clinical record lacked documentation that Pt. #1's state guardian was notified of the procedure or that a consent was obtained from the state guardian.

3. The Social Worker (SW) was interviewed on 9/8/10 at approximately 11:30 AM. The SW stated that an order to refer Pt. #1 to a literacy program to learn to read and write was written on 8/12/10. The SW indicated that during an interview with Pt. #1 on 8/12/10, he stated he was illiterate, had never gone to school, and has had a guardian for 30 years. The SW stated she called the guardian to provide the literacy referral and during the conversation the guardian asked the SW who signed the consent form for the pacemaker placement procedure, and when the SW stated "the patient" the guardian responded, " you realize he cannot consent."

4. The above findings were confirmed with the Vice President of Patient Care Services during interview on 9/8/10 at approximately 1:30 PM

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that, for 3 of 7 (Pt. #s 7, 8, and 10) clinical records reviewed for patients who were restrained, the Hospital failed to ensure patients were assessed/evaluated for release from restraints and that restraints were discontinued at the earliest possible time.

Findings include:

1. Hospital policy #1259.75 entitled, "Restraints and and Protective Devices-Usage for Non-Behavioral Health Units," reviewed on 9/8/10 at approximately 10:00 A.M. required, "Documentation... The patient's response to the intervention(s) used, including the rationale for continued use or readiness for release."

2. The clinical record for Pt. #7 reviewed on 9/8/10 at approximately 10:33 A.M., included that this was a 75-year-old female admitted on 7/5/10 with a diagnosis of Acute Respiratory Distress. The record included documentation of physicians' orders for non-behavioral restraints on 7/5/10 at 2:20 P.M. and 7/6/10 at 10:00 P.M. The restraint assessment/monitoring documentation continued from 7/5/10 at 8:00 P.M.-7/7/10 at 6:00 P.M. indicating that restraints were on and in good condition. The record included that Pt. #7 expired on 7/8/10 at 1:10 A.M. The record lacked documentation to indicate that the patient was evaluated for release from restraints, and when the restraints were discontinued.

3. The clinical record for Pt. #8 reviewed on 9/8/10 at approximately 11:00 A.M., included that this was an 85-year-old male admitted on 7/13/10 with multiple diagnoses including Respiratory Distress, Pneumonia, Altered Mental State, and Acute Renal Failure. The record included documentation of physicians' orders for non-behavioral restraints on 7/14/10 at 12:35 A.M. through 7/17/10 at 1:00 A.M. The restraint assessment/monitoring documentation continued from 7/14/10 -7/17/10 at 6:00 A.M. indicating that restraints were on and in good condition. The record included that Pt. #8 was discharged to Hospice on 7/17/10. The record lacked documentation to indicate that the patient was evaluated for release from restraints, and when the restraints were discontinued.

4. The clinical record for Pt. #10 reviewed on 9/8/10 at approximately 11:54 A.M., included that this was a 28-year-old male admitted on 7/21/10 with a diagnosis of Head Trauma. The record included documentation of a physician's order for non-behavioral restraints on 7/21/10 at 3:15 A.M. The restraint assessment/monitoring documentation continued from 5:00 A.M. - 6:00 A.M. on 7/21/10 indicating that restraints were on and in good condition. The record included that Pt. #8 was discharged home on 7/21/10 at 5:30 P.M. The record lacked documentation to indicate that the patient was evaluated for release from restraints, and when the restraints were discontinued.

5. The above findings were confirmed by the 3 South Nursing Director on 9/8/10 at approximately 1:00 P.M.

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that, for 1 of 1 (Pt. #7) clinical record reviewed of a patient who expired within 24 hours of being in restraints, the Hospital failed to ensure the information was reported as required.

Findings include:

1. Hospital policy #1259.75 entitled, "Restraints and Protective Devices-Usage for Non-Behavioral Health Units," reviewed on 9/8/10 at approximately 10:00 A.M. required, "The hospital... will report the following information to Centers for Medicare and Medicaid Services... Each death that occurs while a patient is in restraint or seclusion... Each death that occurs within twenty-four hours after the patient has been removed from restraint or seclusion...Date and time the death was reported to Centers for Medicare and Medicaid Services should be documented."

2. The clinical record for Pt. #7 reviewed on 9/8/10 at approximately 10:33 A.M., included that this was a 75-year-old female admitted on 7/5/10 with a diagnosis of Acute Respiratory Distress. The record included documentation of physicians' orders for non-behavioral restraints on 7/5/10 at 2:20 P.M. and 7/6/10 at 10:00 P.M. The restraint assessment/monitoring documentation continued from 7/5/10 at 8:00 P.M.-7/7/10 at 6:00 P.M. indicating that restraints were on and in good condition. The record included that Pt. #7 expired on 7/8/10 at 1:10 A.M. The record lacked documentation of date and time the death was reported to Centers for Medicare and Medicaid Services.

3. The above findings were confirmed with the Vice President of Patient Care Services (VPPCS) and the Director of Performance Distinction (DPD), on 9/8/10 at approximately 2:00 P.M. They indicated that the Hospital does not currently have a log of patients who have died in restraints, or an effective mechanism in place to track which patients have been reported to CMS.