HospitalInspections.org

Based on document review and interview, it was determined that for 3 of 6 (Pt #2, 5, and 6) clinical records reviewed for advance directives, the Hospital failed to ensure all patients were allowed to formulate advance directives.

Findings include:

1. Hospital policy entitled, "Patient Rights/Restriction of Rights," (revised 10/15) required, "I. Policy: On admission to the Facility and during the patient's hospitalization, the patient will be informed of his/her rights according to federal and state rules and regulations."

2. Hospital policy entitled, "Advanced Directives," (effective 12/15) required, "...II: Procedure: A. The Assessment and Referral Department will inquire of all patients...whether they have a medical Advance Directive or want information...B. The Hospital's advance directive policy respects the right of the patient to make their own health care decisions..."

3. The clinical record of Pt #2 was reviewed on 4/19/16. Pt #2 was a 31 year male admitted on 4/6/16 with a diagnosis of psychosis. Pt #2's clinical record lacked documentation as to whether he had an advance directive or wanted information regarding an advance directive.

4. The clinical record of Pt #5 was reviewed on 4/19/16. Pt #5 was a 29 year female admitted on 4/16/16 with a diagnosis of psychosis. Pt #5's clinical record lacked documentation as to whether she had an advance directive or wanted information regarding an advance directive.

5. The clinical record of Pt #6 was reviewed on 4/19/16. Pt #6 was a 32 year female admitted on 4/15/16 with a diagnosis of psychosis. Pt #6's clinical record lacked documentation as to whether she had an advance directive or wanted information regarding an advance directive.

6. The Nursing Supervisor (E #8) stated during an interview on 4/19/16 at approximately 9:35 AM that the patients did not have documentation of advance directive information as required.

Based on document review and interview, it was determined that for 4 of 5 days (4/15, 4/16, 4/17 and 4/18/16) reviewed the Hospital failed to ensure safety checks were completed every shift as required. This potentially affected a maximum of 36 patients on the 3rd floor Intensive Treatment Unit (ITU).

Findings include:

1. Hospital policy entitled, "Safety Rounds," (revised 10/15) required, "...II. Procedure: A. During each shift, a staff member will survey the unit using the safety checklist for their unit...."

2. On 4/19/16 at approximately 11:30 AM the 3rd floor ITU Safety Checklists were reviewed. The Checklists failed to include safety checks being conducted every shifty as required; 4/14/16 lacked day shift (7:00 AM - 3:30 PM); 4/16/16 lacked night shift (11:00 PM to 7:30 AM); 4/17/16 lacked day shift (7:00 AM to 3:30 PM); and 4/18/16 lacked day shift (7:00 AM to 3:30 PM and night shift 11:00 PM to 7:30 AM).

3. The Nursing Supervisor stated during an interview on 4/19/16 at approximately 11:20 AM that the safety checks were not completed every shift.

Based on document review and interview, it was determined that for 1 of 2 (Pt #9) clinical records reviewed of a patient with restraint devices, the Hospital failed to ensure the patient was monitored every 15 minutes as required.

Findings include:

1. Hospital policy entitled, "Use of Restraint & Seclusion," (revised 6/15) required, "...II. Procedure...C. Restraint Monitoring...2. The staff member will document observations every (15) minutes...indicating that continuous monitoring is maintained..."

2. The clinical record of Pt #9 was reviewed on 4/19/16. Pt #9 was a 19 year old female admitted on 3/21/16 with a diagnosis of major depression. Pt #9's clinical record contained documentation of restraint usage on 3/22/16. The clinical record lacked documentation of observation checks being performed every 15 minutes as required.

3. The Nursing Supervisor stated during an interview on 4/19/16 at approximately 11:20 AM that the patient's record lacked documentation of the checks being completed.