HospitalInspections.org

Based on review of 13 medical records along with policies and procedures and other documentation, interviews with staff, and observations of care during an unannounced complaint survey ending on 5/16/19, it was determined that the hospital was out of compliance with the condition of Patient Rights related to:
1. Failing to adequately communicate the investigation and outcome of grievances (A-122).
2. Failing to abide by pt. #4's decisions about discharge (A-131).
3. Failing to provide for privacy during care for pt. #8 (-143).
4. Maintaining violent restraints on one patient (pt. #13) without adequate documentation of justifying behaviors; failing to obtain MD orders and face to face; failing to release restraints when patient 13 no longer met behavioral criteria indicating need for violent restraints, and failing to document monitoring and care for several periods of time (A-168, A-172, A-174, A-175, and A-179).

Based on review of 7 grievances it was determined the hospital failed to provide written final resolution letters for 2 of the 7 grievances reviewed and failed to inform 3 out of 7 grievances when a complaint was to take greater than 7 days as per hospital policy.

Per hospital policy titled, "Patient Complaints and/or Allegations for Violations of Patient Rights" (revised 2/19), "If the grievance investigation cannot be completed within 7 days, the complainant will be informed within these seven days that a final written response will be forthcoming within a stated number of days, or not to exceed 30 days when possible."

Grievance #1 was received on 11/15/18. A final resolution letter was dated 1/26/19. There was no indication or documentation found in the grievance record that the complainant was informed of when to expect a final resolution.

Grievance #2 was received on 2/27/19. The grievance was documented to be resolved on 4/10/19. There was no final written resolution letter found nor was their documentation that the complainant was informed of when to expect a final resolution.

Grievance #5 was received on 1/22/19. There was no final resolution letter found or documentation of the complainant being informed of when to expect a final resolution.

In summary, complainants were not informed of when to expect a resolution or provided a written resolution letter.

Based on a review of 13 medical records and other documentation, it was determined that the hospital failed to abide by the wishes and needs of Patient 4 (P4) when they discharged P4 to a homeless shelter that could not accommodate either his physical or emotional needs.

P4 was a 60+ year old patient who presented to the Emergency Department (ED) via Emergency Medical Services (EMS) for complaints of abdominal pain and diarrhea x 3 days. Medical diagnoses included dementia, chronic lung disease, and a psychiatric diagnosis. It was documented that the patient was "covered in feces, disheveled, unshaven and there was a concern for poor nutrition".

Prior to arrival at the ED, the patient had been living in a supportive living situation with a caregiver. The hospital attempted to discharge the patient on day 2 back to this caregiver, however the patient refused to go with the caregiver and the caregiver refused to take the patient back. Case management referred the case to Adult Protective Services (APS) and a psychology consult was ordered.

The psychologist interviewed the patient two days after the consult was ordered. After the evaluation, the psychologist stated the patient "lacked capacity to make decisions regarding his/her care". The following day paperwork for certification for lack of capacity and for obtaining guardianship were received by case management. A day later, the same psychologist returned to assess the patient and deemed him/her to now have capacity to make decisions.

Physical and occupational therapy consults were ordered for the patient secondary to an unsteady gait and chronic muscle weakness. P4 was described as a "functional quadriplegic." Documentation by both specialties stated that the patient was to be discharged with home health, a wheeled walker and 24/7 supervision due to confusion and unsteady gait.

Throughout P4's hospital course, it was consistently documented that the patient did not wish to go to a homeless shelter upon discharge. The stated concerns by P4 were that a person could only sleep there and during the day the patient would have to walk around or find another place to go. The patient was fearful of falling, worried about being able to take medications and how he/she would carry all of their clothing and other belongings around all day. The case manager documented asking the patient "if you had a cane, would you feel more comfortable going to the shelter?"

On the day of discharge, during two separate occasions the patient stated to a nurse that "I want to kill myself" and "I feel like a want to die. I want to kill myself. I don't feel safe going to a shelter." The patient was discharged 90 minutes after the second statement was made. Of note, at the time of discharge the patient was sent out in a cab with only a cane.

Documentation entered after P4's discharge indicated that the homeless shelter had called the hospital and explained they "could not take this person". They stated they could possibly allow the patient to spend the night or maybe the weekend, however he/she would have to keep all of their medications and clothing (3 bags) with them at all times during the day. The shelter noted that the patient had left all of their clothing in the cab upon arrival at the shelter and it was unclear as to whether P4 had medications.

Further investigation was conducted and it was found that 24 hours after discharge the patient was taken from the shelter to another hospital for evaluation. The patient complained of shortness of breath and chest pain, although P4 could give limited history and was confused and malnourished. The cardiac work-up was negative.

Per the physician's admitting documentation, the patient was incapable of caring for him/herself and in need of home health services and physical therapy. When the home health agency was contacted, they stated "services were never started because the patient was never admitted to the Assisted Living facility that we were told he/she was going to be placed upon discharge from the previous hospital". The patient was deemed incapable of making medical decisions regarding their care while at this hospital and P4 remained there until placement could be made to an Assisted Living Facility.

If it was true, as the psychologist documented, that P4 had regained capacity to make decisions, the hospital should have followed P4's stated wishes about discharge, and not discharged P4 to a homeless shelter against P4's will. Even if P4 lacked capacity to make decisions, P4 was adamant about not going to the shelter and was aware enough of physical limitations to make discharge to a shelter unsafe and a violation of P4's rights.

See also A-806)

Based on observation of care in the emergency department it was determined that the hospital failed to maintain personal privacy for patient #8.

Patient #8 was a 70+ year old patient with a history of dementia. Patient #8 presented to the hospital via EMS from a rehab facility for a psychiatric evaluation due to repeat episodes of aggressive behavior. Patient #8 was placed in a video monitored room. The video monitor was located inside a nursing station that was accessible to staff members. While on survey, the surveyor noticed on the video screen patient #8 being provided incontinence care by two nurses. The patient was fully exposed while being assisted by the nurses. The video camera was not turned off. While the patient was being seen as a behavioral health patient, their right to privacy during hygiene activities was violated. There were two nurses in the room at the time who would have been able to monitor the patient while the camera was off.

Based on review of 7 closed and 6 open records, it was determined that hospital staff 1) failed to obtain orders when one patient (Patient #13) was in restraints, 2) failed to follow providers orders and 3) providers failed to sign violent restraint orders immediately.

Patient # 13 was a 25+ year old patient with a history of alcoholism who presented to the emergency department via EMS for possible alcohol intoxication. Patient #13 was admitted to the intensive care unit for management of acute alcohol withdrawal symptoms. While an inpatient, patient #13 had multiple episodes of violent restraints and some non-violent episodes.

Review of the patient's record also revealed that patient was physically held by staff on more than one occasion. Per nursing progress note on the second day of admission at 02:24, "4 nurses were trying to hold the patient down in the bed." A stat dose of IV [anxiolytic] was given. No order was found for this physical hold. Per a provider note on later that day at 10:21, the patient "required 6 team members to hold (patient) down while patient received 8 mg of [anxiolytic and sedative]." No order was found for this physical hold.

For the restraint episode that started a day later at 16:05, patient #13 was ordered to be in locked 4 point restraints. A renewal order at 22:40 changed the restraints from locked to soft. Per nursing restraint flow sheet the patient was in locked 4 point restraint until 23:15 the next day (more than 24 hours). A new order was also not found for the initiation of these new restraints at 23:15.

On the next day (day 6 of admission), patient #13 was released from restraints at 21:45. The last order was written at 14:40. There was no renewal order at 18:40. Therefore, patient was in restraints for about 3 hours without an order.
On day 7, per nursing note patient #13 was in 4 point restraints around 8:00. Per restraint flow sheet, restraints started at 11:00. An order for 4 point violent restraints was written at 8:13 and again at 13:54. Patient was documented to be in restraints until 20:00. There were no renewal orders found.

There were also many other orders that were not signed immediately by a provider. Overall, there were over 35 orders/ renewal orders found in the chart. At least 10 of those orders were signed over an hour after initiation or renewal time. The most concerning were the verbal orders given on day 4 at 22:40 and day 5 at 02:40 that were both signed on day 5 at 7:06. Another verbal order was obtained on day 8 at 10:00 but was not signed by a provider until day 10 at 09:12.

Based on review of 7 closed and 6 open records it was determined that hospital providers failed to correctly document one patient's behavior necessitating greater than 24 hour violent restraints.

Patient # 13 was a 25+ year old patient with a history of alcoholism who presented to the emergency department via EMS for possible alcohol intoxication. Patient #13 was admitted to the intensive care unit for management of acute alcohol withdrawal symptoms. While an inpatient, patient #13 had multiple episodes of violent restraints.

For the restraint episode that started on day 3 at 1605, a 24 hour face-to-face (F2F) was found. The F2F had marked the patient's immediate situation as "Combative/Violent Behavior Posing a Threat," "Spitting" and "other." The check box was marked "Yes" for the need to continue restraints. However, per the restraint flow sheet the patient's behavior at 16:00 and 16:15 was documented as "sleeping."

Another 24 hour F2F was found for day 4 at 16:05. The behaviors checked off were "Combative/Violent Behavior Posing a Threat" and "Self-Mutilation or Self Harm" Per nursing progress note at this time, it was documented a provider (the name of the provider in the note was not the same as the provider who signed the F2F) was at the bedside and stated "(Patient) lethargic but arousable."
Another 24 hour F2F was completed on day 6 at 16:05 that had check boxed the same behaviors as before. Per nursing flow sheet, patient #13 had been sleeping from 15:00 to 17:30. Per nursing progress note at 16:00 "Patient is sleeping quietly without any signs of struggle."

On day 8, per restraint flow sheet, patient #13 was placed in violent 4 point restraints at 02:00 until day 9 at 21:45. The 24 hour F2F was not done until day 9 at 17:50, 15 hours after initiation. In addition, this F2F had checked off "Self-Mutilation or Self Harm" as patient's immediate situation necessitating restraints. However, per restraint flow sheet, patient #13 had been observed to be asleep at 17:45 and 18:00.

In summary, the behaviors documented on the violent restraint flow sheet did not coincide with the behaviors documented on the 24 hour F2F and failed to justify greater than 24 violent restraints. See tag 174.

Based on review of 7 closed and 6 opened records, it was determined that hospital staff failed to release patient #13 from violent restraints at the earliest possible time for multiple restraint episodes.

Patient # 13 was a 25+ year old patient with a history of alcoholism who presented to the emergency department via EMS for possible alcohol intoxication. Patient #13 was admitted to the intensive care unit for management of acute alcohol withdrawal symptoms. While an inpatient, patient #13 had multiple episodes of violent restraints.

Per nursing progress notes, patient #13 was combative and threatening at times, however, patient was also sedated and sleeping for many hours during the time he/she was in violent 4 point restraints and was on a sedation protocol to lessen the symptoms of alcohol withdrawal. On the violent restraint flow sheet, the patient's behavior was documented every 15 minutes.

For multiple restraint episodes, the patient's behavior that was documented did not justify the need for restraints. For example, restraints initiated on day 3 at 16:30 had documented on the flow sheet patient was sleeping or calm for 7 continuous hours. Patient #13 was taken off locked 4 point restraints and placed in 4 point soft restraints soon after. Patient was again observed to be either sleeping or calm for greater than 10 hours. During a restraint episode that lasted until day 6, patient #13 was also observed to be pulling against restraints and angry. These behaviors are not indicative of violent or threatening behavior. Per nursing progress notes on 5/6/19, patient #13 was described as anxious, restless and agitated. Again, these descriptors did not justify keeping the patient in violent restraints.

Per nursing progress note on day 6 at 8:00, "Patient is in 4 point restraints to avoid bouts of violence." Another progress note on day 8 at 05:37 stated, "Pt unfortunately remains in 4 point soft restraints for outbursts of violence w/out indication that they will occur."

In addition, when the restraints were renewed on day 7, staff apparently removed one limb from restraints. Per nursing progress note on day 7 at 22:45, "discussed with (provider) to remove pt from 4pt restraints. Currently in soft bilat [both wrists] restraints and R ankle soft restraints ..." Per non-violent restraint flow sheet, this episode of restraints began on day 7 at 21:46, and lasted until day 10 at 10:02. An order was found for non-violent 3 point. It was unclear why patient #13 was placed in 3 point restraints at this time as a three point restraint can increase the risk of patient injury.

Documentation confirms that patient #13 was maintained in violent restraints without exhibiting violent behavior and not released at the earliest possible time.

Based on review of hospital policy, 7 closed and 6 opened records, it was determined that hospital staff failed to document restraint monitoring for patient #13 for some periods of time.

Per hospital policy titled, "Restraints and Seclusion Policy" (Revised 5/18), under "Monitoring" for violent restraint, documentation for patient behaviors needs to be documented every 15 minutes (Q15). For monitoring of non-violent restraints, documentation of care needs to be done every 2 hours."

Patient # 13 was a 25+ year old patient with a history of alcoholism who presented to the emergency department via EMS for possible alcohol intoxication. Patient #13 was admitted to the intensive care unit for management of acute alcohol withdrawal symptoms. While an inpatient, patient #13 had multiple episodes of violent restraints.

On day 5, per nursing note, patient #13 was in 4 point restraints around 8:00. Per restraint flow sheet, restraints started at 11:00. Patient #13 was in violent restraints for 3 hours without documentation of behaviors to justify violent restraints.

On day 8, per restraint flow sheet, patient #13 was placed in violent 4 point restraints at 02:00 until day 9 at 21:45. Q15 monitoring was not found for the times between 11:00 to 14:45 on day 9.

Based on review of 7 closed and 6 opened records, it was determined that hospital staff failed to obtain 3 face-to-faces within 1 hour during restraint episodes for patient #13.

Patient #13 was a 25+ year old patient with a history of alcoholism who presented to the emergency department via EMS for possible alcohol intoxication. Patient #13 was admitted to the intensive care unit for management of acute alcohol withdrawal symptoms. While an inpatient, patient #13 had multiple episodes of violent restraints.

Per restraint flowsheet for violent restraints, violent restraints began on day 2 at 09:00 and ended at 12:00. There was no 1 hour F2F found for this episode.

Patient #13 was placed in violent restraints again on day 3 at 16:05 to day 4 at 23:15. Per nursing progress note, the patient was taken off "violent/self-destructive restraints" (locked restraints). Patient #13 was documented to be asleep and calm prior to the release. Patient #13 was then assisted in getting bathed and became combative. Patient #13 was then placed in soft 4 point restraints. A 1 hour F2F was not found after this initiation.

Per nursing progress note on day 7, patient #13 was in restraints around 8:00. The F2F for this episode was not done until 13:50, almost 6 hours after initiation.

This CONDITION is not met as evidenced by: Based on an onsite survey on 05/15/2019 to 05/16/2019, review of hospital policies and procedures, interviews with staff and 13 medical record reviews, it was determined that the hospital was out of compliance with the Condition of Discharge Planning due to the following: The hospital failed to reassess the discharge needs of Patient #4 when conditions changed and when it was clear per documentation by multiple staff members that the patient lacked the capacity for self-care. The placement of the patient after discharge was not sufficient to maintain the health and care needs of the patient therefore, this was an unsafe discharge.

See A-0806

Based on medical record review and review of other pertinent documentation it was determined that the hospital failed to execute appropriate discharge planning in order to provide Patient #4 (P4) with a safe discharge.

Findings include:

P4 was a 60+ year old patient who presented to the Emergency Department (ED) via Emergency Medical Services (EMS) for complaints of abdominal pain and diarrhea x 3 days. Medical diagnoses included but were not limited to dementia, chronic lung disease, and a psychiatric diagnosis. It was documented that the patient was "covered in feces, disheveled, unshaven and there was a concern for poor nutrition". The physician ordered consults with case management and nutrition. It was documented several times that the patient "needs encouragement to eat"; however, no documentation was found to support that a nutritional consult was completed at any time during the patient's stay.

Prior to arrival at the ED, the patient had been living in a supportive living situation with a caregiver. The hospital attempted to discharge the patient on day 2 back to this caregiver, however the patient refused to go with the caregiver and the caregiver refused to take the patient back. Case management referred the case to Adult Protective Services (APS) and a psychology consult was ordered.

The psychologist interviewed the patient two days after the consult was ordered. After the evaluation, the psychologist stated the patient "lacked capacity to make decisions regarding his/her care". The following day paperwork for certification for lack of capacity and for obtaining guardianship were received by case management. A day later, the same psychologist returned to assess the patient and deemed him/her to now have capacity to make decisions.

Physical and occupational therapy consults were ordered for the patient secondary to an unsteady gait and chronic muscle weakness. P4 was described as a "functional quadriplegic," meaning that he had severe weakness in all four extremities. Documentation by both specialties stated that the patient was to be discharged with home health, a wheeled walker and 24/7 supervision due to confusion and unsteady gait.

Throughout P4's hospital course, it was consistently documented that the patient did not wish to go to a homeless shelter upon discharge. The stated concerns by P4 were that a person could only sleep there and during the day the patient would have to walk around or find another place to go. The patient was fearful of falling, worried about being able to take medications and how he/she would carry all of their clothing and other belongings around all day. The case manager asked the patient "if you had a cane, would you feel more comfortable going to the shelter?"

On the day of discharge, during two separate occasions the patient stated to a nurse that "I want to kill myself" and "I feel like a want to die. I want to kill myself. I don't feel safe going to a shelter". The patient was discharged 90 minutes after the second statement was made. Of note, at the time of discharge the patient was sent out in a cab with only a cane.

Documentation after P4's discharge indicated that the homeless shelter had called the hospital and explained they "could not take this person". They stated they could possibly allow the patient to spend the night or maybe the weekend, however he/she would have to keep all of their medications and clothing (3 bags) with them at all times during the day. It was noted that the patient had left all of their clothing in the cab upon arrival at the shelter and it was unclear as to whether he/she had their medications with them.

Further investigation was conducted and it was found that 24 hours after discharge the patient was taken from the shelter to another hospital for evaluation. The patient complained of shortness of breath and chest pain, although P4 could give no history and was confused and malnourished. The cardiac work-up was negative.

Per the physicians admitting documentation, the patient was incapable of caring for him/herself and in need of home health services and physical therapy. When the home health agency was contacted, they stated "services were never started because the patient was never admitted to the Assisted Living facility that we were told he/she was going to be placed upon discharge from the previous hospital". The patient was deemed incapable of making medical decisions regarding their care while at this hospital and P4 remained there until placement could be made to an Assisted Living Facility.

Based on review of 7 open and 6 closed medical records and other pertinent records and interviews, it was determined that the hospital failed to provide documentation of a History and Physical (H&P) for Patient #1 (P1) prior to a surgical procedure that was non-emergent, but required anesthesia services.

Findings include:

P1 was a 70+ year old patient with an extensive cardiac history including a pacemaker that presented to the hospital for a planned surgery.

A pre-surgical checklist in the chart contained documentation that multiple attempts were made to contact the patient's cardiologist for medical clearance, however none of the attempts were successful. It was also stated that an EKG was done a month prior, however the results of the EKG were not contained in the medical chart. Furthermore, it was documented on the form that an H&P was to be done on the day of surgery by the physician which was not found prior to or after the surgery.

Review of the electronic chart and the patient's physical chart during the onsite survey, on May 15, 2019, with the assistance of staff members, identified that P1 had no H&P and no cardiac clearance prior to surgery.