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Based on review of the hospital's Death in Restraints log, it was determined that hospital staff failed to properly maintain an internal log for all deaths that occurred while patients were in soft wrist restraints or death that occurred within 24 hours after the patient was released from restraints.

The surveyors reviewed the hospital's restraint policy, dated 2/19. Under "Death Reporting Requirements", the policy stated: "Deaths of patients in restraints are reported to the Nursing Supervisor's Office and Risk Management daily. Risk Management will maintain a log and report deaths as required by CMS guidelines."

Review of the log on 1/2/2020 showed a total of six entries which stated the following:

1. Under the heading "Date entered in log", five of the six entries had dates of either 1/2/19 or 1/2/20. The date of death for those patients ranged from 7/2019 through 11/2019. Two of those 5 entries listed dates of entry to the log prior to the date of death. All 5 entries were well beyond the 7 day requirement.

2. Under the heading "Date noted in medical record", no date was recorded for any of the five records.

After review of the log, the surveyor requested to speak to the person(s) responsible for maintaining the log. The Assistant Vice President of Quality stated that Risk Management was responsible for tracking and entering the information into the log.

An interview was held with two Risk Managers on 1/3/2019 at approximately 1:00 pm. When asked who maintained the log, both managers stated a specific staff member's name; however, it was also stated that this staff member was currently out on leave. When asked who maintained the log in this person's absence, both managers stated they were unaware of anyone else being responsible. In addition, both denied ever seeing the log prior to the day of the survey.

Staff record review determined that the staff member responsible for maintaining the log was out on leave since mid-December. In their absence, no other staff members were educated on how to maintain the log.

Based on review of 12 medical records, policies and procedures, and interviews with staff, it was determined that the hospital failed to implement appropriate discharge planning for 1 of 12 patients reviewed.

According to the hospital's discharge planning policy, titled "Care Management Department: Discharge Planning":
"Care Management discharge planning initial assessment is to be completed by a care manager or social worker within 24 to 48 hours of admission. Patients presenting to Saint Agnes Hospital having three or more bedded stays in one year or a thirty day readmission will have their care management discharge planning initial assessment completed with a goal of 24 hours and no later than 48 hours. Request for additional care management assessments can be made at the request of the physician, a member of the health care team, patient, care giver/support person, or the POA. The patient discharge planning initial assessment is to be completed in a timely manner to eliminate barriers related to preventable hospital readmissions and potential delays in discharge. The assessment is to be completed with a focus on the patient and or caregiver/ support person/ POA goals of care and treatment preferences."

Patient #9 (P9) was an 85+ year old patient admitted to the hospital after a fall at home. The medical record review detertmined that P9 spent 4 days at the hospital. No initial Care Management discharge planning assessment was found in the record for this patient. On day 3 of the hospitalization, the attending physician documented that P9 was ready for discharge and required sub-acute rehabilitation post-hospital due to P9's recent diagnosis. The physician then placed an order for a social worker consult which was performed later that day. Referrals for post-hospital rehabilitation facilities were made on P9's behalf, and P9 was discharged from the hospital on day 4, one day after the physician had documented the patient's readiness for discharge. The facility's failure to perform an initial Care Management assessment in early stages of P9's hospitalization resulted in a failure to timely identify P9's post-hospital needs for sub-acute rehabilitation and to provide a timely discharge.

Based on review of the medical record for Patient #1 (P1) and hospital policies and procedures, it was determined that the hospital failed to ensure that the plan of care for rehabilitation services for P1 was in accordance with requirements of 42 CFR §409.17, as well as failed to provide the rehabilitation services identified in the plan of care prior to the P1's discharge.

The surveyor reviewed the policy titled "Inpatient Treatment Frequency and Goal Setting Procedure". Under the section "Inpatient Recommended Frequencies", the policy stated that that if the discharge plan was for a subacute rehabilitation facility, the frequency of visits should be '3-5x/week'. It also stated if the patient needed rehabilitation, 'set frequency according to above recommendations - plan to see 5 days a week by at least one discipline'.

The surveyor reviewed the policy for Rehabilitation Services Department titled "Inpatient Screening Procedure" which stated: "When a patient requires an evaluation and a screen alone is not sufficient: 4. Patient has recent history of falls/injury."

Patient #1 presented to the ED for symptoms of delirium and recurrent falls at home. The patient was placed in observation status, and review of nursing and physician documentation showed that P1's gait was unsteady and P1 was confused. The physician ordered Physical Therapy (PT) and Occupational Therapy (OT) consultations. Review of discharge recommendations communicated between physicians, nursing, social work, and the PT/OT therapists determined that the patient's tolerance to PT and OT would be factored in to facilitate appropriate discharge timing.

On day 2 of the hospital stay, P1 had an initial evaluation completed by PT and OT which included the formulation of a plan of care. The initial PT evaluation stated that the patient was "highly unsteady", had "no safety awareness", "patient will need 24 hour supervision for safety and to prevent additional falls" and "required PT assistance to prevent collision into walls and doorways". The initial OT documentation stated that the patient was confused, had a short attention span of 30 seconds or less, and was unable to complete the expected tasks. It was documented by both services that they would continue to work with the patient "as needed to facilitate discharge to a sub-acute rehabilitation facility". Both services failed to identify and document the proposed frequency and duration of PT and OT sessions in the plan, as required by 42 CFR §409.17.

Further review of record for P1 determined that these were the only documented sessions with either PT or OT until the day of the patient's discharge 3 days later. P1 had a total stay of 5 days with only one session each of physical therapy and occupational therapy. The patient was found to be in need of extensive assistance by both therapists; however, no other sessions were documented for the remainder of P1's stay at the hospital, which could be attributed to the incompletely documented care plan for rehabilitation services.