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Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0118 - Standard: The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The facility failed to follow their grievance process by not ensuring patients or their representatives were notified of other options for filing a grievance if they were not satisfied with the facility's findings in 13 of 14 grievance reports reviewed (Patients #43, 44, 45, A, B, C, E, F, G, H, I, J and K). This failure created the potential for patients to be unaware of their right to pursue a further grievance investigation.

A-0154 - Standard: Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. The facility failed to ensure seclusion was only imposed to ensure the immediate physical safety of the patient, a staff member, or others. Furthermore the facility failed to ensure seclusion was discontinued at the earliest possible time in 4 of 7 Emergency Department (ED) seclusion records reviewed (Patient #1, #40, #41 and #42). This failure created instances where patients who presented to the ED were placed in a more restrictive environment of seclusion with no documented behaviors of why the patients remained in seclusion.

Based on interviews and document review, the facility failed to follow their grievance process by not ensuring patients or their representatives were notified of other options for filing a grievance if they were not satisfied with the facility's findings in 13 of 14 grievance reports reviewed (Patients #43, 44, 45, A, B, C, E, F, G, H, I, J and K).

This failure created the potential for patients to be unaware of their right to pursue a further grievance investigation.

FINDINGS

POLICY

According to the policy, Patient Complaints and Grievances, the grievance procedure required the Patient Representative to inform the patient or patient's representative of other options for filing a grievance if he/she was not satisfied with the findings. Options included: Forwarding the grievance and hospital findings in writing to the Department of Health or forwarding the grievance to the administrative officer or such officer's designee.

1. The facility did not ensure patients or patient representatives who were unsatisfied with the findings of their grievance investigation were notified of where to forward their concerns.

a) A sample review of 14 grievance reports between 04/20/17 to 11/12/17 was conducted. Of the 14 grievances reviewed, only 1 grievance (Patient D) included evidence of informing the patient that if unsatisfied with the results, s/he could either request the results of the investigate to be sent to the Department of Public Health or contact the Department directly.

b) On 12/06/17 at 2:42 p.m., a joint interview was conducted with the Manager of Patient Relations (Manager #4) and the Director of Quality and Safety (Director #5). Manager #4 stated part of his/her job responsibilities included implementing the grievance process for grievances received from patients or their representative. Manager #4 described the process of closing a grievance by sending a letter to the complainant describing the investigation and findings. Manager #4 stated s/he did not always include information on where to follow up if the complainant was still unsatisfied. Manager #4 stated s/he would call the complainant and ask if they were satisfied with the findings. If the complainant was not satisfied, Manager #4 stated s/he would then inform them on following up with the Department. Manager #4 further stated s/he would then document the phone call; however, after reviewing the sampled grievance reports, there was no documentation noted showing evidence patients were contacted via phone call at the closure of the grievance process.

During the same interview, Director #5 revealed the facility had discussed including the options to forward concerns to the Department in the grievance closure letter. Director #5 stated that due to the majority of complainants being satisfied with results, the facility determined it was not necessary to include forwarding information in the letter. Director #5 stated the closure letter included a phone number to call the patient advocate with further questions but s/he confirmed the letter did not include forwarding information if the complainant was still unsatisfied.

After reviewing the sampled grievances, Director #5 confirmed there was no additional information available showing evidence patients were contacted at the closure of the grievance process to determine if they were still unsatisfied with the results of the investigation. Director #5 then stated s/he could understand how the current process put the onus on the complainant to seek additional information on where to forward concerns.

Based on interviews and document reviews, the facility failed to ensure seclusion was only imposed to ensure the immediate physical safety of the patient, a staff member, or others. Furthermore the facility failed to ensure seclusion was discontinued at the earliest possible time in 4 of 7 Emergency Department (ED) seclusion records reviewed (Patients #1, #40, #41 and #42).

This failure created instances where patients who presented to the ED were placed in a more restrictive environment of seclusion with no documented behaviors of why the patients remained in seclusion.

FINDINGS

POLICY

According to the policy, Patients Rights and Responsibilities, the patient has the right to medical and psychiatric care and treatment in the least restrictive setting as possible, suited to meet the patient's individual needs.

According to the policy, Restraint and/or Seclusion for Violent/Self Destructive Behavior, restraints or seclusion may only be imposed to ensure the immediate physical safety of the patient, an associate, or others, and must be discontinued at the earliest possible time.

Seclusion is defined as the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, an associate, or others. The procedure required by staff is to access patients to determine if there is an immediate threat to the safety of the patient, associates or others. Attempt alternatives to restraint or seclusion by using other measure to enhance patient safety.

Restraint documentation required includes an order as outlined, description of the finding of the initial and subsequent face-to-face evaluation supporting the use of restraints or seclusion. The face-to-face evaluation must include an evaluation of the patient's immediate situation, the reaction to the intervention, the medical and behavioral condition and the need to continue or terminate the restraint/seclusion. The Registered Nurse documents education given to the patient/family.

REFERENCE

According to the Restraint or Seclusion Decision Tree, alternatives or less restrictive interventions attempted must be documented in the patient's medical record, along with the patient's response to interventions, including rationale for continued use of the intervention.

1. The facility failed to ensure seclusion was imposed only to ensure the immediate physical safety of the patient and staff. The facility further failed to ensure seclusion was discontinued at the earliest time possible.

a) Review of Patient #1's medical record revealed the patient presented to the ED on 12/4/17 at 7:18 a.m., for alcohol and possible overdose. Patient #1 was initially ordered seclusion at 7:42 a.m. by the provider with the reason documented as danger to self. The initial face to face by the physician was documented as completed. However, there were no documented details of the evaluation, including the patient's reaction to the intervention and the need to continue seclusion, which was required by policy,

According to the seclusion documentation done by the patient's Registered Nurse (RN) at 7:45 a.m. on 12/4/17, the reason for the seclusion was imminent risk of harm to self. In the RN assessment, the patient's behavior was documented as depressed, cooperative, communicated concerns, sad and somnolent.

At 9:32 a.m., almost 2 hours after seclusion was ordered, Behavioral Health staff evaluated the patient and documented the patient as being cooperative. There was no documented evidence of violent or self-destructive behavior. The patient's documented legal status was voluntary.

On review of the Patient Assist notes for Patient #1's ED visit from 12/04/17 at 7:45 a.m. until 12/05/17 at 4:45 p.m., the patient was not free to leave the bed, the room or the facility. Furthermore, the notes revealed no documented violent or self-destructive behaviors or the reason for continued seclusion for the patient's entire stay in the ED.

Some examples of behaviors on the Patient Assist notes included for 12/4/17:
9:45 a.m., the patient was documented to be resting in bed.
5:00 p.m., the patient was documented to have a laptop.
8:15 p.m., the patient was documented to be in bed.

On 12/5/17, some of examples of the documented behaviors on the Patient Assist notes included:
12:15 p.m., the patient was documented to be sleeping.
3:00 a.m. until 7:30 a.m. the patient was noted to be sleeping.
8:00 a.m., the patient was noted to be awake in bed and then returned to sleep at 9:00 a.m. This pattern of awake and then sleeping continued until 4:55 p.m. on 12/5/17, when the patient was noted to be discharged.

Seclusion continued to be ordered by multiple physicians for a total of 33 hours until the patient was discharged home. However, review of the seclusion orders and the physician progress notes for Patient #1 revealed no documented behaviors which would be used to determine why the patient continued to be in seclusion or if it was possible to terminate the seclusion. This was in contrast to policy.

Additionally, there was no evidence which showed nursing staff educated the patient or family about seclusion, why it was required and the criteria for release from the restrictive intervention.

b) Review of Patient #42's medical record revealed the patient presented to the ED on 11/27/17 at 3:18 p.m. with a chief complaint of depression and suicidal ideations (SI). The patient was ordered seclusion 7 minutes after arrival with the reason stated as a danger to self, specifically SI. An initial face to face by the physician was documented as complete. The ED physician evaluated the patient on arrival and stated the patient had a flat affect and behavior in the progress note.

Patient #42 was evaluated by behavioral health at 3:50 p.m. The behavioral health staff documented the patient's behavior as normal and the patient's legal status was voluntary. On 11/27/17 at 10:00 p.m., 6 hours after seclusion was ordered, the patient was placed on a M1 Hold (involuntary commitment).

Review of the Patient Assist notes started at 3:25 p.m. on 11/27/17, revealed the patient was not free to leave the bed, the room or the facility. Documented behaviors on the Patient Assist notes included:

3:45 p.m., the patient was documented to be playing on a tablet.
4:15 p.m., the patient was documented to be laying in bed until 5:00 p.m.

The seclusion order for Patient #42 was renewed at 7:25 p.m., with the reason documented as danger to self and suicidal ideations. According to the Patient Assist notes documented at 7:00 p.m. the patient was resting in bed; at 7:45 p.m. the patient was escorted to the restroom and at 8:00 p.m., again resting on bed, reading. At 9:15 p.m. Patient #42 was documented as cooperative and in bed, yet the patient remained in seclusion.

Review of all Patient Assist notes, physician progress notes and the seclusion order for Patient #42's stay from 11/27/17 from 3:25 p.m. until 11:30 p.m., when the patient was transferred to an outside facility, showed no documented behaviors of why the patient continued in seclusion prior to the M1 hold being placed. Additionally, there was no evidence in the medical record which showed the patient or family was educated about seclusion.

c) Review of Patient #40's medical record revealed, the patient presented to the ED for SI on 11/06/17 at 12:37 p.m. The patient was immediately placed on seclusion by the physician. The documented reason was SI. According to the Patient Assist notes, documented at 12:37, the patient was not free to leave the bed, the room, or the facility. According to the documentation, at 12:37 p.m., the patient was laying in bed and cooperative. The RN also documented the patient was resting and cooperative.

The seclusion order was renewed at 4:37 p.m. and again at 8:37 p.m. Review of the Patient Assist notes and the Physician progress notes, revealed no documentation of the patient's behaviors which required the patient to remain in seclusion for almost 10 hours.

The patient was evaluated by behavioral health at 9:00 p.m. and determined to not meet criteria for an M1 hold. The patient was discharged at 10:30 p.m.

The patient's medical record had no documented evidence which showed how the need for seclusion was determined by the patient's physician and if the patient was educated on the criteria for release.

Similar findings were found in Patient #41's medical record with no documented behaviors of why the patient remained in seclusion until placed on an M1 Hold.

d) On 12/4/17 at 11:15 a.m., a tour of the ED was conducted with the Charge Nurse (RN #8) who confirmed Patient #1 was in seclusion.

RN #8 reported seclusion was ordered for SI patients. S/he stated the reason for seclusion was to prevent the patient from leaving the facility when the patient was not safe to leave the facility and was considered a danger to themselves or others. RN #8 stated the seclusion was ordered by physicians and M1 holds were placed later once the patient was to be transferred to another facility. S/he stated behavioral health staff could place the M1 hold after the patient was assessed.

After review of Patient #1's record, RN #8 stated the patient was placed in seclusion for SI with a plan and overdose.

e) On 12/6/17 at 9:40 a.m., a second ED RN (RN #9 ) was interviewed. S/he stated if a patient presented with SI, security would meet the patient at the room, the patient would be placed in a green gown, belongings removed and the physician would be notified to obtain a seclusion order. RN #9 stated the criteria for seclusion was harm to self and other people, danger to staff and the patient was gravely disabled. S/he stated seclusion was placed because staff would not want the patient to leave the facility.

When asked what was the difference between the criteria for a M1 hold compared to seclusion, RN #9 stated the criteria was the same, except the M1 hold could be placed by a mental health provider or the police.

f) On 12/7/17 at 8:05 a.m., an interview was conducted with the Chief Operating Officer (COO #13), Director #10 and one of the behavioral health consultants (Employee #14). COO #13 reviewed 3 of the ED patients' medical records (including Patient #1's) and did not see any documentation in the physician notes which indicated the detailed behaviors which would cause the patient to be a danger to self and required seclusion.

g) On 12/7/17 at 8:58 a.m., an interview was conducted with the on call Psychiatrist (Physician #16) who stated seclusion was used when a patient presented with imminent danger. Physician #16 stated an example was when a patient presented to the ED psychotic. Seclusion would be used to manage behaviors immediately and allow time for evaluation.

Physician #16 stated patients in seclusion would be reevaluated ever 4 hours to see if they met criteria required for the level of intervention. S/he reported the decision was based on nursing staff and attending physician input.

When asked why the face to face was important, COO #13 stated it allowed a discussion to occur between the physician and the patient. The evaluation was a quick assessment to ensure the patient was meeting criteria for the seclusion and to assess how to transition to the least restrict measures for that patient.

Physician #16 stated an M1 hold was the most restrictive intervention to keep a patient safe, then seclusion and last would be suicide precautions. S/he stated for suicide precautions, staff would monitor the patient 1 to 1 and be within the patient's line of site.

Physician #16 discussed patient rights. S/he stated patients needed to be aware of what was going with their care in order to maintain autonomy.

COO #13 stated s/he was unable to find any documentation which showed the patients were educated and aware of the release criteria for seclusion. COO #13 stated it looked like there was documentation issues.

h) During an earlier interview, conducted on 12/06/17 at 5:07 PM, COO #13 stated the facility had an obligation to inform patients of their rights. S/he stated if the patients did not understand the care provided to them and the reasons for the care, the patients could not participate in their care.

Based on the onsite validation survey, completed December 5 through December 14, 2017, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code tagsK0222, K0225, K0232, K0325, K0347, K0353, K0363, K0372, and K0712. See survey event ID #HFFP21 for full details of the cited deficiencies.

Based on observations and interviews the facility failed to maintain appropriate infection control processes and follow infection control standards in the area of food storage and sterile supplies.

These failures created the potential for transmission of health care associated infections to patients receiving care in the facility.

FINDINGS

POLICY

According to facility policy Sodexo Food Safety Policies Food Safety Product Labeling & Dating Guide food prepared in Sodexo operation, purchased , ready to eat food removed from original container requires a storage label with the name of the product (unless clearly identifiable) date of preparation and /or "use -by date.

According to facility policy Standard Precautions: Infection Control Practices in the Care of All Patients, all SCL Health hospitals and affiliated clinics will utilize standard precautions. reduce the risk of transmission of microorganisms from both recognized and unrecognized sources in the healthcare setting. Procedure required maintain sterility and /or cleanliness of patient supplies by storing in manners which avoid contamination
1. The facility failed to ensure all food was labeled and dated with a use by date. The facility failed to ensure food was discarded after the expiration date or use by date.

a) On 12/04/17 at 11:29 a.m., a tour was conducted of the kitchen with the Director of Nutrition Services( Director) #1, who was in charge of patient food service for the facility. Observation of the kitchen revealed multiple food items were improperly stored, including expired food and items which lacked a label identifying use by date.

Example of expired foods:

1 - metal pan labeled Ancho Lime Chicken use by 12/01/17
1 -Arrezzio Pesto use by 11/21/17 07:59 am
1- package Garden Black Bean Burgers use by 10/27/17 11:59 am
1 - large metal storage container of frozen potatoes use by date Nov 13
1 - package of Veggie hot dogs use by date 8-20-17
1- container of Chicken tenders used by 07/12/17 01:45 pm
1 - container of McCormick Ground White pepper 18 oz use by 09/12/17
1- metal oblong container of Bell Pepper use by 12/2/17
1 - bottle labeled Oil use by 10/3
1 - Loaf of Block and Barrel Classic Thick sliced bread use by 11/22/17 12:20 pm
1- bottle of Caribbean Jerk Seasoning 18 oz use by date 11/28/17
1 - bottle pf Oregano 5 oz label unreadable but label printed 11/06/16
1 - container of red onions use by 12/2/17
1- McCormick White pepper 18 oz expired 09/12/17 12:49
1- Sysco Oregano 5 oz - label not readable, label printed on 11/06/16
1- Caribbean Jerk Seasoning 18 oz use by date 11/28/17

Examples of food with no label or use-by date:

1-Open package of 10 tortillas
1-Great Lakes Parmesan cheese shredded- opened
1-Sysco Classic frozen corn net wt 40 oz -opened
3- Jalapeno's in a metal container
1-7.5 qt plastic container of shredded cheese
1- Package of Udis gluten free tortillas -opened
2 Frozen containers of cheese and pasta
1 - Large metal container of french fry cut potato's
1- Package of Garden Golden Fishless Fillets -opened
15 - Debys Gluten Free tortillas - opened
1- Nestle Coffee Mate Hazelnut Creamer 50.7 fluid oz -opened
14 - individual solo plastic cups with salsa inside
13- 6" tortillas -opened package
1- bottle of Hidden Valley 32 oz opened
1- bottle Boyajian pure orange oil 32 oz - opened
1- container of green onions
2 -containers of cilantro
1 -Sysco Reliance Mayonnaise 1 gallon -opened
2 -Hidden Valley Blue Cheese dressing 32 oz - opened
1- Franks Red Hot sandwich sauce 1 gallon - opened
1- Sysco 1000 Island dressing 1 gallon - opened
2- 32 oz Liquid egg product - opened
2- trays of pizza dough no label
1 -Arrezza Fresh Mozzarella
1- plastic container of Kosher salt and pepper
1- metal container of shredded cheese
1- metal container of bell peppers

Examples of open spices which were not labeled when opened.

1-Montreal Chicken Spice - Sysco -18 oz
1-Montreal Steak Seasoning - 29 oz
1-Chef Paul Prudhomme Blacken Redfish Magic
1 -bottle of Pepper Supreme 21 oz
1 - Pepper Supreme 21 oz

b) An interview was conducted, while on tour on 12/04/17 at 11:33 a.m., with Cook #3 who reported usually prepared food items were left in the original containers they came in. S/he stated the containers were required to have a label on the products when they were removed from the original container.

c) An interview was conducted with Director #1, while on tour on 12/04/17 at 11:49 a.m. S/he was shown the package of 15 Deby's Gluten Free Tortillas which s/he stated there should have been a label placed on the package.

d) An interview was conducted with Chef #2, while on tour on 12/04/17 at 12:21 p.m. S/he was shown the spices in the kitchen that lacked a label on the containers. S/he stated the spices must have a label on them as it was what was required.

e) On 12/6/17 at 9:26 a.m., an interview was conducted with the Director of Nutritional Services (Director) #1 who was in charge of all kitchen staff. S/he stated the expectation was all items in the kitchen were to be labeled appropriately so items could be identified and it would be known when the food was past its usefulness. Director #1 stated the staff were expected to follow the policies and procedures and there was no excuse for all the unlabeled and expired food items.

2. The facility failed to ensure expired supplies in the outpatient setting were not available for patient use.

a) On 12/4/17 at 2:02 p.m., a tour was conducted at an outpatient clinic. An observation revealed expired supplies that were available for patient use. Examples of expired supplies:

8 packages of 8 ply 2x2 gauze sponges expired 04/2015
Eleven packages of 12 ply 4x4 gauze sponges expired 02/2017
3 boxes of 12 ply 4x4 gauze sponges expired 02/2017
2 boxes of 23 ply 4x4 gauze sponges expired 04/2015
3 standard tongue depressors expired 09/30/2017

b) An interview was conducted on 12/04/17 at 2:20 p.m., with Therapist #6 who stated the expired supplies were for patients who would have come to the clinic and needed wound care. S/he reported the supplies would be used in patient care. Therapist #6 stated expired supplies used for patient care would have created a risk of infection for the patient.

c) An interview was conducted on 12/06/17 at 2:10 p.m., with Director #7 who reported the box of expired supplies was to be discarded and the facility should have gotten rid of the supplies. S/he stated the supplies were not safe and beyond infection control parameters. Director #7 reported if the supplies had been used for patient care there was a chance a patient could get an infection from the expired supplies.