HospitalInspections.org

Based on review of policies and procedures, Sleep Study medical records, observations, and staff interviews, the hospital failed to ensure care in a safe setting for a patient who terminated a sleep study early and failed to ensure that the sleep study tech remained in the sleep study lab during patient testing. The hospital staff identified an average of 30 sleep study patients received sleep study testing per month.

The facility failed to:

- Ensure safe transportation from the hospital for sleep lab patients who terminated their test prior to completion. (Refer to A-0144)

- Ensure safe monitoring of sleep lab patients when the sleep study tech is out of the sleep study lab area to escort another sleep study patient needs to or from the sleep lab. (Refer to A-0144)

The above deficiencies related to the complaint investigation. Additional deficiencies from the review of the Condition of Participation at 42 CFR 482.13 Patient Rights are identified below.

- Ensure all patients were informed of their patient rights. (Refer to A-0117)

- Ensure restraint training included return demonstration of application of restraints to ensure competency of those staff who applied restraints. (Refer to A-208)

- Ensure patient rights policies included all patients were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. (Refer to A-0215)

- Ensure all patients were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. (Refer to A-0216)

The cumulative effects of these systemic practices resulted in the failure of the hospital to ensure patient care for all patients occurred in a safe setting.

Based on document review, observations, and staff interviews, the hospital staff failed to ensure each patient, or when appropriate, the patient's representative, of the patient's rights, in advance of furnishing or discontinuing patient care.

The hospital staff identified an average number of patients served in the following areas:
- Cardiac/Pulmonary Rehabilitation - 160 patients per month
- Respiratory Therapy - 22 patients per month
- Laboratory procedures - 4,253 per month
- Radiology procedures - 1,108 per month

Failure to provide all patients with patient rights could result in patients being unaware of their rights and limit their choice of options.

Findings include:

During an interview and observation during tour of the Radiology area on 3/9/15 at 2:20 PM, Staff F, Radiology Clerk, stated the Radiology, Cardiopulmonary including respiratory therapy, cardiac/pulmonary rehabilitation, and speech outpatients are registered in Radiology. Staff F acknowledged the Patient Rights Information was not available to be provide to the outpatients receiving services.

During an interview and observation during tour of the Laboratory area on 3/9/15 at 2:30 PM, Staff G, Laboratory Assistant, stated the Laboratory outpatients are registered in the Lab and acknowledged the Patient Rights Information was not available to be provided to the outpatients.

Based on review of policies and procedures, Sleep Study medical records, observations, and interview with staff, the hospital:

--failed to ensure a patient terminating a sleep study early and leaving during the night was discharged appropriately and assisted in arranging for safe transportation back to the nursing care facility where the patient resided (Patient #1); and

--failed to ensure care occurred in a safe setting for patients undergoing testing in the sleep study lab and patients were not left unattended while the Sleep Study Tech was away from the sleep study lab (Patients #1 and #2).

The hospital provided sleep study services to an average of 30 sleep study patients per month.

Failure of the hospital to ensure the sleep study lab staff acted appropriately to protect the safety of sleep study lab patients during testing and early discharge placed Patient #1 at significant risk for harm.

Findings include:

1. Patient #1 arrived at the hospital for a second sleep study test on 3/4/15 around 8:45 PM. The patient was transported to the hospital by staff from the nursing care facility, a long term care facility, where the patient lived. Staff A, a Sleep Study Tech was a contracted employee from a staffing agency. Staff A, went to the emergency department area to transport Patient #1 to the Sleep Study Lab by wheelchair. Staff A left Patient #1 unattended while leaving the sleep study lab to retrieve Patient #1's walker from the registration desk by the emergency department entrance.

When Patient #2 arrived at the emergency department area at approximately 9:30 PM on 3/4/15 for testing in the sleep study lab . Staff A left Patient #1 unattended in the sleep study lab to escort Patient #2 to the sleep study lab.

2. The sleep study testing for Patient #1 began about 10:50 PM on 3/4/15. At 11:38 PM the patient was uncomfortable with the wires and the mask and wanted to end the testing and return home. Staff A encouraged the patient to stay and complete the testing but the patient insisted on leaving.

In response to a sleep study patient's desire to terminate the sleep study, the sleep study tech terminated the testing and assisted Patient #1 to leave the hospital at 12:10 AM on 3/5/15. Staff A assisted Patient #1 to the exit of the hospital shortly after midnight on 3/5/05. Staff A left Patient #1 near the exit and returned to the sleep study lab to retrieve the patient's walker. Patient #1 waited for Staff A to return near the emergency department exit. Patient #2 was undergoing testing in the sleep study lab and was left unattended while the Staff A was out of the department.

At the time Staff A was unaware that Patient #1 lived in a nursing care facility although this information was readily available to Staff A in the patient's medical record and the nursing care facility had sent information in the basket of the patient's walker. Patient #1, a 70 year old female used a walker to assist with ambulation. Staff A assisted Patient #1 to leave the exit in the emergency department area alone and on foot using a walker at approximately 12:10 AM on 3/5/15 to walk home independently. Home was a nursing care facility approximately 0.8 of a mile from the hospital.

3. According to the Iowa State Climatologist report at 1:00 AM on 3/5/15, it was 12 degrees Fahrenheit outside with a wind chill of negative 2 degrees Fahrenheit. The facility identified an average of 30 sleep study patients per month.

4. Review of the hospital's Sleep Study policies and procedures revealed the lack of any policy or procedure that addressed the safety of a patient requesting termination of a sleep study early and wanting to leave the hospital during the night or that addressed leaving a patient undergoing testing alone in the sleep study lab while the sleep study tech left the sleep study lab area.

5. Review of Patient #1's Sleep Study medical record revealed the following documentation.

a. The Demographic page listed the patient's contact as the Nursing Care Facility where the patient lived.

b. Patient, a 70 year old female, signed the consent for Sleep Study on 3/4/15 at 8:47 PM.

c. The Admission Assessment form included the following information.
- Risk for Falls: Yes. Use of assistive devices: Yes.

d. Study terminated early. Lights out - 10:50 PM; lights on 11:38 PM. Patient expressed discomfort with wires and mask. Tech attempted to persuade patient to stay, explained possible ramifications of refusing treatment; patient insisted on leaving. No significant events or activity demonstrated; patient appeared to be awake for entire recording.

Patient left hospital by foot; was escorted by tech to emergency department exit door. Tech was unaware that patient had had come to hospital via transportation provided by the nursing care facility. Patient told tech that she walked to the hospital. Patient was later found walking and escorted to the nursing care facility.

6. Observations during tour of the hospital with Staff B, Vice President Patient Services, revealed the distance from Patient #1's sleep study room to the emergency department entrance was about 277 steps using the main elevator and about 210 steps using the service elevator.

Observations during driving the distance from the Emergency Department entrance to Nursing Care Facility A, the distance Patient #1 walked, was as follows.

- Left the emergency department door down a steep hill with a curve to the left and then to the right was approximately 0.1 miles to Cedar Street.

- From the hospital driveway to Nursing Care Facility A on Cedar Street was approximately 0.7 mile for a total distance of 0.8 mile from the hospital's emergency department entrance to the nursing facility where the patient lived.

7. The following information was obtained during interviews with hospital staff.

a. During an interview on 3/10/15 at 1:55 PM, Staff A, Agency Sleep Tech, stated upon her arrival at the facility at approximately 7:55 PM on 3/4/15, she verified orders for her patients that night. Staff A stated at approximately 8:20 PM she received a phone call from registration that Patient #1 had arrived. Staff A reported she went to the registration area, which is just inside the Emergency Department entrance, and saw Patient #1 had her own personal walker. Staff A stated she offered Patient #1 a ride in a wheelchair to go to the sleep study room and the patient accepted a ride in the wheelchair. Staff A stated she wheeled the patient to the sleep study room and then returned to the Emergency Department entrance registration area and retrieved Patient #1's walker. Staff A stated when she asked Patient #1 if she knew what test she was going to have, the patient was quiet and almost lethargic but responsive. Staff A stated the patient was to have a titration test - mask trial. Staff A started the test after explaining to the patient how to contact the tech as the tech had another patient she needed to get started on a test. Staff A stated Patient #1 did not seem mentally disabled and seemed to be coherent.

Staff A stated that at approximately 9:30 PM her second sleep study patient arrived. Staff A gave her second patient paper work to complete while she checked on Patient #1. Staff A stated as she went to the work room to look at her computer, Patient #1 sat up. Staff A asked Patient #1 if she needed to go to the bathroom and the patient said yes. Staff A stated as she unhooked Patient #1 so she could go to the bathroom, the patient told Staff A she wants to leave. Patient #1 stated she could not take the confinement of the equipment/mask. The patient walked to the bathroom without using her walker. When the patient returned from the bathroom, Staff A told the patient she would stop the study and unhook her after she started the other patient's study.

Staff A stated she unhooked Patient #1 after she started her second patient's study and took the patient's walker to the emergency department entrance and then returned to the sleep study room to get Patient #1 in a wheelchair. Staff A stated as she took Patient #1 to the emergency department exit, she asked the patient if she drove her self here and the patient said no. Staff A asked Patient #1 if someone dropped her off at the hospital and the patient said no. When Staff A asked Patient #1 how she got to the hospital, Patient #1 said she walked to the hospital. Staff A stated she again asked the patient if she drove herself here and again the patient said she walked here. The patient stated she lived on Cedar Street and Staff A stated she knew Cedar Street was in close proximity to the hospital. Staff A stated Patient #1 was frantically wanting to leave the hospital. The patient had a basket on her walker with papers tucked into the basket. Staff A stated she helped the patient with her coat and gloves. Staff A offered to call a cab and the patient said no she walked here. Staff A stated the patient never indicated she lived in a nursing care facility.

Staff A stated on 3/5/15 at approximately 12:10 AM Patient #1, using her walker, walked out of the emergency department door and turned left toward Cedar Street. Staff A reported approximately 30 minutes later she received a telephone call from the nursing care facility where the patient lived. The nursing care facility staff said Patient #1 was at their facility and reported that someone saw her walking, picked her up, and brought her back to the nursing care facility where the patient resided. After she received the telephone call from nursing care facility, Staff A reported she looked through Patient #1's file and the file did reflect the patient was a resident at the nursing care facility.

Staff A stated she left her second sleep study patient unattended while she took Patient #1's walker and then the patient to the emergency department exit door.

b. During an interview on 3/10/15 at 11:45 AM, Staff C, Director of Cardiopulmonary Services and sleep study lab, acknowledged Patient #1's medical record identified the patient as a resident of Nursing Care Facility A and also designated the same in the schedule book. Staff C also acknowledged the lack of a Sleep Study policy addressing staff response to a patient wanting to end a sleep study early.

c. During an interview on 3/11/15 at 7:35 AM, Staff E, Sleep Tech, acknowledged the lack of a Sleep Study policy that addressed what to do if a patient wanted to end a sleep study early. Staff E stated it is not standard of practice to permit a patient leave in the middle of the night without a ride as it would not be safe. Staff E reported it had been a standard of practice to leave a patient unattended in the sleep study lab if a patient left in the middle of the night and the tech escorted the patient to the emergency department exit.

8. During an interview on 3/9/15 at 5:30 PM, with Staff D from Nursing Care Facility A where Patient #1 resided, stated Patient #1 resides at the facility due to the patient being unable to live on her own, unable to manage her own medications and illnesses. Staff D stated Patient #1 was unable to comprehend everything including consequences of her actions. Staff D stated she was surprised Patient #1 was able to find her way back to the facility. Staff D stated a person passing by found Patient #1 on a corner less than a block away from Nursing Care Facility A and assisted the patient back to the nursing care facility at 1:00 AM.

Based on review of policies/procedures, documentation, and staff interviews, the hospital failed to ensure restraint training included a return demonstration of application of restraints to ensure competency of those staff who applied restraints. The hospital staff identified the application of restraints occurred for 6 patients within the past year.

Failure to ensure restraint training included a return demonstration of application of restraints could potentially result in unsafe application of restraints and cause patient harm.

Findings include:

1. Review of hospital policy/procedure titled "Restraints Policy", dated August 25, 2011, revealed in part, ". . . Competency will be documented at orientation and on an annual basis. Assessment of competency is determined by testing, return demonstration and compliance with procedure. . . Competency will include staff demonstration of patient assessment and demonstration of the application and removal of restraints. . . ."

2. Review of staff competency for restraint training lacked documentation of return demonstration of application of restraints.

3. During an interview on 3/10/15 at 4:40 PM, Staff H, Registered Nurse (RN), Emergency Department (ED) Charge Nurse, stated she was responsible for restraint training for the ED staff. Staff H stated return demonstration of restraint application was not part of the restraint training to document restraint competencies on an annual basis.

During an interview on 3/10/15 at 5:20 PM, Staff I, RN, Intensive Care Unit acknowledged she did not perform return demonstration of restraint application as part of restraint competencies.

Based on review of policies and interview with staff, the hospital failed to ensure the patient rights policies included the right of all patients to be informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Failure to provide update policies for patient rights with current visitation rights could potentially result in visitors being restricted from visiting or limiting the right of the patients to choose visitors.

The hospital staff identified an average number of patients served in the following areas:
- Average acute admissions - 127 patients per month
- Average Intensive Care Unit admissions - 35 patients per month
- Average obstetric admissions - 83 patients per month
- Outpatient surgery - 172 patients per month
- Sleep lab - 30 patients per month
- Cardiac/Pulmonary Rehabilitation - 160 patients per month
- Respiratory Therapy - 22 patients per month
- Emergency Room - 1,290 patients per month
- Laboratory procedures - 4,253 per month
- Radiology procedures - 1,108 per month
- Infusion Therapy - 185 patients per month
- Eye laser - 8 patients per month
- Pain clinic - 90 patients per month

Findings include:

1. Review of hospital policy titled "Patient's Rights", dated July 2012, revealed the policy lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 3/10/15 at 8:30 AM, Staff B, Vice President Patient Services, acknowledged the Patient Rights policy lacked the current patient visitation rights information as required.

Based on document review, observations, and staff interviews, the hospital staff failed to ensure patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend for all inpatients and outpatients.

The hospital staff identified an average number of patients served in the following areas:
- Average acute admissions - 127 patients per month
- Average Intensive Care Unit admissions - 35 patients per month
- Average obstetric admissions - 83 patients per month
- Outpatient surgery - 172 patients per month
- Sleep lab - 30 patients per month
- Cardiac/Pulmonary Rehabilitation - 160 patients per month
- Respiratory Therapy - 22 patients per month
- Emergency Room - 1,290 patients per month
- Laboratory procedures - 4,253 per month
- Radiology procedures - 1,108 per month
- Infusion Therapy - 185 patients per month
- Eye laser - 8 patients per month
- Pain clinic - 90 patients per month

Failure to provide all patients with current visitation rights could potentially result in limiting or restricting access of visitors to patients that infringed on their right to have a support person present when they are provided any type of care, services, or treatment modalities.

Findings include:

1. Review of undated patient handout, "Patient Rights", revealed the document lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 3/10/15 at 8:30 AM, Staff B, Vice President Patient Services,
acknowledged the Patient Rights patient handout lacked the current patient visitation rights information as required by the regulations.