HospitalInspections.org

Based on review of facility policies and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to protect and promote the rights of each patient; by failing to promptly notify a physician of the patients' choice, of his or her admission, to the facility (A-0133); by failing to ensure that restraint alternatives were utilized, and proven to be ineffective, prior to the application of restraints (A-0164); by failing to ensure that the least restrictive restraint choice was utilized (A-0165); by failing to ensure that restraints were removed in a timely manner (A-0174); and by failing to ensure that patient monitoring was completed, according to facility policy, while the patient was in restraints (A-0175).

Cross Reference:
482.13(b)(4) Patient Rights: Admission Status Notification
482.13(e)(2) Patient Rights: Restraint or Seclusion
482.13(e)(3) Patient Rights: Restraint or Seclusion
482.13(e)(9) Patient Rights: Restraint or Seclusion
482.13(e)(10) Patient Rights: Restraint or Seclusion

Based on a review of facility policies and procedures, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to promptly notify a physician of the patients' choice, of his or her admission to the hospital, for ten (10) of ten (10) patients rights medical records reviewed (MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, and MR11).

Findings include:

Review on January 30, 2018, of the facility policy, "Patient Rights and Responsibilities", dated, "10/10/2017", revealed "... Policy ... At Temple University Hospital, Inc. patients have the following rights ... 25. To have their primary physician and legal representative notified when they are admitted to the hospital ..."

Review on January 29, 2018, of MR2, revealed the patient was admitted to the facility on January 28, 2018. Further review of MR2 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on January 29, 2018, of MR3, revealed the patient was admitted to the facility on January 27, 2018. Further review of MR3 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on January 29, 2018, of MR4, revealed the patient was admitted to the facility on January 28, 2018. Further review of MR4 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on January 29, 2018, of MR5, revealed the patient was admitted to the facility on January 26, 2018. Further review of MR5 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on January 29, 2018, of MR6, revealed the patient was admitted to the facility on January 25, 2018. Further review of MR6 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on January 29, 2018, of MR7, revealed the patient was admitted to the facility on January 28, 2018. Further review of MR7 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on January 29, 2018, of MR8, revealed the patient was admitted to the facility on January 26, 2018. Further review of MR8 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on January 29, 2018, of MR9, revealed the patient was admitted to the facility on January 4, 2018. Further review of MR9 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on January 29, 2018, of MR10, revealed the patient was admitted to the facility on January 27, 2018. Further review of MR10 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on January 29, 2018, of MR11, revealed the patient was admitted to the facility on January 26, 2018. Further review of MR11 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Interview with EMP22, on January 29, 2018, between approximately 11:30 A.M. and 1:00 P.M., confirmed that MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, and MR11, "did not" contain documented evidence that the patient's physician of choice was promptly notified of the patient's admission to the facility.

Interview with EMP3, on January 30, 2018, between approximately 7:00 A.M. and 7:15 A.M. confirmed that MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, and MR11, "did not" contain documented evidence that the Registration Department promptly contacted, or attempted to contact, the patient's physician of choice, notifying them of the patient's admission to the facility.

Based on review of facility policies and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure less restrictive interventions were determined to be ineffective, prior to the application of mechanical restraints, for two (2) of five (5) restraint medical records reviewed (MR22 and MR23).

Findings include:

Review on January 30, 2018, of the facility policy, "Patient Rights and Responsibilities", dated, "10/10/2017", revealed "... Policy ... At Temple University Hospital, Inc. patients have the following rights ... 6. To receive quality care within the professional standards governing clinical practice ..."

Review on January 30, 2018, of the facility policy, "Use of Restraint", dated, "02/17/2016", revealed "... Purpose This policy establishes guidelines: To create a physical, social, and cultural environment that limits the use of restraint to adequately justified, clinically appropriate situations based on a comprehensive individual patient assessment. To ensure the usage of preventative strategies to restraint. To ensure that the least restrictive methods are used. To outline the use of restraint and seclusion in order to preserve the rights, safety, wellbeing, and dignity of the patient at all times ... Policy Temple University Hospital strives to create and maintain a safe environment for patients and staff. Patients have the right to be free from restraint ... Prior to restraint, alternatives should be attempted. When restrain is necessary, the patient shall be retrained in the least restrictive manner possible ... Use of Restraint for Violent or Self-Destructive Behavior ... B. Patient Assessment The use of restraint for violent or self-destructive behavior must be based on an individual patient assessment. Restraints will be initiated only when less restrictive measures have been found to be ineffective ... F. Documentation Each episode of restraint is documented in the medical record ... Documentation also includes the rationale for restraint, alternatives considered and/or attempted, monitoring and nursing interventions ..."

Review on January 30 and 31, 2018, or MR22, revealed the patient was treated in the facility ED on December 2, 2017. Further review of MR22 revealed the patient was placed in four-point mechanical restraints on December 2, 2017. Further review of MR22 revealed no documented evidence that restraint alternatives and/or less restrictive interventions, were determined to be ineffective, prior to the application of mechanical restraints on the patient.

Review on January 30 and 31, 2018, or MR23, revealed the patient was treated in the facility ED on December 2, 2017. Further review of MR23 revealed the patient was placed in four-point mechanical restraints on December 2, 2017. Further review of MR23 revealed no documented evidence that restraint alternatives and/or less restrictive interventions, were determined to be ineffective, prior to the application of mechanical restraints on the patient.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient's in MR22 and MR23 were placed in four-point mechanical restraints on December 2, 2017. Further interview with EMP8 and EMP25 confirmed that MR22 and MR23 "did not" contain documented evidence that restraint alternatives and/or less restrictive interventions, were determined to be ineffective, prior to the application of mechanical restraints on the patient's.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient's in MR22 and MR23 were placed in four-point mechanical restraints on December 2, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR22 and MR23 "did not" contain documented evidence that restraint alternatives and/or less restrictive interventions, were determined to be ineffective, prior to the application of mechanical restraints on the patient's.

Based on review of facility policies and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the type or technique of restraint used must be the least restrictive intervention that will be effective, to protect the patient or others from harm, for five (5) of five (5) restraint medical records reviewed (MR22, MR23, MR24, MR25, and MR26).

Findings include:

Review on January 30, 2018, of the facility policy, "Patient Rights and Responsibilities", dated, "10/10/2017", revealed "... Policy ... At Temple University Hospital, Inc. patients have the following rights ... 6. To receive quality care within the professional standards governing clinical practice ..."

Review on January 30, 2018, of the facility policy, "Use of Restraint", dated, "02/17/2016", revealed "... Purpose This policy establishes guidelines: To create a physical, social, and cultural environment that limits the use of restraint to adequately justified, clinically appropriate situations based on a comprehensive individual patient assessment. To ensure the usage of preventative strategies to restraint. To ensure that the least restrictive methods are used. To outline the use of restraint and seclusion in order to preserve the rights, safety, wellbeing, and dignity of the patient at all times ... Policy Temple University Hospital strives to create and maintain a safe environment for patients and staff. Patients have the right to be free from restraint ... Prior to restraint, alternatives should be attempted. When restrain is necessary, the patient shall be retrained in the least restrictive manner possible ... Use of Restraint for Violent or Self-Destructive Behavior ... B. Patient Assessment The use of restraint for violent or self-destructive behavior must be based on an individual patient assessment ... F. Documentation Each episode of restraint is documented in the medical record ... Documentation also includes the rationale for restraint, alternatives considered and/or attempted, monitoring and nursing interventions ..."

Review on January 30 and 31, 2018, or MR22, revealed the patient was treated in the facility ED on December 2, 2017. Further review of MR22 revealed the patient was placed in four-point mechanical restraints on December 2, 2017. Further review of MR22 revealed no documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR22 was placed in four-point mechanical restraints on December 2, 2017. Further interview with EMP8 and EMP25 confirmed that MR22 "did not" contain documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR22 was placed in four-point mechanical restraints on December 7, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR22 "did not" contain documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Review on January 30 and 31, 2018, or MR23, revealed the patient was treated in the facility ED on December 2, 2017. Further review of MR23 revealed the patient was placed in four-point mechanical restraints on December 2, 2017. Further review of MR23 revealed no documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR23 was placed in four-point mechanical restraints on December 2, 2017. Further interview with EMP8 and EMP25 confirmed that MR23 "did not" contain documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR23 was placed in four-point mechanical restraints on December 2, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR23 "did not" contain documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Review on January 30 and 31, 2018, or MR24, revealed the patient was treated in the facility ED on December 7, 2017. Further review of MR24 revealed the patient was placed in four-point mechanical restraints on December 7, 2017. Further review of MR24 revealed no documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR24 was placed in four-point mechanical restraints on December 7, 2017. Further interview with EMP8 and EMP25 confirmed that MR24 "did not" contain documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR24 was placed in four-point mechanical restraints on December 7, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR24 "did not" contain documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Review on January 30 and 31, 2018, or MR25, revealed the patient was treated in the facility ED on December 27, 2017. Further review of MR25 revealed the patient was placed in four-point mechanical restraints on December 27, 2017. Further review of MR25 revealed no documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR25 was placed in four-point mechanical restraints on December 27, 2017. Further interview with EMP8 and EMP25 confirmed that MR25 "did not" contain documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR25 was placed in four-point mechanical restraints on December 27, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR25 "did not" contain documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Review on January 30 and 31, 2018, or MR26, revealed the patient was treated in the facility ED on December 28, 2017. Further review of MR26 revealed the patient was placed in four-point mechanical restraints on December 28, 2017. Further review of MR26 revealed no documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR26 was placed in four-point mechanical restraints on December 28, 2017. Further interview with EMP8 and EMP25 confirmed that MR26 "did not" contain documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR26 was placed in four-point mechanical restraints on December 28, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR26 "did not" contain documented evidence that a least intrusive restraint or restrictive alternative was attempted prior to the application of four-point mechanical restraints.

Based on review of facility policies and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure restraints were discontinued at the earliest possible time, regardless of the length of time identifed in the order, for four (4) of five (5) restraint medical records reviewed (MR22, MR23, MR25, and MR26).

Findings include:

Review on January 30, 2018, of the facility policy, "Patient Rights and Responsibilities", dated, "10/10/2017", revealed "... Policy ... At Temple University Hospital, Inc. patients have the following rights ... 6. To receive quality care within the professional standards governing clinical practice ..."

Review on January 30, 2018, of the facility policy, "Use of Restraint", dated, "02/17/2016", revealed "... Purpose This policy establishes guidelines: To create a physical, social, and cultural environment that limits the use of restraint to adequately justified, clinically appropriate situations based on a comprehensive individual patient assessment. To ensure the usage of preventative strategies to restraint. To ensure that the least restrictive methods are used. To outline the use of restraint and seclusion in order to preserve the rights, safety, wellbeing, and dignity of the patient at all times ... Policy Temple University Hospital strives to create and maintain a safe environment for patients and staff. Patients have the right to be free from restraint ... Restraint may only be utilized to ensure the physical safety of the patient, staff member or others and must be discontinued at the earliest time possible ... Use of Restraint for Violent or Self-Destructive Behavior ... B. Patient Assessment The use of restraint for violent or self-destructive behavior must be based on an individual patient assessment ... E. Discontinuation All episodes of restraint are to be ended at the earliest possible time, regardless of the length of time identified in the order ... Restraints will be discontinued when the behavior precipitating the restraint episode is no longer present and the patient does not pose any immediate serious danger to his/her safety or that of others. F. Documentation Each episode of restraint is documented in the medical record ... Documentation also includes the rationale for restraint, alternatives considered and/or attempted, monitoring and nursing interventions ... At discontinuation the reason for discontinuation and the time of discontinuation are documented ..."

Review on January 30 and 31, 2018, or MR22, revealed the patient was treated in the facility ED on December 2, 2017. Further review of MR22 revealed the patient was placed in four-point mechanical restraints on December 2, 2017. Further review of MR22 revealed the patient was documented as "sleeping" over a one (1) hour and fifteen (15) minute span of time while in four-point mechanical restraints. Further review of MR22 revealed no documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR22 was placed in four-point mechanical restraints on December 2, 2017. Further interview with EMP8 and EMP25 confirmed that MR22 "did not" contain documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR22 was placed in four-point mechanical restraints on December 7, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR22 "did not" contain documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Review on January 30 and 31, 2018, or MR23, revealed the patient was treated in the facility ED on December 2, 2017. Further review of MR23 revealed the patient was placed in four-point mechanical restraints on December 2, 2017. Further review of MR23 revealed the patient was documented as "resting comfortably" during a twelve (12) minute span of time while in four-point mechanical restraints. Further review of MR23 revealed no documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR23 was placed in four-point mechanical restraints on December 2, 2017. Further interview with EMP8 and EMP25 confirmed that MR23 "did not" contain documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR23 was placed in four-point mechanical restraints on December 7, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR23 "did not" contain documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Review on January 30 and 31, 2018, or MR25, revealed the patient was treated in the facility ED on December 27, 2017. Further review of MR25 revealed the patient was placed in four-point mechanical restraints on December 27, 2017. Further review of MR25 revealed the patient was documented as "sleeping" and/or "cooperative" over a two (2) hour span of time while in four-point mechanical restraints. Further review of MR25 revealed no documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR25 was placed in four-point mechanical restraints on December 27, 2017. Further interview with EMP8 and EMP25 confirmed that MR25 "did not" contain documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR25 was placed in four-point mechanical restraints on December 27, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR25 "did not" contain documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Review on January 30 and 31, 2018, or MR26, revealed the patient was treated in the facility ED on December 28, 2017. Further review of MR26 revealed the patient was placed in four-point mechanical restraints on December 28, 2017. Further review of MR26 revealed the patient was documented as "quiet" and/or "sleeping" over a fifty (50) minute span of time while in four-point mechanical restraints. Further review of MR26 revealed no documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR26 was placed in four-point mechanical restraints on December 28, 2017. Further interview with EMP8 and EMP25 confirmed that MR26 "did not" contain documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR26 was placed in four-point mechanical restraints on December 28 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR26 "did not" contain documented evidence of any attempts to partially, or completely, discontinue the patients restraints at the earliest possible time.

Based on review of facility policies and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure patients in restraints were monitored by a physician, other licensed independent practitioner or trained staff, at an interval determined by hospital policy, for three (3) of five (5) restraint medical records reviewed (MR22, MR23, and MR25).

Findings include:

Review on January 30, 2018, of the facility policy, "Patient Rights and Responsibilities", dated, "10/10/2017", revealed "... Policy ... At Temple University Hospital, Inc. patients have the following rights ... 6. To receive quality care within the professional standards governing clinical practice ..."

Review on January 30, 2018, of the facility policy, "Use of Restraint", dated, "02/17/2016", revealed "... Purpose This policy establishes guidelines: To create a physical, social, and cultural environment that limits the use of restraint to adequately justified, clinically appropriate situations based on a comprehensive individual patient assessment. To ensure the usage of preventative strategies to restraint. To ensure that the least restrictive methods are used. To outline the use of restraint and seclusion in order to preserve the rights, safety, wellbeing, and dignity of the patient at all times ... Policy Temple University Hospital strives to create and maintain a safe environment for patients and staff. Patients have the right to be free from restraint ... Restraint may only be utilized to ensure the physical safety of the patient, staff member or others and must be discontinued at the earliest time possible. While in restraint, the patient shall receive ongoing care to insure that their dignity, physical and psychosocial needs are met ... Use of Restraint for Violent or Self-Destructive Behavior ... B. Patient Assessment The use of restraint for violent or self-destructive behavior must be based on an individual patient assessment ... D. Monitoring 1. Patients who are restrained for behavioral health purposes will have continous one-to-one in-person observation for the duration of the restraint. The patient is monitored when restraint is initiated and every 15 minutes thereafter. The patient's rights, dignity and safety will be maintained at all times. Monitoring is accomplished by observation, interaction with patient, or direct examination by qualified staff. 2. The following are monitored every 15 minutes: The patient's physical and emotional well-being. Signs of any injury associated with application of restraint. The following are to be carried out every two hours or more frequently if the patient's condition warrants: Fluid, food, and toilet needs. Circulation and range of motion. Skin checks. Vital signs ... F. Documentation Each episode of restraint is documented in the medical record ... Documentation also includes the rationale for restraint, alternatives considered and/or attempted, monitoring and nursing interventions ..."

Review on January 30 and 31, 2018, or MR22, revealed the patient was treated in the facility ED on December 2, 2017. Further review of MR22 revealed the patient was placed in four-point mechanical restraints on December 2, 2017. Further review of MR22 revealed no documented evidence of the ongoing physical monitoring of the patient, specifically, every two (2) hour checks of skin condition/circulation, joint range-of-motion, and/or the offering of fluids, food, and toilet needs, as required by facility policy, while the patient was in four-point mechanical restraints.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR22 was placed in four-point mechanical restraints on December 2, 2017. Further interview with EMP8 and EMP25 confirmed that MR22 "did not" contain documented evidence of the ongoing physical monitoring of the patient, specifically, every two (2) hour checks of skin condition/circulation, joint range-of-motion, and/or the offering of fluids, food, and toilet needs, as required by facility policy, while the patient was in four-point mechanical restraints.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR22 was placed in four-point mechanical restraints on December 7, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR22 "did not" contain documented evidence of the ongoing physical monitoring of the patient, specifically, every two (2) hour checks of skin condition/circulation, joint range-of-motion, and/or the offering of fluids, food, and toilet needs, as required by facility policy, while the patient was in four-point mechanical restraints.

Review on January 30 and 31, 2018, or MR23, revealed the patient was treated in the facility ED on December 2, 2017. Further review of MR23 revealed the patient was placed in four-point mechanical restraints on December 2, 2017. Further review of MR23 revealed no documented evidence of the ongoing physical monitoring of the patient, specifically, every two (2) hour checks of skin condition/circulation, joint range-of-motion, and/or the offering of fluids, food, and toilet needs, as required by facility policy, while the patient was in four-point mechanical restraints.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR23 was placed in four-point mechanical restraints on December 2, 2017. Further interview with EMP8 and EMP25 confirmed that MR23 "did not" contain documented evidence of the ongoing physical monitoring of the patient, specifically, every two (2) hour checks of skin condition/circulation, joint range-of-motion, and/or the offering of fluids, food, and toilet needs, as required by facility policy, while the patient was in four-point mechanical restraints.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR23 was placed in four-point mechanical restraints on December 7, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR23 "did not" contain documented evidence of the ongoing physical monitoring of the patient, specifically, every two (2) hour checks of skin condition/circulation, joint range-of-motion, and/or the offering of fluids, food, and toilet needs, as required by facility policy, while the patient was in four-point mechanical restraints.

Review on January 30 and 31, 2018, or MR25, revealed the patient was treated in the facility ED on December 27, 2017. Further review of MR25 revealed the patient was placed in four-point mechanical restraints on December 27, 2017. Further review of MR25 revealed no documented evidence of the ongoing physical monitoring of the patient, specifically, every two (2) hour checks of skin condition/circulation, joint range-of-motion, and/or the offering of fluids, food, and toilet needs, as required by facility policy, while the patient was in four-point mechanical restraints.

Interview with EMP8 and EMP25, on January 30, 2018, between approximately 10:45 A.M. and 12:00 P.M., confirmed that the patient in MR25 was placed in four-point mechanical restraints on December 27, 2017. Further interview with EMP8 and EMP25 confirmed that MR25 "did not" contain documented evidence of the ongoing physical monitoring of the patient, specifically, every two (2) hour checks of skin condition/circulation, joint range-of-motion, and/or the offering of fluids, food, and toilet needs, as required by facility policy, while the patient was in four-point mechanical restraints.

Interview with EMP7, EMP8, and EMP9, on January 31, 2018, between approximately 7:00 A.M. and 8:15 A.M., confirmed that the patient in MR25 was placed in four-point mechanical restraints on December 27, 2017. Further interview with EMP7, EMP8, and EMP9 confirmed that MR25 "did not" contain documented evidence of the ongoing physical monitoring of the patient, specifically, every two (2) hour checks of skin condition/circulation, joint range-of-motion, and/or the offering of fluids, food, and toilet needs, as required by facility policy, while the patient was in four-point mechanical restraints.

Based on review of facility policies and procedures, facility documents, and interview with staff (EMP), it was determined the facility failed to ensure an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program; by ensuring the program incorporates quality indicator data including patient care data, and other relevant data, to monitor the effectiveness and safety of services and quality of care (A-0273); by ensuring program activities focus on high-risk, high-volume, or problem-prone areas that affect health outcomes, patient safety, and quality of care (A-283); and by ensuring the hospital's Governing Body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the that the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated.

Cross Reference:

482.21(b)(1)(2)(i): Data Collection & Analysis
482.21(c)(i)(ii)(iii): Quality Improvement Activities
482.21(c)(1)(2): QAPI Executive Responsibilities

Based on review of facility policies and procedures, facility documents, and interview with staff (EMP), it was determined that the facility failed to ensure that specific patient care data, regarding the use of mechanical restraints in the Emergency Department, was incorporated into the Quality Assurance and Performance Improvement program, to monitor the effectiveness and safety of the quality of care provided.

Findings include:

Review on January 30, 2018, of the facility policy, "Temple University Hospital Performance Improvement Plan FY 2018", dated, "11/01/2017", revealed "I. Introduction A. Purpose ... The hospital's Board of Governors ensures that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors ... B. Goals ... 2. Temple University Hospital's Performance Program ... a) Setting priorities to guide performance assessment and improvement activities designed to measure, analyze, assess and manage variation in the performance of processes that effect patient care outcomes, treatment, services and operations ... c) Ensuring appropriate communication of performance assessment and improvement activities to the Performance Improvement/Patient Safety Committee, Medical Staff, Board of Governors, employees and the community. d) Complying with standards of regulatory/accrediting agencies including ... the Centers for Medicare & Medicaid Services (CMS) and the Pennsylvania Deparment of Health (DOH) ... III. Performance Improvement Planning Objectives A. Performance Improvement Program Objectives ... 2. Identify opportunities for improvement and changes that will lead to improvement by focusing on high risk, high volume, and problem prone areas. When focusing on these areas, incidence, prevalence, and severity in these areas are considered ... B. Scope The program includes, but is not necessarily limited to, participation of the following ... g) Temple University Hospital-Episcopal Campus; All departments and units at the Episcopal Campus report their activities through the Temple University Hospital Episcopal Campus /Northeastern Campus Ad Hoc Performance Improvement Committee and provide the results of their PI metrics to the TUH Performance Improvement/Patient Safety Committee ... VI. Structure/Responsibility A. The Board of Governors of Temple University Hospital has the authority and responsibility for the quality and effectiveness of patient care services provided by its medical staff members and other professional and support staff ..."

Review on January 30, 2018, of the facility policy, "Use of Restraint", dated, "02/17/2016", revealed "... Purpose This policy establishes guidelines: To create a physical, social, and cultural environment that limits the use of restraint to adequately justified, clinically appropriate situations based on a comprehensive individual patient assessment. To ensure the usage of preventative strategies to restraint. To ensure that the least restrictive methods are used. To outline the use of restraint and seclusion in order to preserve the rights, safety, wellbeing, and dignity of the patient at all times. To strive to prevent, reduce and eliminate the use of restraint through effective performance improvement initiatives ... Performance Improvement TUH collects data on the use of restraints including the review of event reports in order to reduce restraint utilization and assure patients safety when restrains are in use. Activities are directed to improve care processes that reduce precipitating factors and strategies aimed at decreasing duration of restraint when it is required."

Review on January 31, 2018, of the facility documents, "Performance Improvement Committee Meeting Minutes", dated, "January 10, 2017", "February 14, 2017", "March 14, 2017", "April 11, 2017", "May 9, 2017", "June 13, 2017", "July 11, 2017", "August 8, 2017", "September 12, 2017", "October 10, 2017", "November 14, 2017", and "December 12, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the Temple University Hospital Episcopal Campus /Northeastern Campus Ad Hoc Performance Improvement Committee or the Temple University Hospital Performance Improvement Committee.

Review on January 31, 2018, of the facility documents, "Patient Safety Committee Meeting Minutes", dated, "January 10, 2017", "February 14, 2017", "March 14, 2017", "April 11, 2017", "May 9, 2017", "June 13, 2017", "July 11, 2017", "August 8, 2017", "September 12, 2017", "October 10, 2017", "November 14, 2017", and "December 12, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the facilities Patient Safety Committee.

Review on January 31, 2018, of the facility documents, "Medical Staff Executive Committee Meeting Minutes", dated, "January 19, 2017", "February 16, 2017", "March 16, 2017", "April 20, 2017", "May 18, 2017", "June 15, 2017", "July 20, 2017", "September 28, 2017", "November 16, 2017", and "December 21, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the Medical Staff Executive Committee.

Review on January 31, 2018, of the facility documents, "Board of Governors Meeting Minutes", dated, "February 24, 2017", "May 22, 2017", "June 29, 2017", "August 11, 2017", "October 27, 2017", and "December 8, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the Temple University Hospital Governing Body.

Interview with EMP7 and EMP8, on January 31, 2018, at 8:19 A.M., confirmed that the facilities Emergency Department currently "does not" complete chart audits on all restraint medical records. Further interview with EMP7 and EMP8 confirmed the Emergency Department "does not" submit restraint performance improvement data to any of the facilities Quality Assessment and Performance Improvement Committees or the Patient Safety Committee.

Interview with EMP5, on January 31, 2018, at 8:19 A.M., confirmed that the facilities Emergency Department "does not" submit restraint performance improvement data to the facilities Quality Assessment and Performance Improvement Episcopal Campus Ad Hoc Committee. Further interview with EMP5 confirmed that the facilities Emergency Department "does not" submit restraint performance improvement data to the facilities oversight Performance Improvement Committee. Further interview with EMP5 confirmed that the facilities Emergency Department "does not" submit restraint performance improvement data to the facilities Patient Safety Committee. Further interview with EMP5 confirmed that facility "does" complete the ongoing review and monitoring of restraint utilization data, for Behavioral Health Services, by the facilities Quality Assessment and Performance Improvement program.

Based on review of facility policies and procedures, facility documents, and interview with staff (EMP), it was determined that the facility failed to ensure that the Quality Assurance and Performance Improvement program activities focus on high-risk, high-volume, or problem-prone areas that affect health outcomes, patient safety, and the quality of care in the Emergency Department.

Findings include:

Review on January 30, 2018, of the facility policy, "Temple University Hospital Performance Improvement Plan FY 2018", dated, "11/01/2017", revealed "I. Introduction A. Purpose ... The hospital's Board of Governors ensures that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors ... B. Goals ... 2. Temple University Hospital's Performance Program ... a) Setting priorities to guide performance assessment and improvement activities designed to measure, analyze, assess and manage variation in the performance of processes that effect patient care outcomes, treatment, services and operations ... c) Ensuring appropriate communication of performance assessment and improvement activities to the Performance Improvement/Patient Safety Committee, Medical Staff, Board of Governors, employees and the community. d) Complying with standards of regulatory/accrediting agencies including ... the Centers for Medicare & Medicaid Services (CMS) and the Pennsylvania Deparment of Health (DOH) ... III. Performance Improvement Planning Objectives A. Performance Improvement Program Objectives ... 2. Identify opportunities for improvement and changes that will lead to improvement by focusing on high risk, high volume, and problem prone areas. When focusing on these areas, incidence, prevalence, and severity in these areas are considered ... B. Scope The program includes, but is not necessarily limited to, participation of the following ... g) Temple University Hospital-Episcopal Campus; All departments and units at the Episcopal Campus report their activities through the Temple University Hospital Episcopal Campus /Northeastern Campus Ad Hoc Performance Improvement Committee and provide the results of their PI metrics to the TUH Performance Improvement/Patient Safety Committee ... VI. Structure/Responsibility A. The Board of Governors of Temple University Hospital has the authority and responsibility for the quality and effectiveness of patient care services provided by its medical staff members and other professional and support staff ..."

Review on January 30, 2018, of the facility policy, "Use of Restraint", dated, "02/17/2016", revealed "... Purpose This policy establishes guidelines: To create a physical, social, and cultural environment that limits the use of restraint to adequately justified, clinically appropriate situations based on a comprehensive individual patient assessment. To ensure the usage of preventative strategies to restraint. To ensure that the least restrictive methods are used. To outline the use of restraint and seclusion in order to preserve the rights, safety, wellbeing, and dignity of the patient at all times. To strive to prevent, reduce and eliminate the use of restraint through effective performance improvement initiatives ... Performance Improvement TUH collects data on the use of restraints including the review of event reports in order to reduce restraint utilization and assure patients safety when restrains are in use. Activities are directed to improve care processes that reduce precipitating factors and strategies aimed at decreasing duration of restraint when it is required."

Review on January 31, 2018, of the facility documents, "Performance Improvement Committee Meeting Minutes", dated, "January 10, 2017", "February 14, 2017", "March 14, 2017", "April 11, 2017", "May 9, 2017", "June 13, 2017", "July 11, 2017", "August 8, 2017", "September 12, 2017", "October 10, 2017", "November 14, 2017", and "December 12, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the Temple University Hospital Episcopal Campus /Northeastern Campus Ad Hoc Performance Improvement Committee or the Temple University Hospital Performance Improvement Committee.

Review on January 31, 2018, of the facility documents, "Patient Safety Committee Meeting Minutes", dated, "January 10, 2017", "February 14, 2017", "March 14, 2017", "April 11, 2017", "May 9, 2017", "June 13, 2017", "July 11, 2017", "August 8, 2017", "September 12, 2017", "October 10, 2017", "November 14, 2017", and "December 12, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the facilities Patient Safety Committee.

Review on January 31, 2018, of the facility documents, "Medical Staff Executive Committee Meeting Minutes", dated, "January 19, 2017", "February 16, 2017", "March 16, 2017", "April 20, 2017", "May 18, 2017", "June 15, 2017", "July 20, 2017", "September 28, 2017", "November 16, 2017", and "December 21, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the Medical Staff Executive Committee.

Review on January 31, 2018, of the facility documents, "Board of Governors Meeting Minutes", dated, "February 24, 2017", "May 22, 2017", "June 29, 2017", "August 11, 2017", "October 27, 2017", and "December 8, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the Temple University Hospital Governing Body.

Interview with EMP7 and EMP8, on January 31, 2018, at 8:19 A.M., confirmed that the facilities Emergency Department currently "does not" complete chart audits on all restraint medical records. Further interview with EMP7 and EMP8 confirmed the Emergency Department "does not" submit restraint performance improvement data to any of the facilities Quality Assessment and Performance Improvement Committees and/or the Patient Safety Committee.

Interview with EMP5, on January 31, 2018, at 8:19 A.M., confirmed that the facilities Emergency Department "does not" submit restraint performance improvement data to the facilities Quality Assessment and Performance Improvement Episcopal Campus Ad Hoc Committee. Further interview with EMP5 confirmed that the facilities Emergency Department "does not" submit restraint performance improvement data to the facilities oversight Performance Improvement Committee. Further interview with EMP5 confirmed that the facilities Emergency Department "does not" submit restraint performance improvement data to the facilities Patient Safety Committee. Further interview with EMP5 confirmed that facility "does" complete the ongoing review and monitoring of restraint utilization data, for Behavioral Health Services, by the facilities Quality Assessment and Performance Improvement program.

Based on review of facility policies and procedures, facility documents, and interview with staff (EMP), it was determined that the facilities Governing Body failed to ensure that the hospital-wide quality assessment and performance improvement activities address the ongoing monitoring and evaluation of restraint utilization in the Emergency Department.

Findings include:

Review on January 30, 2018, of the facility policy, "Temple University Hospital Performance Improvement Plan FY 2018", dated, "11/01/2017", revealed "I. Introduction A. Purpose ... The hospital's Board of Governors ensures that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors ... B. Goals ... 2. Temple University Hospital's Performance Program ... a) Setting priorities to guide performance assessment and improvement activities designed to measure, analyze, assess and manage variation in the performance of processes that effect patient care outcomes, treatment, services and operations ... c) Ensuring appropriate communication of performance assessment and improvement activities to the Performance Improvement/Patient Safety Committee, Medical Staff, Board of Governors, employees and the community. d) Complying with standards of regulatory/accrediting agencies including ... the Centers for Medicare & Medicaid Services (CMS) and the Pennsylvania Deparment of Health (DOH) ... III. Performance Improvement Planning Objectives A. Performance Improvement Program Objectives ... 2. Identify opportunities for improvement and changes that will lead to improvement by focusing on high risk, high volume, and problem prone areas. When focusing on these areas, incidence, prevalence, and severity in these areas are considered ... B. Scope The program includes, but is not necessarily limited to, participation of the following ... g) Temple University Hospital-Episcopal Campus; All departments and units at the Episcopal Campus report their activities through the Temple University Hospital Episcopal Campus /Northeastern Campus Ad Hoc Performance Improvement Committee and provide the results of their PI metrics to the TUH Performance Improvement/Patient Safety Committee ... VI. Structure/Responsibility A. The Board of Governors of Temple University Hospital has the authority and responsibility for the quality and effectiveness of patient care services provided by its medical staff members and other professional and support staff ..."

Review on January 30, 2018, of the facility policy, "Use of Restraint", dated, "02/17/2016", revealed "... Purpose This policy establishes guidelines: To create a physical, social, and cultural environment that limits the use of restraint to adequately justified, clinically appropriate situations based on a comprehensive individual patient assessment. To ensure the usage of preventative strategies to restraint. To ensure that the least restrictive methods are used. To outline the use of restraint and seclusion in order to preserve the rights, safety, wellbeing, and dignity of the patient at all times. To strive to prevent, reduce and eliminate the use of restraint through effective performance improvement initiatives ... Performance Improvement TUH collects data on the use of restraints including the review of event reports in order to reduce restraint utilization and assure patients safety when restrains are in use. Activities are directed to improve care processes that reduce precipitating factors and strategies aimed at decreasing duration of restraint when it is required."

Review on January 31, 2018, of the facility documents, "Performance Improvement Committee Meeting Minutes", dated, "January 10, 2017", "February 14, 2017", "March 14, 2017", "April 11, 2017", "May 9, 2017", "June 13, 2017", "July 11, 2017", "August 8, 2017", "September 12, 2017", "October 10, 2017", "November 14, 2017", and "December 12, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the Temple University Hospital Episcopal Campus /Northeastern Campus Ad Hoc Performance Improvement Committee or the Temple University Hospital Performance Improvement Committee.

Review on January 31, 2018, of the facility documents, "Patient Safety Committee Meeting Minutes", dated, "January 10, 2017", "February 14, 2017", "March 14, 2017", "April 11, 2017", "May 9, 2017", "June 13, 2017", "July 11, 2017", "August 8, 2017", "September 12, 2017", "October 10, 2017", "November 14, 2017", and "December 12, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the facilities Patient Safety Committee.

Review on January 31, 2018, of the facility documents, "Medical Staff Executive Committee Meeting Minutes", dated, "January 19, 2017", "February 16, 2017", "March 16, 2017", "April 20, 2017", "May 18, 2017", "June 15, 2017", "July 20, 2017", "September 28, 2017", "November 16, 2017", and "December 21, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the Medical Staff Executive Committee.

Review on January 31, 2018, of the facility documents, "Board of Governors Meeting Minutes", dated, "February 24, 2017", "May 22, 2017", "June 29, 2017", "August 11, 2017", "October 27, 2017", and "December 8, 2017", revealed no documented evidence of the ongoing monitoring and evaluation of the Episcopal Campus Emergency Departments, utilization of mechanical restraints, by the Temple University Hospital Governing Body.

Interview with EMP7 and EMP8, on January 31, 2018, at 8:19 A.M., confirmed that the facilities Emergency Department currently "does not" complete chart audits on all restraint medical records. Further interview with EMP7 and EMP8 confirmed the Emergency Department "does not" submit restraint performance improvement data to any of the facilities Quality Assessment and Performance Improvement Committees and/or Patient Safety Committee.

Interview with EMP5, on January 31, 2018, at 8:19 A.M., confirmed that the facilities Emergency Department "does not" submit restraint performance improvement data to the facilities Quality Assessment and Performance Improvement Episcopal Campus Ad Hoc Committee. Further interview with EMP5 confirmed that the facilities Emergency Department "does not" submit restraint performance improvement data to the facilities oversight Performance Improvement Committee. Further interview with EMP5 confirmed that the facilities Emergency Department "does not" submit restraint performance improvement data to the facilities Patient Safety Committee. Further interview with EMP5 confirmed that facility "does" complete the ongoing review and monitoring of restraint utilization data, for Behavioral Health Services, by the facilities Quality Assessment and Performance Improvement program.