HospitalInspections.org

Based on review of Medical Staff Bylaws, Medical Staff credential files and interview, it was determined that the hospital failed to require that members of the Medical Staff exercise clinical privileges only after reappointment by the hospital Governing Body for 7 of 7 Medical Staff members (MD's #1, 2, 3, 4, 5, 6 and PA-C #7).

Findings include:

Review of Medical Staff Bylaws, 2010-2012 revealed: "...All appointments to the Medical Staff shall be made by the Governing Body upon recommendation of the Chief Medical Officer and the Medical Staff Executive Committee...The term of Medical Staff appointment shall be for no more than two years...Appointment to the Medical Staff does not, in itself, confer clinical privileges on the appointee. Privileges are separately requested and granted by the Governing Body upon recommendation by the Medical Staff Executive Committee...Reappointment and re-privileging shall be made at two-year intervals...."

MD #1's credential file contained a form titled Medical Staff Evaluation for Reappointment. Review of this form revealed: "...Reappointment Expires 10-20-11...." The credential file contained documentation that the Medical Staff Executive Committee: "...recommends forwarding the application to Governing Body for approval of privileges as requested...." The Medical Staff President, Chief Medical Officer (CMO) and Chief Executive Officer (CEO) signed on 9/27/11, indicating recommendation of MD #1 for reappointment to the hospital Medical Staff with privileges "as requested." The Governing Body Chair approved the reappointment on 11/1/2011.

The CMO confirmed on 2/24/12, that MD #1's privileges expired on 10/20/11 and s/he continued to see patients between 10/20/11 and 11/1/11, before his/her reappointment was approved by the Governing Body.

MD #2's credential file contained a form titled Medical Staff Evaluation for Reappointment. Review of this form revealed: "...Reappointment Expires 5/27/10...." The credential file contained documentation that the Medical Staff Executive Committee: "...recommends forwarding the application to Governing Body for approval of privileges as requested...." The Medical Staff President, CMO and CEO signed on 5/25/10, indicating recommendation of MD #2 for reappointment to the hospital Medical Staff with privileges "as requested." The Governing Body Chair approved the reappointment on 6/15/10.

The CMO confirmed on 2/24/12, that MD #2's privileges expired on 5/27/10, and s/he continued to see patients between 5/27/10 and 6/15/10, before his/her reappointment was approved by the Governing Body.

Review of MD #3's credential file revealed that s/he completed the Provisional Period on 5/23/11, and that the CMO and Medical Staff President recommended, by signatures on 4/25/11, that full privileges be granted as requested. A representative of the Governing Body approved full privileges on 8/23/11.

The CMO confirmed on 2/24/12, that MD #3 continued to see patients between 5/23/11 and 8/23/11, without privileges granted by the Governing Body.

MD #4's credential file contained a form titled Medical Staff Evaluation for Reappointment. Review of this form revealed: "...Reappointment Expires 7/7/2011...." The credential file contained documentation that the Medical Staff Executive Committee: "...recommends forwarding the application to Governing Body for approval of privileges as requested...." The Medical Staff President, CMO and CEO signed on 6/28/11, indicating recommendation of MD #4 for reappointment to the hospital Medical Staff with privileges "as requested." The Governing Body Chair approved the reappointment on 8/23/2011.

The CMO confirmed on 2/24/12, that MD #4's privileges expired on 7/7/2011, and s/he continued to see patients between 7/7/2011 and 8/23/2011, before his/her reappointment was approved by the Governing Body.

MD #5's credential file contained a form titled Medical Staff Evaluation for Reappointment. Review of this form revealed: "...Reappointment Expires 8/26/10...." The credential file contained documentation that the Medical Staff Executive Committee: "...recommends forwarding the application to Governing Body for approval of privileges as requested...." The Medical Staff President, CMO and CEO signed on 8/24/10, indicating recommendation of MD #5 for reappointment to the hospital Medical Staff with privileges "as requested." The Governing Body Chair approved the reappointment on 9/23/2010.

The CMO confirmed on 2/24/12, that MD #5's privileges expired on 8/26/10, and s/he continued to see patients between 8/26/10 and 9/23/10, before his/her reappointment was approved by the Governing Body.

MD #6's credential file contained a form titled Medical Staff Evaluation for Reappointment. Review of this form revealed: "...Reappointment Expires 12/16/10...." The credential file contained documentation that the Medical Staff Executive Committee: "...recommends forwarding the application to Governing Body for approval of privileges as requested...." The Medical Staff President and CMO signed on 11/23/10, and the CEO signed on 11/24/10, indicating recommendation of MD #6 for reappointment to the hospital Medical Staff with privileges "as requested." The Governing Body Chair approved the reappointment on 1/18/11.

The CMO confirmed on 2/24/12, that MD #6's privileges expired on 12/16/10, and s/he continued to see patients between 12/16/10 and 1/18/11, before his/her reappointment was approved by the Governing Body.

Physician Assistant (PA-C) #7's credential file contained a form titled Medical Staff Evaluation for Reappointment. Review of this form revealed: "...Reappointment Expires 7/7/2011...." The credential file contained documentation that the Medical Staff Executive Committee: "...recommends forwarding the application to Governing Body for approval of privileges as requested...." The Medical Staff President, CMO and CEO signed on 6/28/11, indicating recommendation of PA-C #7 for reappointment to the hospital Medical Staff with privileges "as requested." The Governing Body Chair approved the reappointment on 8/23/2011.

The CMO confirmed on 2/24/12, that PA-C #7's privileges expired on 7/7/2011, and s/he continued to see patients between 7/7/2011 and 8/23/2011, before his/her reappointment was approved by the Governing Body.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that the use of restraint or seclusion be in accordance with a written modification to the patient's plan of care for 6 of 6 seclusion/restraint episodes for 3 of 3 patients (Pts # 1, 2 and 3).

Findings include:

Review of the hospital policy/procedure titled Seclusion or Restraint revealed that it did not contain a requirement that seclusion and/or restraint be in accordance with a written modification to the patient's plan of care.

Pt #1 was admitted on 3/29/11 with a diagnosis of Schizoaffective Disorder, Bipolar type and a history of noncompliance with treatment.

Review of his medical record revealed documentation that he was placed in a physical restraint on 4/29/11, from 1145 until 1156 and a mechanical restraint from 1205 until 1320. Pt #1 was placed in a physical restraint on 9/1/11, from 0735 until 0736 and seclusion from 0737 until 2115.

Review of Pt #1's Master Inpatient Treatment and Discharge Plan and Master Inpatient Treatment and Discharge Plan Reviews between 4/29/11 and 9/2/11, revealed that seclusion and/or restraint was not in accordance with a modification in his treatment plan.

On 2/23/12, the Performance Improvement Coordinator confirmed that Pt #1's treatment plan did not contain mention of seclusion and/or restraint.

Pt #2 was admitted on 1/26/11 with Post Traumatic Stress Disorder, Mood Disorder "NOS" (Not Otherwise Specified), "R/O" (Rule Out) Bipolar Mood Disorder NOS, R/O Schizoaffective Disorder Bipolar Type, Marijuana Abuse Abstinent and Alcohol Abuse Abstinent.

Review of her medical record revealed that she was placed in a mechanical restraint on 4/22/11, from 2045 until 2215. She was placed in a physical restraint on 9/3/11 from 0047 until 0117 and a mechanical restraint from 0117 until 0330. She was placed in a physical restraint on 9/3/11 from 1615 until 1722 and a mechanical restraint from 1722 until 1820.

Review of Pt #2's Master Inpatient Treatment and Discharge Plan and Master Inpatient Treatment and Discharge Plan Reviews between 4/22/22 and 7/25/11, revealed that restraint was not in accordance with a modification in her treatment plan. The treatment plan dated 7/25/11, contained documentation that the patient was to be restrained using a "Posey Restraint Net" instead of four point leather restraints. The treatment plan dated 8/11/11, contained documentation that: "...Nursing will perform brief physical hold or...'Posey Restraint Net'...."

On 2/23/12, the Performance Improvement Coordinator confirmed that the first documentation on Pt #2's treatment plan regarding seclusion and/or restraint was on 7/25/11, and the patient had been restrained prior to that date. In addition, she confirmed that the treatment plan dated 8/11/11, contained intervention of nursing to perform a brief physical hold and that the physical hold on 9/3/11 of 1 hr. and 7 min. was not brief.

Pt #3 was admitted on 1/18/11 with diagnoses of Impulse Control Disorder NOS, Schizoaffective Disorder NOS and Attention Deficit Hyperactive Disorder.

Review of his medical record revealed that he was placed in a physical restraint on 1/22/12, from 0808 until 0819 and seclusion from 0819 until 1100.

Review of Pt #3's Master Inpatient Treatment and Discharge Plan and Master Inpatient Treatment and Discharge Plan Reviews revealed that his physical restraint and seclusion was not in accordance with a modification in his treatment plan.

On 2/23/12, the Performance Improvement Coordinator confirmed that Pt #3's treatment plan contained no mention of seclusion and/or restraint.

Based on review of hospital policy/procedure, hospital document, medical records and interview, it was determined that the hospital failed to require that the face-to-face assessment within one hour of a seclusion and/or restraint of a violent or self-destructive patient include an evaluation of the patient's medical condition for 7 of 7 face-to-face assessments which were required for 3 of 3 patients who were secluded and/or restrained for violent or self-destructive behavior (Pt's #1, 2 and 3).

Findings include:

Review of hospital policy/procedure titled Seclusion or Restraint revealed: "...Document the results of the assessment...and include the following:...the patient's medical and behavioral condition...Responsible Persons: Treating Psychiatrist or O.D. (Officer of the Day) Psychiatrist...Only one (1) renewal order may be made without a face-to-face examination of the patient by the Psychiatrist...If the emergency situation continues after the time frame for the renewal order has expired (constituting a total of six (6) hours or more), the psychiatrist must conduct a face-to-face examination of the patient before writing an order for continuation of Seclusion or Mechanical Restraint...If the emergency situation still exists after the time frame for the continuation order has expired (constituting a total of nine (9) hours or more for adults)...obtain a written or verbal/telephone renewal order...not to exceed an additional three (3) hours...One (1) renewal order may be made without a face-to-face examination of the patient by the Psychiatrist...."

Review of the hospital form titled Emergency Seclusion or Restraint Record, Page 2 revealed: "...To be completed by Psychiatrist...Physician Assessment (including:...3) patient's medical and behavioral condition...."

Pt #1's medical record contained an Emergency Seclusion or Restraint Record dated 4/29/11. Documentation included: "...Physical Restraint...Time Started 1145...Time Ended 1156...Mechanical Restraint...Time Started 1205...Time Ended 1320...Patient Precautions for Behavioral Emergencies...Cardiomyopathy--elevate HOB (Head of Bed) & monitor resp (respirations)...." The Physician Assessment completed at 1215, did not contain evaluation of the patient's medical condition.

Pt #1's medical record contained an Emergency Seclusion or Restraint Record dated 9/1/11. Documentation included: "...Physical Restraint...Time Started 0735...Time Ended 0736...Seclusion...Time Started 0737...Time Ended 2115...." The Physician Assessment completed at 0825 did not contain evaluation of the patient's medical condition. The documentation of the face-to-face examinations of the patient completed by the psychiatrist at 1330 and 1930 did not contain evaluation of the patient's medical condition.

Pt #2's medical record contained an Emergency Seclusion or Restraint Record dated 9/3/11. Documentation included: "...Physical Restraint...Time Started 0047...Time Ended 0117...Mechanical Restraint...Time Started 0117...Time ended 0330...." The psychiatrist noted in the Physician Assessment completed at 0113: "...She was found digging her wound with a toothbrush and was redirected and attempted to bang her head. She was place (sic) on (sic) physical hold. She was loud, wailing on the hallway...." The Physician Assessment did not contain evaluation of the patient's medical condition.

Pt #2's medical record contained an Emergency Seclusion or Restraint Record dated 9/3/11. Documentation included: "...Physical Restraint...Time Started 1615...Time Ended 1722...Mechanical Restraint...Time Started 1722...Time ended 1820...Patient Precautions for Behavioral Emergencies...History of asthma-stable-support airways...Other Precautions:...Past history of sexual molestation at age 15 y.o....." The Physician Assessment did not contain evaluation of the patient's medical condition.

Pt #3's medical record contained documentation of the following stable medical issues: "...Hypothyroidism, Hypertension, Dyslipidemia, Vitamin D Deficiency, Hyperemia...."

Pt #3's medical record contained an Emergency Seclusion or Restraint Record dated 1/22/12. Documentation included: "...Physical Restraint...Time Started 0808...Time Ended 0819...Seclusion...Time Started 0819...Time ended 1100...Patient Precautions for (Medical, Behavioral or Other):...elevate head & shoulders, monitor respiratory rate and effort...." The Physician Assessment completed at 0820 did not contain evaluation of the patient's medical condition.

On 2/23/12, the Performance Improvement Coordinator confirmed that none of the one hour face-to-face assessments completed by the physicians contained evaluation of the patients' medical conditions as required by hospital policy.