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Based on clinical record review, review of hospital policies, and staff interview for 8 of 11 patients admitted to the hospital, the hospital failed to ensure that the clinical record identified that patient's rights were reviewed on admission and/or that the information was provided in a language that the patient could understand. The findings include:

a. A review of the clinical records of Patients #5, #6, #7, #8, #9 and #10 lacked documentation that patient's rights were reviewed with each patient, on admission. Interview with Registered Nurse (RN) #2 on 8/10/11 at 2:30 PM identified that a brochure containing patient's rights information was provided to each patient on admission, and a nurse would review the information with every patient. RN #2 identified that the review of the patient's rights information was not documented in the clinical record, unless the nurse identified this in a nurses note.

b. Patient #2 was admitted to the hospital on 8/9/11 with a diagnosis of ascites. An interview with Registered Nurse (RN) #2 on 8/10/11 at 2:30 PM identified that Patient #2 was non-English speaking. Review of the clinical record identified that a Medicare inpatient and discharge rights form was signed by Patient #2 on 8/10/11. Despite the patient being non-English speaking, the information was written in English. The medical record lacked documentation that Medicare inpatient and discharge rights were explained/provided to Patient #2 in a language that the patient could understand.


The hospital's Patient's Rights and Responsibilities policy indicated that all patient's shall receive a copy of patient's rights and responsibilities on admission, be fully informed, and assisted in exercising their rights and responsibilities.

Based on clinical record reviews, review of hospital policies, and staff interview for 1 of 12 patients (Patient #2), the hospital failed to ensure that the plan of care identified an effective mode of communication for a non-English speaking patient. The findings include:

Patient #2 was admitted to the hospital on 8/9/11 with a diagnosis of ascites. An interview and review of the clinical record with Registered Nurse (RN) #2 on 8/10/11 at 2:30 PM identified that Patient #2 was non-English speaking. RN #2 identified that Patient #2's plan of care failed to identify the communication barrier and failed to identify interventions to ensure appropriate and effective communication, to enable the patient to participate in his/her plan of care.

Based on observations and interviews with hospital staff for 1 patient (Patient #2), the hospital failed to maintain confidentiality of the patients clinical record. The findings include:

Patient #2 was admitted to the hospital on 8/9/11 with a diagnosis of ascites. A tour of Unit N11 was conducted on 8/10/11 at 1:05 PM with the Director of Professional Development and Performance Improvement, Manager (Mgr.) #1 and Registered Nurse (RN) #1. Computer screens containing patient information were observed facing the hallway (public access area). Physician's orders for Patient #2 were in the process of review between two staff members on the computer screen. Patient #2's name and medication orders were clearly visible from approximately three feet behind the staff member while standing in the hallway. The observation was reviewed and verified by the Director of Professional Development and Performance Improvement, Manager (Mgr.) #1 and RN #1.

Based on clinical record reviews, review of policies, and interviews with staff for 2 of 8 patients (Patients #1 and #8) who were placed in medical restraints, the hospital failed to ensure that physician orders were obtained every twenty-four hours, per policy. The findings include:

a. Patient #1 was admitted to the hospital on 5/10/11 with diagnoses that included right sided cerebral vascular accident, respiratory failure requiring a tracheostomy, congestive heart failure, dysphagia requiring a feeding tube, and agitated delirium. Progress notes dated 5/31/11 through 8/2/11 indicated Patient #1 had agitation and delirium, the patient's medication regime was reviewed frequently, and medication changes were made. On 5/29/11 at 6:00 AM, P#1 attempted to climb out of bed, was combative, was pulling at tubes and lines, and a sitter was placed at Patient #1's bedside. Due to the patient's continued interference with medical lines and devices, a physician order for a medical restraint was written on 5/30/11 at 8:02 AM. Between 5/31/11 and 8/2/11, Patient #1 was assessed as requiring 2-point and 4-point restraints on most days, and had periods of time when the restraints were intermittently released. The clinical record was reviewed with the Director of Risk Management on 8/16/11 at 1:39 PM. The clinical record lacked medical restraint orders on 6/1/11, 6/2/11, 6/4/11, 6/5/11 and 6/6/11, while the patient was in restraints.
According to the hospital Medical Restraint policy, the Medical Doctor (MD) is to write an order for the medical restraint each calendar day and medical restraint orders expire every twenty-four hours.

b. Patient #8 was admitted on 7/5/11 and underwent a coronary artery by-pass with valve replacement. Between 7/6/11 and 8/10/11, the patient was placed in medical restraints intermittently to protect critical lines and medical devices. The clinical record was reviewed with the Nurse Manager and Director of Quality on 8/11/11 at 11:45 AM. The clinical record lacked medical restraint orders on 7/20/11, 7/21/11, 7/22/11, 7/31/11, 8/1/11, 8/2/11, 8/3/11, and 8/4/11.

Based on clinical record review, interviews with staff, and review of policies for 1 of 2 patients (Patient #4) who required behavioral restraints, the hospital failed to ensure that the restraints were discontinued at the earliest possible time. The findings include:

Patient #4 was admitted to the emergency department on 7/26/11 following an unprovoked assault on a staff member at the patient's place of residence. The patient had a history of dementia and was assessed as combative, aggressive, and unable to follow directions. Patient #4 was placed in 4-point soft behavioral restraints from 7/26/11 at 3:43 PM to 7/27/11 at 12:30 AM. Review of the restraint flow sheets identified that from 7/26/11 at 9:15 PM to 7/27/11 at 12:30 AM (3 hours and 15 minutes), Patient #4 remained in restraints despite being identified as sleeping and/or without behaviors necessitating the restraints. According to the hospital's restraint policy, restraints occur no longer than absolutely necessary.