HospitalInspections.org

Based on policy and procedure review, patient medical record review, and staff interview, the facility case management staff failed to inform the patient, or patient's representative, of their rights regarding the Medicare Important Message document/information, as per facility policy, for 2 of 2 Medicare patients. (pts. #1 and #3)

Findings:
1. at 5:00 PM on 10/24/12, review of the policy and procedure "Notification of Discharge Appeal Rights", with a most recent revision date of 1/11 (no policy number), indicated:
a. under section "I. Policy Statement", it reads: "The Important Message from Medicare (IM) will be given to all Medicare...Beneficiaries admitted to [facility]...The follow-up copy of the IM, informing the beneficiary or his/her designated representative of his/her right to an expedited review of the planned discharge, will be given to the beneficiary no more than two (2) days prior to discharge."
b. under section "IV. Procedure", it reads: "A. All patients with Medicare as their primary or secondary payer, and all Medicare Advantage patients will receive the IM within two days of admission to [facility]..."

2. review of patient medical records on 10/24/12 indicated:
a. pt. #1 was admitted on 9/21/12, discharged 10/4/12, and lacked documentation related to the supplying of the Medicare IM to the patient or POA prior to discharge on 10/4/12

b. pt. #3 was admitted on 9/5/12 and had:
A. the earliest Medicare important message form in the medical record dated 9/15/12 (at 1742 hours) with "verbal" noted in the area "Signature of Patient or Representative" with two witnesses signing in that same area after the "verbal" notation (this was 10 days post admission for supplying this information to the patient or their representative)
B. another Medicare important message form in the chart dated 9/17/12 (no further signatures noted)
C. a note in the case manager section of the medical record indicating the "IM-Medicare letter given to patient" was on 9/17/12 (no time noted)

3. at 3:30 PM on 10/24/12, interview with staff members #52 and #53, the Director of Nursing and 7th floor nursing unit manager respectively, indicated:
a. there is no documentation in the medical record for pt. #1 that would indicate the patient or their representative received the Medicare IM form within two days of their discharge on 10/4/12
b. there is no documentation in the medical record for patient #3 that would indicate the patient or their representative received the Medicare IM form within two days of admission as the first one noted in the record was 10 days after admission

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that an order was received for restraints used on 2 of 3 patients (pts. # 2 and #3), and failed to ensure that physicians ordered the type of restraint to be utilized for patients for 1 of 3 records reviewed. (Pt. #2)

Findings:
1. at 11:15 AM on 10/24/12, review of the policy and procedure "Restraint - Seclusion", with a most recent review/revision date of 8/12, and no policy date, indicated:
a. on page one under "Emergency", it reads: "Restraint-Seclusion is used only when there is an imminent risk of the patient harming self or others, including staff. If it is an emergency, staff can place the patient into restraint-seclusion and then obtain orders immediately, or as soon as reasonably possible, afterwards."
b. on page one under "Orders", it reads: "Only a physician can order restraint-seclusion. Orders should precede restraint-seclusion..."

2. review of patient medical records on 10/24/12 indicated:
a. pt. #2 had:
A. documentation of a "waist belt" at 1956 hours on 9/21/12, but lacked a physician's order for this type of restraint
B. a blank section on the restraint order form "EBM 54500 Restraint - Seclusion, in the area for documenting the type(s) of restraint ordered by the physician (form authenticated by the practitioner at 7:55 AM on 9/24/12)

b. pt. #3 had:
A. physician's orders on 9/6/12 at 1019 hours for "soft wrist" restraints
B. nursing documentation on 9/11/12 that the patient had "Ankle-both" restraints on at 1256 hours and 1456 hours, but lacked a physician order for ankle restraints

3. at 3:30 PM on 10/24/12, (and during a phone interview at 2:00 PM on 10/29/12 for follow up) staff members #52, the Director of Nursing, and #53, the RN (registered nurse) manager of the 7th floor nursing unit, indicated:
a. the waist belt documented for patient #2 had no physician order
b patient #2 was documented by nursing staff as being restrained with soft wrist restraints at 1156 hours, 1302 hours, and 1556 hours on 9/21/12
c. pt. #2 was noted by nursing to have "ankle-both" and "waist belt" restraints at 1956 hours on 9/21/12
d. pt. #2 had no restraint type(s) noted on the order authenticated by the physician on 9/24/12
e. the ankle restraints documented twice for patient #3 had no physician order for their use
f. the restraint policy (see #1. above) does not specify that the physician ordering restraints must order the type of restraint

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that physician orders were not written as PRN (as needed) for 2 of 3 patients.
(pts. #1 and # 3)

Findings:
1. at 11:15 AM on 10/24/12, review of the policy and procedure "Restraint - Seclusion", with a most recent review/revision date of 8/12, and no policy date, indicated:
a. on page one under the "Orders" section, it reads: "...Restraint-seclusion orders must never be written as a standing order or "as needed" (PRN)"

2. review of patient medical records during the survey process of 10/24/12 indicated:
a. pt. #1 had:
A. physician's orders at 0815 hours on 9/27/12 were to "D/C (discontinue) Restrains [restraints] while awake & during daytime..."
b. pt. #3 had:
A. at 1030 hours on 9/6/12, a telephone order written by nursing for: "Restraints on UE (upper extremities) when on BiPap"

3. at 3:30 PM on 10/24/12, interview with staff members #52, the Director of Nursing, and #53, the RN (registered nurse) manager of the 7th floor nursing unit, indicated:
a. the order for restraints to be off while the patient is awake and during daytime hours for pt. #1 is a PRN/standing order
b. the order for restraints to be on when the patient is on the BiPap machine for pt.. #3 is a standing order
c. the orders for patients #1 and #3 should not have been written as they were, per facility policy
d. once the patient has restraints released, a new order must be written to re apply restraints

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that restrained patients were documented as being monitored, related to the restraints, at least every two hours, per facility policy, for 3 of 3 patients (pts. #1, #2, and #3).

Findings:
1. at 11:15 AM on 10/24/12, review of the policy and procedure "Restraint - Seclusion", with no policy number and a review/revision date of 8/12, indicated:
a. on page one under "Orders", it reads: "...If the restraint-seclusion is removed (or additional elements are added to the current restraint-seclusion), a NEW order is necessary."
b. on page one under "Monitoring", it reads: "The need for restraint-seclusion is assessed (circulation, sensation, movement, skin integrity) on an ongoing basis and documented at least every 2 hours..."

2. review of patient medical records on 10/24/12 indicated:
a. pt. #1 had soft wrist restraints ordered for safety, [pulling at IV (intravenous) Central Line, NG (naso gastric) tube, and Foley catheter], lacked documentation of every two hour monitoring, related to the restraint assessments, as follows:
A. between 2136 hours on 9/21/12 and 0136 hours on 9/22/12
B. on 9/22/12 between 0339 hours and 0548 hours; between 0548 hours and 0844 hours; between 0844 hours and 1221 hours; between 1221 hours and 1514 hours; and between 1514 hours and 1736 hours
C. between 0432 hours on 9/23/12 and 0530 hours on 9/24/12
D. between 0530 hours on 9/24/12 and 0536 hours on 9/25/12, and between 0536 hours and 0936 hours on 9/25/12
E. between 0936 hours on 9/25/12 and 0535 hours on 9/26/12; between 0535 hours and 1530 hours (also a note at 1536); and between 1536 hours and 1900 hours
F. between 1900 hours on 9/26/12 and 0101 hours on 9/27/12; between 0230 hours and 0536 hours; and between 0936 hours and 1805 hours
G. between 0210 hours and 0428 hours; between 0428 hours and 0736 hours; and between 1336 hours and 1736 hours on 9/28/12

b. pt. #2 lacked every two hours monitoring and reassessment documentation while the patient was restrained (soft wrist restraints, soft ankle restraints, and/or waist restraints) for safety related to agitation/combativeness due to alcohol detoxing as follows:
A. between 1302 hours and 1556 hours on 9/23/12
B. between 1556 hours and 1956 hours on 9/23/12

c. pt. #3 had soft wrist restraints ordered for safety, pulling at IV and BiPap, and lacked documentation of every two hour monitoring, related to the restraint assessments, as follows:
A. between 1106 hours and 1701 hours on 9/6/12
B. between 1701 hours on 9/6/12 and 0256 hours on 9/7/12
C. between 0256 hours and 1256 hours; between 1256 hours and 1604 hours (skin assessment) and 1646 hours (specific to restraints) on 9/7/12
D. between 1646 hours on 9/7/12 and 0445 hours on 9/8/12
E. between 0445 hours on 9/8/12 and 1256 hours on 9/9/12; between 1256 hours and 1700 hours; and between 1700 hours and 2201 hours on 9/9/12
F. between 0005 hours and 0239 hours; between 0239 hours and 0508 hours; between 0508 hours and 0722 hours; and between 0722 hours and 0933 hours on 9/10/12
G. between 1302 hours on 9/10/12 and 0359 hours on 9/11/12; between 0359 hours and 1256 hours; and between 1456 hours and 2000 hours on 9/11/12
H. between 0551 hours and 0856 hours on 9/12/12
I. between 0056 hours and 0429 hours on 9/13/12,

3. at 3:30 PM on 10/24/12, interview with staff members #52, the Director of Nursing, and #53, the RN (registered nurse) manager of the 7th floor nursing unit, indicated:
a. review of the patient medical records #1, #2 and #3 on line with the surveyor indicated nursing documentation related to restraint assessment is greater than every 2 hours, as required by facility policy for all three patients as listed in 2. above
b. patients are documented as being rounded on and monitored more frequently than every two hours, but restraint documentation and assessments are not per facility policy
c. it is thought that some of the greater gaps in documentation were when the patients had restraints discontinued, but no new orders were received once restraints were re instituted as is required per facility policy
d. nursing is not documenting when restraints are initiated and when they are discontinued making it difficult to tell when restraints are actually on or off

Based on patient medical record review, and staff interview, the nursing supervisor failed to ensure that nursing staff documented the implementation of physician ordered nutritional supplements for 2 of 2 patients with supplements ordered (pts. #1 and #3) and failed to document patient meal intake as per standards of practice (three meals/day) for 3 of 3 patients. (pts. #1, #2 and #3)

Findings:
1. review of patient medical records on 10/24/12, indicated (in the I & O--intake and output--section of the records):

a. pt. #1 was admitted NPO (to be without oral intake) on 9/21/12, had tube feedings until 9/28/12 with orders to begin a dental soft diet on 9/28/12, had a physician's order at 9:00 AM on 9/29/12 to begin Ensure "with meals TID (three times a day)" as a nutritional supplement, and:
A. lacked documentation of 1 of 3 meals on 9/29/12, 9/30/12 and 10/3/12
B. lacked documentation of 2 of 3 meals on 10/2/12
C. lacked documentation of Ensure being provided with any meals from 9/29/12 (when ordered) through discharge on 10/4/12

b. pt. #2 was admitted NPO on 9/21/12, had physician's orders on 9/23/12 to change the patient's diet to clear liquids and "advance as tolerated", and:
A. lacked documentation of 1 of 3 meals on 9/24/12 and 9/25/12

c. pt. #3 was admitted on 9/5/12, had orders on 9/6/12 to be NPO then later on 9/6/12 (9:05 PM) to change the patient's diet to "...clear liquids/advance to regular diet as tolerated...", had physician's orders on 9/8/12 at 6:15 PM for "Ensure Plus 2 can[s]/day", and:
A. lacked documentation of 1 of 3 meals on 9/9/12, 9/11/12, and 9/16/12
B. lacked documentation of 2 of 3 meals on 9/7/12, 9/8/12, 9/10/12, 9/13/12, 9/14/12, and 9/18/12
C. lacked documemtation of Ensure Plus being provided (2 cans/day, as per order) from 9/8/12 to discharge on 9/18/12

2. at 3:30 PM on 10/24/12, interview with staff members #52 and #53, the Director of Nursing and 7th floor nursing unit manager respectively, indicated:
a. there is no policy and procedure related to documentation of meals and/or supplements
b. nursing staff work 12 hour shifts (3 AM to 3 PM and 3 PM to 3 AM) so that most I & O is documented two times/day
c. meals at the facility are per room service so that nursing staff aren't always aware when meal trays are supplied to patients
d. it is thought that the dietary staff notify the patient and/or nursing staff if patients fail to order a meal during specific meal times, but the details of this process are not clear for these staff members
e. there is no specific place in the medical record for nursing to document supplemental feedings to ensure that physician orders are carried out, such as for pt. #1 where Ensure was ordered TID and for pt. #3 had Ensure Plus ordered for two times/day
f. it cannot be determined that pts. #1 and #3 received supplements as ordered, or how much was taken by the patient when it was offered as the documented ml (milliliters) taken po (orally) includes all liquid intake
g. it is a standard of practice that three meals/day are offered to patients, but it cannot be determined that pts. #1, #2, and #3 received three meals each day with documentation of % eaten only documented once a day or twice a day as listed in 1. above

Based on policy and procedure review, patient medical record review (of case management notes), and staff interview, the facility failed to ensure complete documentation of discharge planning that included the patient and/or family for 1 of 3 patient records reviewed. (pt. #3)

Findings:
1. at 11:25 AM on 10/24/12, review of the policy and procedure "Discharge Planning, Main Unit", with no policy number and a last revision date of 1/11, indicated:
a. under section "I. Policy Statement", it reads: "...Outcomes:...B. Facilitate a smooth transition from one level of care to another...F. The discharge planning process is multi-disciplinary in nature based on the patient's health care needs. It involves the patient, his/her family, ..."
b. on page two under section "II. Procedure", it reads: "...D. This information will be communicated in terms the patient and/or his/her family can understand. Feedback should be solicited from them regarding their level of understanding..."

2. review of case management notes in patient medical records reviewed during the survey process of 10/24/12 indicated:
a. pt. #3 had documentation as follows:
A. the first note of discharge discussion with family was at 1101 hours on 9/7/12 with notation of a "preferred facility" per the family
B. a note on 9/13/12 at 1539 hours indicated more discussion with family related to "possible" ECF (extended care facility) placement at a different (2nd) facility
C. at 1701 hours on 9/17/12, case management listed a 3rd facility that was "called" for a referral without any indication that family was part of this decision/referral
D. on 9/18/12 at 1700 hours, charting reads: "Pt ready for discharge today. Transportation arranged with the facility (#3) for 3:15 PM pick up today. Nursing staff and pt's [family member] notified."

3. at 3:30 PM on 10/24/12, interview with staff members #52, the Director of Nursing, and #53, the RN (registered nurse) manager of the 7th floor nursing unit, indicated:
a. it is not clear why a third ECF was notified for a referral for pt. #3
b. there is no documentation that transfer to the third ECF was discussed/planned with the patient's family
c. documentation is lacking as to the time of notification to the patient's family regarding the patient's transfer