HospitalInspections.org

20148

Based on document review, interview, and observation, it was determined that the governing body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

CFR 482.13 Patient Rights

20148

Based on observation, medical record review and staff interview, it was determined that the facility failed to protect and promote each patient's rights.

Findings include:

1. The facility failed to ensure patient safety while patients are being restrained. (Cross refer to Tags A-0144 and A-0168)

2. The facility failed to implement its Plan of Correction (PoC) for restraint monitoring. (Cross refer to Tag A-0285)

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21953

Based on medical record review and review of facility policy and procedure, it was determined that the facility failed to ensure implementation of its policies for patient safety.

Findings include:

Reference #1: Facility policy and procedure Subject: 'ED Patients Requiring Monitoring for Safety' states, "... D. Types of Observation Status in the Emergency Department ... 3. Close Observation- Patients must be in open area and observed every 15 minutes. ... III. RELATED POLICIES: PCS: Close or Constant Observation of Patients."

Reference #2: Facility policy and procedure titled 'Close or Constant Observation of Patients' states, "... Procedure: ... Close Observation of Patients for Patient Safety ... 3. Documentation ... b. The assigned staff member is to document on --- Observation Sheet every 15 minutes."

1. Review of Medical Record #2 indicated that the patient arrived in the Emergency Department on 8/7/12 at 1:05 AM with the chief complaint of suicide with a plan. According to the nurses notes, "Pt [Patient] reports taking 10 ambien and smoking crack tonight ..."

a. Upon interview on 12/10/12 at 2:30 PM, Staff #1 stated that the "Observation Sheets" prior to 7:00 AM on 8/7/12 are missing from the medical record. Therefore, it can not be determined if the patient was being observed for safety every 15 minutes from 1:05 AM until 7:00 AM on 8/7/12, in accordance with facility policy.

2. Review of Medical Record #3 on 12/10/12 indicated that the patient arrived at the Emergency Department on 8/6/12 at 1958 for suicidal complaints. According to a nurses note at 2056, the patient took a couple of handfuls of Motrin and reports feeling suicidal, and was placed on close observation.

a. The 'One to One/ Q 15 Observation Documentation Sheet' dated 8/6/12 lacked evidence that Patient #3 was observed every 15 minutes at 0300, 0315, and 0330.

20148

Repeat Deficiency

Based on medical record review and review of facility policy and procedure, it was determined that the facility failed to ensure that patients are restrained in accordance with the order of a physician.
Findings include:
Reference: Facility policy titled "Restraints and Seclusion" states on page 7 of 20, "VI. NON-SELF DESTRUCTIVE, NONVIOLENT RESTRAINT: ... B. Physician Order and responsibility: 1. The attending physician or designee will write order in EHR time limited to 24 hours..."
1. Review of Medical Record #1 revealed the following:
a. According to the nursing documentation in the electronic medical record (EMR), the patient was placed in 4-point soft restraints for non-violent/non-self destructive behavior at 0800 on 8/28/12.
b. The order was placed in the EMR by the registered nurse on 8/28/12 at 1544 and co- signed by the physician on 8/28/12 at 2241.
c. The patient was in restraints without a valid physician's order from 0800 until 2241.
d. The above findings were confirmed by Staff #1 and Staff #2.

Based on review of QAPI activities for restraints, it was determined that the facility failed to ensure implementation of its Plan of Correction (PoC) for restraint monitoring from the full federal survey completed 6/7/12.

Findings include:

1. On 12/10/12, the facility's QA was reviewed for restraint monitoring. There was no evidence that the facility implemented its PoC. The facility's PoC from the 6/7/12 full federal survey indicated that the facility would review 30 medical records per month and if results are 95% or higher, the monitoring and review of 30 medical records will then be done on an ongoing quarterly basis to ensure the following:

a. Chemical Restraint is not used on patients.

b. Patients are in the correct restraint ordered.

c. Documentation is completed to indicate food and fluids were offered to a restrained patient.

d. Every 15 minute checks of patients restrained is documented as completed.

e. Assessments and interventions are documented when a patient is restrained.

2. The QA reviewed indicated that the facility reviewed 27 charts in July and 32 charts in August.

a. The data collected for July 2012 and August 2012 was not aggregated to ascertain if the monitoring results were 95% or higher to determine if the facility could decrease the monitoring to a quarterly basis, or if the results were less than 95% and the facility needed to continue monthly monitoring. This was confirmed by Staff #8.

b. There was no evidence of chart monitoring for restraint use for September, October, and November 2012. Staff #1 and Staff #8 confirmed on 12/10/12 at 1:45 PM that there was no monitoring done for these months.

c. Staff #8 provided random monitoring sheets that he/she completed on 33 charts in the month of October. Staff #8 confirmed that this monitoring was not aggregated and was not incorporated into the main QA activity for restraints.