HospitalInspections.org

Based on document review,observation and interview, it was determined the Hospital failed to promote and protect the rights of the patients. As a result, the Condition of Participation of Patient Rights, 42 CFR 482.13, was not met. This has the potential to affect all patients serviced by the LTAC with an average daily census of 25 patients.

Findings include:

1. The Hospital failed to ensure advance directive request was provided. See A-132

2. The Hospital failed to ensure personal privacy was protected. See A-143

3. The Hospital failed to ensure allegation of verbal sexual abuse/assault was reported, investigated and followed up on. See A-145

4. The Hospital failed to ensure physician order for the initiation of the restraint was obtained. See A-168.

5. The Hospital failed to ensure Medical Doctors ordering restraint and/or seclusion had a working knowledge of the Hospital's policy. See A-176.

Based on document review and interview, it was determined for 1 of 7 (Pt #1) patients reviewed for Advanced Directives, the Long Term Acute Care (LTAC) Hospital failed to ensure patient/family requests for Advance Directive information was provided. This has the potential to affect all patients serviced by the LTAC with an average daily census of 25 patients.

Findings include:

1. Pt #1's record was reviewed on 6/20/17 thru 6/21/17. Pt #1 was admitted to the LTAC on 4/7/17 with the diagnosis Meningitis. The following were noted related to Advance Directives:
a. On 4/7/17, the nursing admission assessment stated "Advance directive No advance directive information provided."
b. On 4/8/17, the form titled "Advance Directive and Patient Self-Determination", signed by Pt #1's spouse stated "Number 8 stated "If I request, I will receive information on the development of an Advance Directive." The box "Yes, I would like information." was marked."
c. On 4/11/17, the Case Management Social Services Initial Assessment lacked any information as to whether Pt #1 had an Advance Directive and/or whether information was provided as requested by Pt #1's spouse.

2. An interview was conducted with the Case Manager (E#4) on 6/20/17 at approximately 1:30 PM. E#4 had reviewed Pt #1's record and verbally agreed the record lacked documentation as to whether Advance Directive information was given as requested.

Based on observation and interview, it was determined for 2 of 6 High Acuity Unit (HAU) patient rooms (HAU2 and HAU6), the Long Term Acute Care (LTAC) Hospital failed to ensure patient personal privacy was protected. This has the potential to affect all patients serviced by the LTAC with an average daily census of 25.

Findings include:

1. An observational tour of the HAU was conducted on 6/20/17 at approximately 9:55 AM with the Case Manager (E#4). The HAU was observed to have 6 rooms with full length glass windows for the corridor walls of the patient rooms and patient doorways. The patients in rooms HAU2 and HAU6 were observed to have the curtains open and were observed laying in the beds with only a gown over them and easily visible from the hallway.

2. An interview was conducted with E#4 on 6/20/17 at approximately 10:00 AM. E#4 also observed the patients in HAU2 and HAU6 being visible from the hallway and being covered only in a gown. E#4 stated "They should have the curtains pulled for privacy."

Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient reviewed for an allegation of verbal sexual abuse/assault, the Long Term Acute Care (LTAC) Hospital failed to ensure allegations of verbal sexual abuse/assault were reported, investigated, and followed up on in accordance with its policy. This has the potential to affect all patients serviced by the LTAC with an average daily census of 25 patients.

Findings include:

1. The LTAC policy titled "Abuse and Neglect Suspected" (approved 3/2017) was reviewed on 6/20/17 at approximately 1:30 PM. The policy stated "PURPOSE ... to describe the procedures for preventing and responding to allegation of abuse, neglect or mistreatment of a patient... POLICY ... The Hospital maintains a strict policy to prevent or respond to allegations of abuse, neglect or mistreatment, including prompt reporting of any alleged abuse incident to hospital leaders... DEFINITIONS 1. Patient Abuse, Neglect, and/or Mistreatment is defined as any incident of physical, sexual, or verbal abuse, neglect, and/or mistreatment that is reported by the patient or family; or is witnessed reported, or suspected by an employee... 3. Verbal Abuse is any derogatory, threatening, derisive, or demeaning language... 5. Neglect/Mistreatment is the failure or refusal by any person having the care or custody of another... L. Failure to intervene or protect a patient from abuse/mistreatment by another (patient, employee, family member, etc.);... SUSPECTED ABUSE: FIRST RESPONDER/SUPERVISOR RESPONSIBILITIES The employee who first becomes aware of a patient who is said to be abused, neglected, mistreated and/or exploited must take all appropriate steps necessary to protect the patient, including but not limited to, reassignment of staff, removal of staff from patient care, and restriction of visitors... 3. Notify the CEO (Chief Executive Officer) or designee (Administrator On Call) immediately in any instance of reported, observed, or suspected patient abuse, neglect, mistreatment and/or exploitation. 4. Notify the patient's attending physician. 5. Document the allegations on a complaint form and enter as an event report... Investigation Guidelines 2. If the suspected abuse, neglect, mistreatment and/or exploitation involve an employee, the Hospital Chief Executive Officer will determine the action to be taken based on the investigation performed by appropriate Administration/Management..."

2. An observational tour of the High Acuity Unit (HAU) was conducted on 6/20/17 at approximately 9:55 AM with the Case Manager (E#4). The HAU is a 6 bed unit with full length glass windows for the corridor wall and doorway to the rooms. The unit is an "L" shaped unit with the patient rooms located along the "L" and the nursing station in the center. A telemetry monitor area is located at the central corner of the nursing station, directly facing HAU2, which is approximately 9 feet from the telemetry monitor.

3. Interviews were conducted 6/20/17 thru 6/21/17, with the Case Manager (E#4) present.
a. A phone interview was conducted with the Hospitalist (MD#1) on 6/21/17 at approximately 11:50 AM with the Case Manager (E#4) present. MD#1 had reviewed Pt #1's record for 4/7/17 thru 4/10/17 prior to the phone interview. MD#1 stated Pt #1 had one complaint "that I would label as an abuse complaint. It was just one, but it was a startling abuse complaint, shocking." MD#1 stated uncertainty as to the date but "the nurses were talking about it and called (the night shift supervisor-E#8) up. (E#8) was already there when I got there and said the (Pt #1's spouse) wanted to talk to me. The (Pt #1's spouse) said some male nurse said if (Pt #1) does something, I can't remember what, that (the male nurse) would rape (Pt #1) in the a.. (MD#1 spelled out the word). I asked the nursing supervisor (E#8) who all the male nurses were that worked that night and (E#8) said (E#8) was the only one. I asked (E#8) if (E#8) did this and (E#8) looked at me like 'Why would you even ask me that because we've worked together for years. I did instruct the (Pt #1's spouse) that (Pt #1's spouse) should report this to Administration. I don't know if (Pt #1's spouse) did. I didn't put it in my notes because I didn't think I should. Should I have? I rely on the nursing supervisors to relay information to Administration if they think it is necessary. Both (Pt #1's spouse) and the(Pt #1) were emphatic about it. I didn't think it was confusion and the patient believed what (Pt #1) said was true. (E#8) was standing right at the door (a glass door) and was visible and was talking and they didn't appear afraid."

b. An interview was conducted with the Case Manager (E#4) on 6/21/17 at approximately 12:05 PM. E#4 was present during MD#1's phone interview and stated "I'm shocked. The staff and the physician's know they are suppose to report these things (allegations of suspected abuse) to Administration. We (Administration) should have done an investigation and followed up on this. They (the staff) are inserviced on this every year. They know they are suppose to report it."

c. An interview was conducted with the Chief Executive Officer (E#3) on 6/21/17 at approximately 12:30 PM. E#3 stated "(E#4) has told me about the situation. I was not aware of it until now. Yes, we should have been aware of it..."

d. An interview was conducted with the Nursing Supervisor (E#8) on 6/21/17 at approximately 3:00 PM, with the Case Manager (E#4) present. "I kinda remember (Pt #1)... Throughout the night, (Pt #1) tried to get up I called Dr (MD#1) and (Pt #1's spouse) ... I think, but I may be thinking of another patient. I don't really remember. (E#10- a Telemetry Technician) would know. (E#10) makes comments to me about it all the time trying to be funny, but it's not ... (Pt #1) called me something along the lines of being a gay person just because I was a man and was a nurse. I just didn't go back in (Pt #1's) room. I don't remember why I called Dr. (MD#1) or who the nurses were that called me up there (to the HAU) to call (MD#1)."

e. A phone interview was conducted with the Telemetry Technician (E#10) on 6/21/17 at approximately 4:15 PM with the Case Manager (E#4) present. E#10 laughed and stated "I remember (Pt #1) well. (Pt #1) was in room 2 and was loud and screamed a lot and cussed a lot. I hear everything because of where I sit watching the monitors ... (Pt #1) was rude with (the Nursing Supervisor- E#8) and would be screaming, cussing, and thought (E#8) wanted to sexually assault (Pt #1) and said (E#8) wanted to rape (Pt #1). (Pt #1) would say that to the nurses. The nurse (E#6) said something to me about it too. I think it happened pretty early on (in the Hospitalization). (Pt #1) would refer to (E#8) as a F ....Stick (E#10 stated the word during the interview). I don't remember if I actually heard (Pt #1) say it. I could have just remembered being told. My role in reporting these things is a pretty passive one. The nurse was aware of the allegations being made, so again my role would be fairly passive."

f. An interview was conducted with the Registered Nurse (E#6) on 6/22/17 at approximately 8:15 AM with the Case Manager (E#4) present. E#6 stated "I do remember that (Pt #1) thought (E#8) was gay and that (Pt #1) thought (E#8) was wanting to rape (Pt #1). I didn't actually hear (E#8) say it but (Pt #1) said that (E#8) said it. I didn't do a report because (E#8) just would never say something like that."

4. Pt #1's record was reviewed 6/20/17 thru 6/21/17 with the Case Manager (E#4). Pt #1 was admitted to the LTAC on 4/7/17 with the diagnoses Meningitis and Osteomyelitis. The record lacked any nursing or physician documentation of Pt #1's allegations and/or assessments related to the stated allegations.

5. An interview was conducted with the Chief Clinical Officer (E#1), the Director of Quality (E#2), and E#4 on 6/22/17 at approximately 9:00 AM. All stated the allegations of Pt #1 should have been documented in the patient's record and should have been reported to Administration for investigation and was not. E#1 stated "It's not up to the staff to determine if it occurred. We (Administration) should be the ones to investigate it and determine if it's occurred or not. That's why we have policies in place to address things like this and it wasn't followed."

Based on document review and interview, it was determined for 1 of 2 (Pt#2) patients with restraints, the Long Term Acute Care (LTAC) Hospital failed to ensure a physician order was obtained as required by policy. This has the potential to affect all patients receiving care at the LTAC with an average daily census of 25 patients.

Findings include:.

1. The LTAC policy titled "Restraint Use" (Reviewed 3/2017) was reviewed on 6/20/17 at approximately 11:00 AM. The policy required "4. The RN initiates emergency use of restraints and obtains a telephone order from the physician".

2. The clinical record for Pt. #2 was reviewed on 8/2/16. The clinical record of Pt#2 was reviewed on 6/20/17 at approximately 10:45 AM. Pt#2 was admitted to the LTAC on 6/14/17 with a diagnosis of Respiratory Failure.
On 6/14/17 at 11:00 PM Registered Nurse (E#9) initiated a soft limb restraint on Pt#2's right arm. There was no order for the soft limb restraint.

3. On 6/20/17 at approximately 11:00 AM, an interview was conducted with the Director of Quality (E#2). E#2 had reviewed Pt #2's record and stated that "A physician order is to be obtained when restraints are applied."

Based on document review and interview, it was determined for 2 of 5 (MD-Medical Doctor #2 and MD #5) physicians whom have the ability to order the use of violent and/or non-violent restraints, the Long Term Acute Care (LTAC) Hospital failed to ensure MD's ordering restraint and/or seclusion had a working knowledge of the Hospital's policy. This has the potential to affect all inpatients serviced by the LTAC with an average daily census of 25.

Findings include:

1. The LTAC policy titled "Restraint Use" (revised 3/2017) was reviewed on 6/21/17 at approximately 11:30 AM. The policy stated "Training Of Staff ... 2. Physician's who order restraints shall be trained in the requirements of this policy and shall demonstrate a working knowledge of this policy through ongoing compliance."

2. The physician (MD#2 and MD#5) files were reviewed on 6/21/17 at approximately 1:40 PM with the Medical Staff Coordinator (E#7). The Chief Clinical Officer (E#1) and Director of Quality (E #2) were also present. The files of MD#2 and MD#5 lacked documentation the physicians had been trained and had a working knowledge of the LTAC's restraint policy.
a. MD#2- initial appointment 11/18/12 and reappointed 11/16/16.
b. MD#5- Initial appointment 11/29/11 and reappointed 12/4/16.

3. An interview was conducted with The Chief Clinical Officer (E#1) and Director of Quality (E #2) on 6/21/17 at approximately 1:40 PM.
E#1 and E #2 were in agreement that both physicians had no documentation to verify initial and/or updated restraint use education.