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Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Patient Rights. This failure had the potential to affect all patients receiving services in the hospital.

The facility failed to ensure compliance with restraint/seclusion requirements:

The facility failed to identify and treat antipsychotic and sedative medications given intramuscularly (IM) to control patient aggressive behaviors as restraints:

a. the restraint policy was unclear that IM emergency medications given to control aggressive, violent behaviors were considered restraints. The policy did not address all regulatory requirements for restraint usage regarding drug restraints.

b. nursing staff failed to verbalize that IM emergency medications used to control a patient's aggressive behaviors were restraints;

c. record review of 2 of 2 sampled patient records showed they received IM antipsychotic & sedative drugs to control their violent and aggressive behaviors (Patient #6 & #7). There was no required post-administration documentation of patient monitoring or face-to-face assessments 1-hour post restraint initiation (refer to Tags A-0175 and A-0179).

Refer to Tag A-0160

Based on interview and record review, the facility failed to uphold the patient's right to develop his / her plan of care regarding a possible surrogate decision-maker. The facility failed to inquire about the presence of of a Durable Power of Attorney for Healthcare / Medical Power of Attorney (MPOA) for 4 of 6 current sampled patients ( Patient ID# 1,2,3,4).

Refer to Tag A-0130

Based on interview and record review, the facility failed to uphold the patient's right to formulate an advance directive and / or to ensure copy of their advance directive was placed in their medical record. The facility failed to inquire about the presence of an advance directive for 4 of 6 current sampled patients ( Patient ID# 1,2,3,4 ).


Refer to Tag A-0132

Based on interview and record review, the facility failed to uphold the patient's right to develop his / her plan of care regarding a possible surrogate decision-maker. The facility failed to inquire about the presence of of a Durable Power of Attorney for Healthcare / Medical Power of Attorney (MPOA) for 4 of 6 current sampled patients ( Patient ID# 1,2,3,4).

Findings included :

Record review of facility policy titled "Advance Directives, Medical Power of Attorney, Out of Hospital Do Not Resuscitate [DNR], Mental Health Declaration", last review date 11/2020, showed:

-Duty of Hospital to Comply with Medical Power of Attorney: If the hospital knows of the existence of an MPOA , the hospital shall follow the directive of the Principal's Agent to the extent it is consistent with desires of the Principal. [Policy definition of Principal: adult who has executed an MPOA]. The policy did not describe the process of determining the presence of an MPOA. This query is included in the electronic medical record during the admission process.

Review of six(6) current patient electronic medical records (EMR) with Staff ID -E, registered nurse (RN) charge, showed an area titled " Health History Assessment." Staff ID -E stated this section contained multiple questions and was completed by a registered nurse [RN] during the patient admission process.

Two (2) of the questions were as follows:

1. " Durable Power of Attorney for Healthcare " YES/NO? ; "Durable Power of Attorney agent name and phone number "

2. "Surrogate decision maker " YES/NO ? ; "Surrogate decision maker name and phone number "

Review of the current sampled patient EMRs showed that 4 of 6 records were left blank with respect to a Durable Power of Attorney and Surrogate decision maker [Patient ID # 1,2,3,4].

During an interview with Staff-E during the EMR review, she stated these areas should have been completed.

Based on interview and record review, the facility failed to uphold the patient's right to formulate an advance directive / and or to ensure copy of their advance directive was placed in their medical record. The facility failed to inquire about the presence of an advance directive for 4 of 6 current sampled patients ( Patient ID# 1,2,3,4 ).

Findings included :

Record review of facility policy titled "Advance Directives, Medical Power of Attorney, Out of Hospital Do Not Resuscitate [DNR], Mental Health Declaration", last review date 11/2020, showed:

-Upon admission to the unit, the patient's nurse will determine if the patient has been asked about Advance Directives.
-This information will be documented in the Admission Assessment Form.
-If patient/family indicate these directives have been executed, the nurse will obtain copies or request they be brought in and place them in the patient's medical record.

Review of six(6) current patient electronic medical records (EMR) with Staff ID -E, RN charge, showed an area titled " Health History Assessment." Staff ID -E stated this section contained multiple questions and was completed by an RN during the patient admission process.

Two (2) of the questions were as follows:

1. "Do you have a advance directive ?" " YES/NO"

2. "Copy of advance directive in chart?" YES/NO"

Review of the current sampled patient EMRs showed that 4 of 6 records were left blank with respect to Advance Directives [Patient ID # 1,2,3,4].

During an interview with Staff-E during the EMR review, she stated these questions should have been completed. "We do not know if these patients have advance directives."

Record review of Patient# 1's admission "History & Physical" exam, dated 8/29/2023, showed documentation that he did have advance directive. There was no copy of this located in the paper or electronic medical record.

Based on record review and interview, the facility failed to identify and treat intramuscular (IM) antipsychotic and sedative medications used to control patients during behavioral emergencies as restraints:

A. The facility restraint policy was unclear that IM emergency medications were drug restraints and did not address all regulatory requirements for restraint usage;

B. Nursing staff were unaware that IM emergency medications used to control a patient's aggressive behaviors were restraints;

C. Record review of 2 of 2 sampled patient records showed they received IM antipsychotic & sedative drugs to control their violent and aggressive behaviors (Patient #6 & #7). There was no required post-administration documentation of patient monitoring or face-to-face assessments 1-hour post restraint initiation (refer to Tags A-0175 and A-0179).


Findings included:


A. Facility restraint policy


Review of facility policy #13843520 titled "Patient Restraint Policy Cog.Cog.001-July", last revised 06/2023 revealed that it did not state IM emergency medications used to control patients' aggressive behaviors were restraints. The policy did not reference the requirements for: restraint order, face-to-face assessment, required patient monitoring for emergency drugs used as restraints (*not all inclusive of requirements).

Further review of the policy showed there was a section titled "Drugs as restraints" and a section titled "Standards Treatment". However; the policy failed to provide specific guidance for staff decision-making related to administration of IM antipsychotics and IM sedatives used in behavioral emergencies.

B. Nursing staff unaware IM emergency medications were restraints:


In an interview on 9/6/23 at 10:30 am, Behavioral Health Unit (BHU) Nurse Manager-Staff #J stated there had been no incidences of restraints for at least two years in the BHU. Record review at the time of interview of facility's Restraint & Seclusion log for 2023 showed there were no incidents of restraints documented.

In an interview on 9/6/23 at 2:45 pm, BHU Manager-Staff #J stated that intramuscular (IM) antipsychotic and sedative medications given to patients during behavioral emergencies to control their behavior were not considered restraints because the patients were not physically held during the administration of those drugs. Staff #J also stated that antipsychotics and sedatives given IM for behavioral emergencies were not logged or tracked.

In an interview on 9/6/23 at 2:50, VP of Quality-Staff #B stated that the facility did not consider the use of emergency behavioral medications to be restraints.

C. Lack of patient monitoring and face-to- face assessments:

(*please refer to Tags A-0175 and A-0179)

Based on record review and interview, the facility failed to ensure 2 of 2 patients who received intramuscular (IM) antipsychotic & sedative drug restraints (Patient #6 & #7) were monitored and assessed appropriately.

Findings included:

Review of facility policy#13843520 titled "Patient Restraint Policy Cog.Cog.001-July", last revised 06/2023, showed that patients are to be assessed by an RN immediately after restraints are initiated and monitored at least every two hours or more, which includes assessment of circulation, respiratory system, cardiac status, psychological status, cognitive functioning, and patient's understanding of reasons for restraint.

In an interview on 9/6/23 at 2:45 pm, Behavioral Health Unit (BHU) Manager-Staff #J stated that intramuscular (IM) antipsychotic and sedative medications given to patients during emergencies to control behavior were not considered restraints because the patients were not physically held during the administration of those drugs.

Staff #J also stated that because the emergency drug administrations were not considered restraints, no monitoring of the patient was done post administration.

In an interview on 9/6/23 at 2:50, VP of Quality-Staff #B stated that that the facility did not consider the use of emergency behavioral medications as restraints.

Record review of Patient #6's clinical chart showed she received drug restraints on 8/24/23 at 8:04 pm for violent behavior. The "Emergent medication" administered consisted of Haldol 5 mg IM, Ativan 1 mg IM, and Benadryl 25 mg IM one time.

On 9/4/23 at 11:01 am, the patient was again administered drug restraints for violent behavior which consisted of Haldol 5 mg IM, Ativan 1 mg IM, and Benadryl 25 mg IM once, while three staff held her during administration "to maintain safety".

For both the 8/24/23 & 9/4/23 drug restraints, there was no evidence the patient was monitored and assessed after restraint initiation.

Record review of Patient #7's clinical records showed that the patient received drug restraints for violent behavior twice:

On 8/29/23 at 12:22 am, patient was aggressive with staff and given Haldol 5 mg IM, Ativan 2 mg IM, and Benadryl 25 mg IM.

On 9/2/23 at 10:32 am, the patient became very aggressive and was given Haldol 5 mg IM, Ativan 2 mg IM, and Benadryl 25 mg IM.

For both 8/29/23 and 9/2/23 drug restraints, there was no evidence the patient was monitored and assessed after restraint initiation.

Based on interview and record review, the facility failed to ensure that 2 of 2 patients who received intramuscular emergency medications (Patient #6 & #7) received a face-to-face assessment within one hour post initiation of the restraint.

Findings included:

Review of facility policy#13843520 titled "Patient Restraint Policy Cog.Cog.001-July", last revised 06/2023, (page 6 of 19) showed that a face-to-face assessment must be done within one hour after the administration of medication used to manage violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, staff members, or others.

In an interview on 9/6/23 at 2:45 pm, Behavioral Health Unit Nurse Manager-Staff #J stated that intramuscular (IM) antipsychotic and sedative medications given to patients during behavioral emergencies to control behavior were not considered restraints because the patients were not physically held during the administration of those drugs.

Staff #J also stated that because the emergency drug administrations were not considered restraints, no face-to-face assessment was performed within one hour post administration.

In an interview on 9/6/23 at 2:50, VP of Quality-Staff #B stated that that the facility did not consider the use of emergency behavioral medications to be restraints.

Record review of Patient #6's clinical records showed she received drug restraints on 8/24/23 at 8:04 pm for violent behavior. The "Emergent medication" consisted of Haldol 5 mg IM, Ativan 1 mg IM, and Benadryl 25 mg IM, given one time.

On 9/4/23 at 11:01 am, the patient was again administered drug restraints for violent behavior which consisted of Haldol 5 mg IM, Ativan 1 mg IM, and Benadryl 25 mg IM given once, while three staff held patient during administration "to maintain safety".

For both the 8/24/23 & 9/4/23 drug restraints, there was no evidence the patient received a face-to-face assessment within one hour post initiation of the restraints.

Record review of Patient #7's clinical chart showed that the patient received drug restraints for violent behavior twice:

8/29/23 at 12:22 am; patient was aggressive with staff and given Haldol 5 mg IM, Ativan 2 mg IM, and Benadryl 25 mg IM, one time.

On 9/2/23 at 10:32 am, the patient became very aggressive and was given Haldol 5 mg IM, Ativan 2 mg IM, and Benadryl 25 mg IM.

For both 8/29/23 and 9/2/23 drug restraints, there was no evidence the patient received a face-to-face assessment within one hour post initiation of the restraints.

Based on observation, interview, and record review, nursing staff failed to evaluate and meet patient care needs regarding education. Nursing staff failed to provide patient / family education per policy regarding continuous visual monitoring ["TeleSitter"] for 3 of 3 current patients (Patient ID #1, 2, 10).

Findings included:

Review of facility policy titled" Continuous Visual Monitoring for Patent Safety Using the AvaSure TeleSitter Solution," last reviewed 8/2023, showed:

Primary RN: Document all communication in the patient electronic health record as a nursing intervention to include: education of patient and family.

Patient and Family Education :

Educate the patient and family on continuous visual monitoring using the AvaSure Telesitter.
Provide the patient and family a copy of the educational handout.
Document all education, including patient and family teach-back response and any follow-up needed in the patient's electronic education record.

Observation during a tour of the 4th floor on 09/06/2023 between 10 AM and 11:30 AM showed the rooms of two(2) patients ( ID # 1, 2) had small green flags posted at the top of their door frames. During an interview at the time of observation with Staff -O, RN, she stated the flags meant those patients were under continuous video surveillance; usually due to being at high risk for falls. The patients on this TeleSitter were being monitored continuously by a technician located on the 2nd floor. This "TeleSitter" tech could also verbally communicate with the patient through the monitoring system.

Review of the current sampled patients placed on AvaSure TeleSitter [Patients ID # 1, 2, 10] with Staff-E, RN, failed to show any documented education was provided by nursing to the patient or family,including the provision of the educational handout per the policy. Staff E said this education was a nursing responsibility.

During an interview on 09/06/2023 at 2:05 PM with Staff-M, Director of Clinical Operations, he stated he was one of the two persons responsible for the AvaSure TeleSitter program. He said the techs educate the patient and family (if present) when they bring the monitor into the room. Staff -M was asked where this education was documented. He said the techs did not have access to document in the medical records.

Record review showed Patients # 1, 2, 10 signed a general consent [ Conditions of Admission and Consent for Inpatient Care ] for "photographs, and video, digital and audio recordings" upon admission.

Based on interview and record review, the facility failed to ensure a current History & Physical examination was placed in the patient's record prior to surgery [citing Patient ID # 4 ].

Findings included:

Record review of the facility "Medical Staff Rules & Regulations,"last revised 07/2019, showed: " a complete medical history & physical examination must be performed and documented within 24 hours of admission...but in all cases prior to surgery or procedures involving anesthesia services,...all clinical entries in the patient's medical record shall be accurately timed and dated"

Record review on 09/06/2023 of Patient ID # 4's medical record with Staff-E, RN showed a handwritten History & Physical examination that was not dated or timed. Staff -E, RN verified this finding and said there was no way to show when this H & P was completed , as it was not dated and timed.

During an interview on 09/06/2023 at 11:10 AM with Patient # 4's primary nurse, Staff -ID-X, she stated this patient underwent an open hernia repair yesterday ( 9/5/2023) and was having issues with the incision.

Based on record review and interview, the facility failed to ensure a fully completed informed consent for Patient ID # .

Findings included:

Record review of facility policy titled " Consents/Refusals," last reviewed 01/2022, showed: Documentation: A properly executed disclosure and consent for medical treatment form will contain: c. Name of responsible practitioner who is performing the procedure.

Record review of the facility "Medical Staff Rules & Regulations,"last revised 07/2019, showed: "Consents: a consent form shall be obtained by the physician or other licensed independent practitioner.....all clinical entries in the patient's medical record shall be accurately timed and dated"

Record review of Patient ID #1's medical record with Staff-E, RN, showed a consent form for a Midline catheter insertion. Consent showed:

-sentence that read: "My PICC line will be inserted by:_________ [showed an illegible name with no credentials listed after the name].

-"Proceduralist" signature at the bottom of the consent form [Box tabled "Date/Time"] showed an incomplete date and no time.

During an interview at the time of review with Staff-E, she stated the facility uses a PICC line team so the staff person was likely a specially trained RN She said the credentials should have been listed after the staff person's name/ signature and the consent should have been dated and timed by the staff completing it.