HospitalInspections.org

Based on staff interviews and a review of facility documents, it was determined the facility's governing body failed to ensure the hospital-wide quality program included data from their contracted dialysis service.

The findings were:

On 11/18/15 at 3:53 p.m., the Vice President of Patient Care Services (VP-PCS) was notified by the surveyor, via phone, that evidence of quality data from the facility's contracted dialysis services had not been found in the quality documentation provided. The Vice President stated he/she would check for that information. At 4:20 p.m. on the same day, the VP-PCS was interviewed in person. He/She stated evidence of the quality data from the contracted dialysis services was not found. He/She explained that approximately 18 months prior to the survey, there had a been a change in the way the contracted company managed the staff they provided to the facility and that since that change, he/she didn't recall receiving their quality information. The Vice President acknowledged that the missing quality information had not been identified before now and stated that the contracted dialysis company used to provide their quality data consistently. The VP-PCS informed the surveyor that he/she had called the facility's Quality Director (who was out of town at the time of the survey) to ask about dialysis quality data. Even after speaking with the Quality Director, the facility staff was unable to provide evidence of the contracted dialysis quality data. The VP-PCS informed the facility's Chief Executive Officer (CEO) of this quality data omission on 11/18/15 at approximately 4:30 p.m.

See tag A-0308 for details related to Quality Assessment Performance Improvement (QAPI).

Based on interviews and document review, it was determined the facility staff failed to ensure physician orders for restraints were obtained in a timely manner for 2 of 4 patients sampled for restraint use (Patient #3 and Patient #4).

The findings include:

1. Patient #4 was documented to have restraints in use on 10/2/15 at 4:15 AM; the order for the restraints was dated and timed as 10/2/15 at 6:00 AM.

Review of Patient #4's clinical documentation with registered nurse (RN) #1 and RN #2 on the afternoon of 11/17/15 revealed documentation that indicated soft bilateral wrist restraints were in use at 4:15 AM on 10/2/15. The physician order for the aforementioned restraints was documented on 10/2/15 at 6:00 AM; this order was 1 hour and 45 minutes after the restraints were documented as being in use.

The following information was found in a document entitled "Restraints ((facility initials removed) Policy)": "Emergency Order ... If the application of a restraint is an emergency, the restraint can be applied and physician order obtained either during the emergency application or immediately afterward (within a few minutes)".

The delay in obtaining a physician order for Patient #4's use of restraints was discussed with the facility's Vice-President of Patient Care Services on 11/18/15 at 4:20 PM.

2. Patient #3 was documented to have restraints in use on 4/30/15 at 3:15 AM; the order for the restraints was dated and timed as 4/30/15 at 4:00 AM.

Review of Patient #3's clinical documentation with registered nurse (RN) #1 on the morning of 11/18/15 revealed documentation that indicated soft bilateral wrist restraints were in use at 3:15 AM on 4/30/15. The physician order for the aforementioned restraints was document on 4/30/15 at 4:00 AM; this order was 45 minutes after the restraints were documented as being in use.

The following information was found in a document entitled "Restraints ((facility initials removed) Policy)": "Emergency Order ... If the application of a restraint is an emergency, the restraint can be applied and physician order obtained either during the emergency application or immediately afterward (within a few minutes)".

The delay in obtaining a physician order for Patient #3's use of restraints was discussed with the facility's Vice-President of Patient Care Services on 11/18/15 at 4:20 PM.

Based on interviews and document review, it was determined the facility staff failed to ensure documentation of a patient assessment and subsequent discontinuation of restraints for 1 of 4 patients sampled for restraint use (Patient #4).

The findings include:

Patient #4's clinical record failed to include documentation indicating when the patient's restraints were discontinued and what the change in the patient's condition was that allowed for the discontinuation of the restraints.

Patient #4's clinical documentation was reviewed with registered nurse (RN) #1 and RN #2 on the afternoon of 11/17/15. Documentation indicated Patient #4 had bilateral soft wrist restraints in use on: (a) 10/2/15 at 4:15 AM, (b) 10/2/15 at 6:00 AM, and (c) 10/2/15 at 10:01 AM. No documentation to indicate when Patient #4's restraints were removed was found in the clinical documentation; RN #2 acknowledged he/she was unable to find documentation of when the restraints were discontinued.

The following information was found in a document entitled "Restraints ((facility initials removed) Policy)": "Discontinuation ... The decision to discontinue the intervention should be based on the determination that the need for restraint is no longer present, or that the patient's needs can be addressed using less restrictive methods ... Patient assessment and evaluation should focus on determining if the patient is no longer a threat to self or others."

The absence of clinical documentation relating to Patient #4's restraints discontinuation was discussed with the facility's Vice-President of Patient Care Services on 11/18/15 at 4:20 PM.

Based on staff interviews and a review of facility documents, it was determined the facility's quality program failed to include data from their contracted dialysis service.

The findings were:

Throughout the survey, the facility's quality-related information, the minutes from their various quality committee and team meetings, as well as their overall quality program plan was reviewed. Various staff throughout the hospital were interviewed in relation to the "Centers for Medicare & Medicaid Services (CMS) Hospital Quality Assessment Performance Improvement (QAPI) Worksheet."

On 11/18/15 at approximately 3:30 p.m., the quality data provided by the facility was compared to the "Hospital/CAH Database Worksheet" (CMS Exhibit 286) for services provided by the facility. The database documented that renal dialysis (acute inpatient) services were provided by arrangement or agreement only (not a combination of facility staff and through agreement) however, the quality data reviewed did not include evidence the contracted dialysis service was included in the hospital wide quality process.

On 11/18/15 at 3:53 p.m., the Vice President of Patient Care Services (VP-PCS) was notified by the surveyor, via phone, that evidence of quality data from the facility's contracted dialysis services had not been found in the information provided. The Vice President stated he/she would check for that information. At 4:20 p.m. on the same day, the VP-PCS was interviewed in person. He/She stated evidence of the quality data from the contracted dialysis services was not found. He/She explained that approximately 18 months prior to the survey, there had a been a change in the way the contracted company managed the staff they provided to the facility and that since that change, he/she didn't recall receiving their quality information. The Vice President acknowledged that the missing quality information had not been identified before now and stated that the contracted dialysis company used to provide their quality data consistently. The VP-PCS informed the surveyor that he/she had called the facility's Quality Director (who was out of town at the time of the survey) to ask about dialysis quality data. Even after speaking with the Quality Director, the facility staff was unable to provide evidence of the contracted dialysis quality data.