HospitalInspections.org

Based on review of facility documents and employee interview (EMP), it was determined that the facility failed to provide written policies and procedures for directing the care and referral of medical emergencies within the facility.

Findings include:

1. On June 24, 2010, at 11:00 AM, a review of facility policies and procedures failed to reveal a documented plan for appraisal, initial treatment and referral of medical emergencies, when applicable.

2. During an interview on June 24, 2010, at 1:00 PM, EMP1 confirmed, "I can tell you what we would do in the case of an emergency, but we do not have a written organizational plan to address this issue."

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to develop a plan of care related to use of restraints for one of one medical records (MR17).

Findings include:

1. A review of facility policy "Restraint Devices," #1700.3, reviewed by the facility on June 21, 2010, failed to reveal a requirement that staff document restraint use in the patient's ongoing plan of care.

2. A review of MR17 revealed that the patient was ordered elbow restraints on December 17, 2009. Further review of the MR failed to reveal documentation in the patient's ongoing plan of care regarding restraint use.

3. During an interview on June 22, 2010, at 2:50 PM, EMP1 confirmed, "That [care plan modification] is not part of our current restraint policy."

Based on review of medical records (MR) and facility documents, and staff interview (EMP), it was determined that the facility failed to follow their own policy regarding regarding ongoing assessment for one of one patients while in restraints (MR17).

Findings include:

Facility policy # 1700.3, "Restraint Devices", last reviewed by the facility on June 21, 2010, indicated that "...Utilization of Elbow Restraints: 4. Restraints must be removed for at least 10 minutes out of every 2 hrs when the patient is awake. You must document ROM (range of motion) and a skin assessment."

1. Review of MR17 revealed an order for elbow restraints, written on December 17, 2009. The order also indicated "...When restraints are on - check every 2 hrs - take off for 10 min (minutes), while awake. Please document ROM and skin assessment."

2. Review of the 24 Hour Flow Sheet and Registered Nurse (R.N.) Progress Notes dated between December 17, 2009, and December 22, 2009, for MR17, revealed inconsistent documentation regarding use of restraints, removal of restraints, ROM and skin assessments during restraint use.

3. During an interview on June 23, 2010, at 3:00 PM, EMP1 confirmed the lack of documentation regarding restraint use and ROM and skin assessment documentation.

Based on review of facility policy, personnel files (PF) and staff interview (EMP), it was determined that the facility failed to ensure direct care staff members demonstrated knowledge and competency regarding the facility's restraint policy and proper use of restraints for nine of nine personnel files reviewed (PF1, PF2, PF4, PF6, PF7, PF8, PF9, PF10 and PF11).

Findings include:

1. On June 23, 2010, at 10:15 A.M., a review of personnel records PF1, PF2, PF4, PF6, PF7, PF8, PF9, PF10 and PF11, failed to reveal any documented evidence of training and competency related to proper assessment, application and monitoring of patients requiring restraints.

2. During an interview on June 23, 2010, at 10:40 A.M., EMP1 stated "We don't currently do routine education for staff on restraints."

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure that medical record entries were authenticated, dated and timed by the person responsible for providing or evaluating the service provided for 12 of 16 medical records. (MR1, MR2,MR5, MR8, MR9, MR10, MR11, MR12, MR13, MR14, and MR15).

Findings Include:

1) A review of MR1, MR2, MR5, MR8, MR9, MR10, MR11, MR12, MR13, MR14, and MR15, revealed no date and time accompanied physician countersignature on orders written and authenticated by Certified Registered Nurse Practitioner (CRNP).

2) A review of MR16 revealed that the care plan was not dated or timed.

3) During an interview on June 23, 2010, at 2:30 P.M., EMP1 stated, "The policy was added and it does indicate for all entries in the record to be signed, dated and time. We still have issues with timing and dating the entries."

Based on review of facility documents and staff interview it was determined that the facility failed to have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs.

Findings include:

1) Review of facility documents failed to reveal a utilization review plan.

2) Interview with EMP1 June 23, 2010 at approximately 9:30 AM "I can honestly tell you, we do not have a utilization review plan. We do have an interdiciplinary team meeting, all the disciplines meet to discuss the patient's progress, discharge goals and how to best meet their needs."

Based on a review of facility policies and staff interview (EMP), it was determined that the facility failed to have a utilization plan for review for Medicare and Medicaid patients with regard to the medical necessity of admissions to the institution, duration of stays; and Professional services furnished including drugs and biologicals.

Findings include:

Review of facility policy "Interdisciplinary Team Meeting Guidelines, reviewed, May, 2010, "Purpose: ... The purpose of the team meetings is to share medical information, define goals for discharge, and make plans to meet those goals and to solve problems. ... Definition: The Interdisciplinary Team is a group of professionals who come together with the family to bring their expertise of their disciplines in order to provide the best quality of care to all patients. The team includes the Attending Physician, the Nurse Practitioner, Staff Nurse, Developmental Specialist, the Social Worker, Case Manager and the Parents."

1) Review of facility documents failed to reveal a utilization review plan.

2) Interview with EMP1 June 23, 2010 at approximately 9:30 AM "I can honestly tell you, we do not have a utilization review plan. We do have an interdisciplinary team meeting, all the disciplines meet to discuss the patient's progress, discharge goals and how to best meet their needs."