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The Condition of Participation for Patient Rights was not met as evidenced by:


Based on review of the clinical record, review of hospital policies, review of hospital documentation and interviews with hospital personnel for one (Patient #39) of ten ED patients who had a change in condition and/or required CPR, documentation and interviews failed to reflect that the patient received appropriate care in a safe setting and failed to ensure that restraint policies were followed for 6 of 10 patients. The findings include:


Patient #39 was admitted to the hospital's ED on 5/8/14 with the diagnosis of Adjustment Disorder. The patient was found pale with a thready pulse by the ED technician on 5/12/14 at 5:45 AM. The patient required CPR which was started eight minutes later, at 5:53 AM. Patient #39 expired on 5/12/14 at 6:05 AM. Documentation and interviews failed to reflect that the Observation of Patients Policy, the Hyperglycemia Management Protocol and the CPR Policies were followed.

Patient's #39, 40, 41, 42, 43 and 45 were reviewed for restraint use and the hospital failed to ensure that restraints were used in accordance with hospital policies to ensure that they were least restrictive, identified in the plan of care, were applied per physician order, were reviewed daily for continued use, and that monitoring of the restrained patient was documented.



Please refer to A144, A165, A166, A168, and A175.

Based on review of the clinical record, review of hospital policies, review of hospital documentation and interviews with hospital personnel for one (Patient #39) of ten ED patients who had a change in condition and/or required CPR, documentation and interviews failed to reflect that the patient received care in a safe setting related to a lack of medical monitoring, lack of communication between disciplines, and a delay in initiating CPR. The findings include:

Patient #39 was admitted to the hospital's ED from a skilled nursing facility on 5/8/14 at 9:02 PM due to agitated behavior. Review of the clinical record identified that the patient's past diagnoses included coronary artery disease (CAD), dementia with psychosis, anxiety, depression, ischemic cardiomyopathy, congestive heart failure (CHF), diabetes and status post (s/p) fall with facial ecchymosis. Review of the clinical record and interview with the Assistant ED Director, MD #13 on 5/22/14 at 1:30 PM identified that Patient #39 was diagnosed with Adjustment Disorder Unspecified. Patient #39 had been placed in an enclosure bed due to behavioral problems from 5/9/14 at 2:46 AM through 5/11/14 at 9:37 AM, when it was discontinued. MD #13 indicated that the patient was ruled out for a urinary tract infection (UTI) and was medically cleared on 5/9/14 at 1:49 PM. The patient was transferred to the ED's ABU on 5/10/14 at 7:02 AM.

a. Review of the ED record and interview with MD #13 on 5/22/14 identified that Patient #39 was waiting for disposition (geriatric-psychiatric bed placement). Patient #39 remained in the ED's ABU until the patient expired on 5/12/14. The ED record and interview with the ABU assigned nurse RN #11 on 5/27/14 at 2:25 PM (5/12/14, 7PM-7AM) identified that Patient #39 was on every (q) 15 minute observational checks. The Observation of Patients Policy identified that fifteen minute checks included visualizing the patient every 15 minutes and to document appropriate data on the Patient Safety Check Form. The record failed to reflect that q 15 minute checks were completed and/or documented on a Patient Safety Check Form for 24 hours, from 5/11/14 at 6:45 AM through death on 5/12/14 at 6:05 AM.

b. Review of the Physician Order dated 5/9/14 directed glucose fingersticks: Protocol order. The Hyperglycemia Management Protocol indicated that the RN would call the physician before the 9 PM dose of basal insulin if supplemental insulin was required during the day. Patient #39 required supplemental insulin on 5/11/14. The patient had received Humalog insulin subcutaneous (sq) 2 Units coverage at 7:12 PM on 5/11/14 (glucose fingerstick at 4:59 PM = 179). Three hours later, at 10:30 PM, RN #11 administered the bedtime basal insulin, Levemir sq 20 Units (glucose fingerstick at 8:46 PM = 179), without notifying a physician of the supplemental insulin as per protocol.

c. Review of Patient #39's clinical record identified that vital signs were not completed for 20 hours (from 5/11/14, 9:07 AM through 5/12/14, 5:53 AM, when Patient #39 suffered a cardiopulmonary arrest). Interview with the ABU Director on 5/22/14 at 9:45 AM indicated that vital signs would be completed every 8 hours after the enclosure bed was discontinued. Additionally, on 5/12/14 at 4:00 AM Patient #39 complained that he/she felt little snakes in his/her body and that there was a woman coming to get him/her to finish him/her off. Documentation and interview with RN #11 failed to reflect that a complete assessment was performed at that time (including vital signs and/or blood glucose fingerstick). Two hours after the patient's complaint regarding feeling snakes in the body, the patient expired.

d. The hospital CPR Policy indicated that the assigned nurse conveys pertinent information regarding the patient's status and medication. Upon surveyor inquiry, the assigned nurse, RN #11 identified that he/she did not convey the need for insulin coverage to the ED physician team leader, MD #14. Although hospital documentation indicated that appropriate patient information was given to the responding team, interview with MD #14 on 5/27/14 at 1:40 PM identified that he/she was not aware that Patient #39 was a diabetic and was not notified that Patient #39 received insulin coverage the night before. In addition, MD #14 was not aware that the patient's morning glucose fingerstick was 51 on 5/11/14 at 8:09 AM. Review of the CPR Flowsheet and interview with RN #13 on 6/6/14 at 8:15 AM identified that a glucose fingerstick was not obtained and the only medication the patient received during the code (CPR) was an ampule of epinephrine (no dose or concentration identified) intravenously (IV).

e. The clinical record identified Patient #39 was a full code which would include providing CPR if needed. The ED technician found Patient #39 pale with a thready pulse at 5:45 AM on 5/12/14 and notified the nurse assigned to the patient, RN #11. RN #11 indicated that the patient was unresponsive with a question of pulseless upon assessment and RN #11 pushed the code button. RN #11 identified that he/she cleaned out the room, moving the tables and chairs so that other hospital personnel could enter the room. Interview with the ED nurse, RN #12 on 5/29/14 indicated that responded to the code and on arrival to Patient #39's room, upon arrival to the code, no hospital personnel were in the room providing CPR to Patient #39. RN #11 and the ED technician were observed standing in the hallway when RN #12 arrived. Review of documentation and interview with RN #12 identified that on arrival, Patient #39 was pulseless and he/she began compressions at 5:53 AM. RN #13 retrieved the code cart and attached the quick combo pads. Review of hospital documentation identified that the backboard had not been placed initially. Review of the CPR policy identified that the ED technician would maintain compressions and the nurse assigned to the patient places the CPR board under the patient, provided oxygenation utilizing the ambu-bag until respiratory staff arrive and also attaches the quick combo pads to the patient. Bag-valve-mask (BVM) was started 3 minutes later, at 5:56 AM by the respiratory therapist. Review of documentation and interviews failed to reflect that the CPR policy was initiated timely and according to policy.

f. Review of the CPR Flow Sheet indicated that CPR was started at 5:53 AM. Initial vital signs were not documented. Although asystole was noted as the initial rhythm on the CPR Flow Sheet, the cardiac monitor strip recorded an actual rhythm as the "initial rhythm" with a heart rate of 123 at 5:52:24 AM. No asystole rhythm (without compressions) was documented. The CPR Policy indicated that the ED RN would provide ongoing rhythm interpretation and would communicate to the physician. Interview with the ED physician team leader, MD #14 on 5/27/14 identified that he/she had not seen the monitor rhythm strip. MD #14 indicated that someone told him/her that the patient was receiving compressions at the time when the strip was obtained. Interview with the ED nurse, RN #13 identified that he/she applied the quick combo pads, indicated that the patient was in asystole, but did not print any rhythm strips. RN #13 identified that the "initial rhythm" strip was printed out at the end of the code as the code summary. Review of the monitor operating instructions identified that the code summary documented the initial rhythm wave form data 8 seconds after the leads were placed. MD #14 indicated that the patient was cold when he/she arrived and had believed that the patient was in asystole the entire time. Documentation and RN #13 identified that an ampule of epinephrine (no dose or concentration identified) was administered at 6:02 AM. The patient did not receive any other medication. The code summary identified that the elapsed time was 12 minutes 52 seconds. MD #14 pronounced the patient deceased at 6:05 AM. The Code Policy identified that BLS and ACLS per AHA guidelines would be provided to all patients.

Based on review of the clinical records, review of policies and interviews with hospital personnel for 1 (Patient #39) of ten patients sampled patients for restraint usage, documentation and interviews failed to reflect that the least restrictive restraints/interventions were used/considered first as per hospital policy. The findings include:

a. Patient #39 was admitted to the hospital's ED from a skilled nursing facility on 5/8/14 at 9:02 PM due to agitated behavior. Review of the clinical record identified that the patient's past diagnoses included CAD, dementia with psychosis, anxiety, depression, ischemic cardiomyopathy, CHF, diabetes and s/p fall with facial ecchymosis. Patient #39 became agitated and was placed in an enclosure bed on 5/9/14 at 2:46 AM through 5/11/14 at 9:37 AM, when it was discontinued. Review of the hospital's Restraint Policy identified that the less restrictive interventions would be used/considered first and if alternative interventions were ineffective and a restraint was justified, the least restrictive restraint would be implemented. The policy identified the enclosure bed as the least restrictive type that was indicated to prevent falls from bed. Also, the readiness to discontinue would be assessed every 2 hours. Documentation reflected that the patient was not at risk to fall on 5/10/14 at 7:57 AM and failed to reflect readiness to discontinue the enclosure bed. Also, documentation failed to reflect that the less restrictive interventions were used/considered first.

Based on review of clinical records, review of hospital policies and interviews with hospital personnel for 2 (Patients #41, #42) of ten patients reviewed for restraint usage, the hospital failed to develop a plan of care when the restraints were implemented. The findings include:

a. Patient #41 was admitted to the hospital on 5/2/14 with a change in mental status, dementia with super imposed delirium and was identified as a fall risk. Review of the verbal physician's order dated 5/3/14 directed that the patient be place in a non-violent/medical restraint, the enclosure bed. Review of the clinical record identified that Patient #41 was confused, disoriented and was placed in the enclosure bed on 5/3/14 at 12:25 PM. Review of documentation with hospital administrative personnel failed to identify that a care plan was developed to address the use of the enclosure bed.

b. Patient #42 was admitted to the hospital on 5/8/14 at 11 AM and was unresponsive with question of seizure activity. Review of the hospitalist progress note dated 5/10/14 indicated that the patient was confused, attempting to get out of bed multiple times, was unable to be redirected and needed the enclosure bed for safety. Review of the telephone physician order dated 5/10/14 at 8:42 AM directed to initiate the non-violent medical restraint, enclosure bed. Review of documentation with hospital administrative personnel failed to identify that a care plan was developed to address the use of the enclosure bed.

Based on review of clinical records, review of hospital policies and interview with hospital personnel for 3 (Patients #41, #42 and #45) of ten patients reviewed for restraint usage, the hospital failed to ensure that the restraints were applied with a physician order according to the hospital's policy. The findings include:

a. Patient #41 was admitted to the hospital on 5/2/14 with a change in mental status, dementia with super imposed delirium and was identified a fall risk. Review of the hospital's Restraint Policy indicated that the physician would be notified for non-violent medical restraints; the order would be obtained within 12 hours of initiation of the restraint; the physician must see the patient within 24 hours; the physician must evaluate the patient daily and write a new restraint order daily. Patient #41 was in the enclosure bed from 5/3/14 at 2:28 PM through 5/4/14 at 7:15 AM. Review of the verbal physician's order dated 5/3/14 at 12:20 PM directed that the patient be place in a non-violent/medical restraint, the enclosure bed. Review of documentation with hospital administrative personnel identified that although the hospitalist's progress note dated 5/4/14 identified the patient's delirium, the verbal restraint order was not signed by the physician, nor was the enclosure bed reordered and/or discontinued on 5/4/14 as per policy.

b. Patient #42 was admitted to the hospital on 5/8/14 at 11 AM and was unresponsive with a question of seizure activity. Review of the hospitalist progress note dated 5/10/14 indicated that the patient was confused, attempting to get out of bed multiple times, was unable to be redirected and needed the enclosure bed for safety. Review of the hospital's Restraint Policy indicated that the physician would be notified for non-violent medical restraints; the order would be obtained within 12 hours of initiation of the restraint; the physician must see the patient within 24 hours; the physician must evaluate the patient daily and write a new restraint order daily. Review of the telephone physician order dated 5/10/14 at 8:42 AM directed the non-violent medical restraint, enclosure bed. The patient was in the enclosure bed until 5/12/14 at 5 PM. Review of documentation with hospital administrative personnel identified that the telephone order was not signed by the physician, nor was the enclosure bed ordered daily and/or discontinued according to the hospital's policy.

Based on review of clinical records, review of hospital policies and interviews with hospital personnel for 2 (Patients #39, #41) of ten patients reviewed for restraint usage, documentation and interviews failed to reflect that the patient was evaluated daily (for the restraint need) by a physician as per hospital policy. The findings include:

a. Patient #39 was admitted to the hospital's ED from a skilled nursing facility on 5/8/14 at 9:02 PM due to agitated behavior. Review of the clinical record identified that the patient's past diagnoses included dementia with psychosis, anxiety, depression and s/p fall with facial ecchymosis. Patient #39 became agitated and was placed in an enclosure bed from 5/9/14 at 2:46 AM through 5/11/14 at 9:37 AM, when it was discontinued. Review of the hospital's Restraint Policy indicated that the physician must evaluate the patient daily. Review of documentation and interview with the ED Assistant Director, MD #13 on 5/22/14 identified that the patient was not evaluated daily by the ED physician as per policy.

b. Patient #41 was admitted to the hospital on 5/2/14 with a change in mental status, dementia with super imposed delirium and was identified a fall risk. Review of the hospital's Restraint Policy indicated that the physician would be notified for non-violent medical restraints; the order would be obtained within 12 hours of initiation of the restraint; the physician must see the patient within 24 hours; the physician must evaluate the patient daily and write a new restraint order daily. Patient #41 was in the enclosure bed from 5/3/14 at 2:28 PM through 5/4/14 at 7:15 AM. Review of the verbal physician's order dated 5/3/14 at 12:20 PM directed that the patient be place in a non-violent/medical restraint, the enclosure bed. Although the hospitalist's progress note dated 5/4/14 identified the patient's delirium, documentation failed to reflect the daily physician evaluation for the need of the enclosure bed as per policy.




Based on review of clinical records, review of hospital policies and interviews with hospital personnel for 5 (Patients #39, #40, #41, #42, #43) of ten patients reviewed for restraint usage, the hospital failed to ensure that the patients were monitored in accordance with hospital policy. The findings include:

a. Patient #39 was admitted to the hospital's ED from a skilled nursing facility on 5/8/14 at 9:02 PM due to agitated behavior. Review of the clinical record identified that the patient's past diagnoses included dementia with psychosis, anxiety, depression and s/p fall with facial ecchymosis. Patient #39 became agitated and was placed in an enclosure bed on 5/9/14 at 2:46 AM through 5/11/14 at 9:37 AM, when it was discontinued. Review of the hospital's Restraint Policy indicated that the enclosure bed was the least restrictive restraint (when alternatives were ineffective) to prevent falls from bed. The policy identified that for the non-violent medical restraint, monitoring would include type, behavior, comfort/dignity, circulation/skin checks and readiness to discontinue every 2 hours. Vital signs would be completed at least every 4 hours. Nutrition, hydration, elimination, mobility and ROM would be assessed every 2 hours and every 4 hours while asleep. Review of the clinical record failed to reflect that patient monitoring was completed according to policy: behavior, readiness to discontinue every 2 hours, as well as nutrition, hydration, elimination, mobility and ROM assessment every 2 hours and every 4 hours while asleep. Additionally, review of the ED record indicated that Patient #39 was on q 15 minute observation checks from admission through expiration on 5/12/14 at 6:05 AM. Interview with RN #11 on 5/7/14 indicated that the patient was on q 15 minute checks. However, review of the Patient Safety Check Flow sheets failed to reflect that q 15 minute checks were completed from 5/11/14 at 6:45 AM through death on 5/12/14 at 6:05 AM.

b. Patient #40 was admitted to the hospital on 5/3/14 at 5 PM with sepsis. Review of the clinical record indicated that the patient was alert, confused and a high fall risk. The patient was placed in an enclosure bed on 5/3/14 at 9:47 PM through 5/4/14 at 3:37 PM. Review of the hospital's Restraint Policy indicated that the enclosure bed was the least restrictive restraint (when alternatives were ineffective) to prevent falls from bed. The policy identified that for the non-violent medical restraint, monitoring would include type, behavior, comfort/dignity, circulation/skin checks and readiness to discontinue every 2 hours. Vital signs would be completed at least every 4 hours. Nutrition, hydration, elimination, mobility and ROM would be assessed every 2 hours and every 4 hours while asleep. Review of the clinical record failed to reflect that the patient's vital signs were monitored every 4 hours as per policy.

c. Patient #41 was admitted to the hospital on 5/2/14 with a change in mental status, dementia with super imposed delirium and was identified a fall risk. The patient was in the enclosure bed from 5/3/14 at 2:28 PM through 5/4/14 at 7:15 AM. Review of the hospital's Restraint Policy indicated that the enclosure bed was the least restrictive restraint (when alternatives were ineffective) to prevent falls from bed. The policy identified that for the non-violent medical restraint, monitoring would include type, behavior, comfort/dignity, circulation/skin checks and readiness to discontinue every 2 hours. Vital signs would be completed at least every 4 hours. Nutrition, hydration, elimination, mobility and range of motion (ROM) would be assessed every 2 hours and every 4 hours while asleep. Review of the clinical record failed to reflect that the patient's vital signs were monitored every 4 hours as per policy.

d. Patient #42 was admitted to the hospital on 5/8/14 at 11 AM and was unresponsive with a question of seizure activity. Review of the hospitalist progress note dated 5/10/14 indicated that the patient was confused, attempting to get out of bed multiple times, was unable to be redirected and needed the enclosure bed for safety. Review of the telephone physician order dated 5/10/14 at 8:42 AM directed the non-violent medical restraint, enclosure bed. The patient was in the enclosure bed until 5/12/14 at 5 PM. Review of the hospital's Restraint Policy indicated that the enclosure bed was the least restrictive restraint (when alternatives were ineffective) to prevent falls from bed. The policy identified that for the non-violent medical restraint, monitoring would include type, behavior, comfort/dignity, circulation/skin checks and readiness to discontinue every 2 hours. Vital signs would be completed at least every 4 hours. Nutrition, hydration, elimination, mobility and ROM would be assessed every 2 hours and every 4 hours while asleep. Review of the clinical record failed to reflect that the patient's vital signs were monitored every 4 hours as per policy.

e. Patient #43 was admitted to the hospital on 5/9/14 at 10:26 PM with an acute cerebral vascular accident (CVA) and confusion. Review of the physician's order dated 5/10/14 at 2:46 AM directed that the patient be placed in an enclosure bed. The patient remained in the enclosure bed until 5/13/14 at 12:30 PM. Review of the hospital's Restraint Policy indicated that the enclosure bed was the least restrictive restraint (when alternatives were ineffective) to prevent falls from bed. The policy identified that for the non-violent medical restraint, monitoring would include type, behavior, comfort/dignity, circulation/skin checks and readiness to discontinue every 2 hours. Vital signs would be completed at least every 4 hours. Nutrition, hydration, elimination, mobility and ROM would be assessed every 2 hours and every 4 hours while asleep. Review of the clinical record failed to reflect that the patient's vital signs were monitored every 4 hours as per policy.