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Based on observation, interview, record review and facility policy review the facility failed to protect and promote patient's rights when they did not:
-ensure patients received informed consent for decision making
-ensure patients received care in a safe setting;
-screen employees periodically for abuse and/or neglect;
-ensure patients medical records in outpatient rehabilitation are maintained confidential and secure
-document required notification to Center for Medicare and Medicaid (CMS) of a death associated with the use of seclusion or restraint.

The cumulative effect of these systemic practices resulted in the overall noncompliance with the Condition of Participation of Patient's Rights.

See deficiencies provided at: A 131, 144, 145,147, and 214.

Based on record review, policy review and interview, the facility failed to ensure informed consent was obtained prior to one (#25) of one patient's leaving against medical advice (AMA) placing the patient at risk for coma (loss of consciousness). The facility census was 73.

Findings included:

1. Review of the facility's policy titled, "Informed Consent Policy", dated 01/11, showed the following:
- Each Patient will receive a full explanation of the types of care, treatment, and services provided.
- To ensure that the patient is fully informed and understands the treatments and services provided in order to make informed decisions regarding care.

Review of the facility's policy titled, "Patients leaving against Medical Advice (AMA)" dated 01/01, showed the following:
- A patient who desires to leave the hospital without medical approval should not be physically detained. For patients who appear to be a danger to themselves or others, refer to Social Services Manual
- The medical record should contain documentation that the patient was informed of possible complications of early discharge

Review of the facility's policy "Patient's Bill of Rights" dated 12/06/02 showed the following:
- You have the right to receive from your physician the information necessary to give informed consent prior to the start of any procedure and/or treatment. Except in emergencies, such information for informed consent should include, but not necessarily be limited to the specific procedure and/or treatment, the medically significant risks involved and the probable duration of incapacitation. Where medically significant alternatives for care or treatment exist, or when you request information concerning medical alternatives, you have the right to know the name of the person responsible for the procedures and/or treatment.
- You have the right to refuse treatment to the extent permitted by law and to be informed of the medical consequences of your action.

Review of the Medical Staff - Rules and Regulations titled "Informed Consent - 104" dated 04/05/01 showed the following staff direction:
- The duty to inform a patient regarding proposed treatment and to obtain consent to such treatment rests with the physician. The information provided to a patient by the physician prior to obtaining consent should include:
- The patient's condition, including diagnosis and prognosis with and without the proposed treatment.
- The nature and purpose of the proposed treatment
- The risks and consequences of the proposed treatment
- The alternatives to the proposed treatment
-Evidence of informed consent should be maintained in the medical record.

Review of the facility's Social Services Policy and Procedure titled, "Hospital and Outpatient Referrals", dated 09/06 showed the following staff direction:
- Emergency Room Referrals
- Persons who inappropriately ask for help in the emergency department and seem unwilling or unable to accept referrals to the appropriate agency.
- Patients who have minor medical problems, but major social problems
- Other needs as identified by the emergency room staff.

2. Review of discharged emergency room (ED) Patient #25's medical record showed:
- 26-year-old complaining of lower abdominal pain, accompanied by two young children
- 12:28 PM to ED room
- 12:46 PM Staff GG, ED physician, examined patient
- 12:58 PM Blood obtained for lab tests
- 13:34 PM Lab called with critical value - Staff GG, physician, made aware
- Lab values:
White Blood Count (determine infection) 21.0 (4.0-11.0 Normal range)
Glucose (sugar) 601 (74 - 106 normal)
- 14:26 PM Staff GG checked admit on disposition
- 14:40 Nurses' note - informed of possible admit, Patient request to leave AMA informed of risks, refused repeat fasting blood sugar and other care
- 14:40 Staff GG documented Patient left AMA at 14:40
- Record reflects physician failed to follow facility policy of Informed Consent by failing to discuss:
- The patient's condition, including diagnosis and prognosis with and without the proposed treatment.
- The nature and purpose of the proposed treatment
- The risks and consequences of the proposed treatment
- The alternatives to the proposed treatment
-Documentation informing patient of risks of leaving AMA
- Record failed to show treatment for pain and/or patient's elevated glucose level.
- Record shows on discharge a pain rating of "9" (Pain scale of 0 - 10 with a 9 as very severe).
- Record failed to show Social Service referral for assistance with small children.

During an interview on 05/12/11 at 3:20 PM, Staff M, ED nurse manager, stated that:
- Staff followed guidelines of the physician, to have patient sign AMA, since patient refused care.
- No it was not appropriate care; the physician should have been questioned
- Social Service should have been called for assistance with the children
-Patient placed at risk by leaving

During an interview on 05/12/11 at 2:00 PM, Staff D, Vice President of Nursing, stated physician did not write an order for insulin (decreases blood sugar); there is no insulin dosage on the physician order sheet.

According to current Medline Medical Encyclopedia - hyperglycemia (elevated blood glucose) can lead to severe illness or death.






18075

18075

Based on staff interviews, review of facility policies and procedures, and medical record reviews the facility failed to determine and implement the safety precautions necessary to prevent falls for two of two Patients (#6 and #10) with falls on the Geriatric Behavioral Health Inpatient Unit. The facility failed to initiate and/or update the patient's treatment goal/plans in order to direct staff regarding the individualized patient interventions necessary to prevent falls. The facility census was 73. The Geriatric Behavioral Health Inpatient Unit (Senior Lifestyle) census was 10.

Findings included:

1. Review of the facility policy titled: "Fall Prevention" effective March 1991 showed the patient should be assessed on admission, daily, and when there is a change in status/condition, and may be designated as fall prone. When patients are designated as fall prone, safety guidelines should be initiated and used for those patients.

2. Review of the facility nursing policy and procedure titled: Documentation P.I.E. (Problem, Intervention, Evaluation) effective February 1992 showed the guidelines for practice included the following:
- After formulation of the nursing diagnosis, the registered nurse should decide on the nursing actions necessary to achieve desired goals.
- Interventions may include: At the beginning of the shift, nursing personnel should review documentation from the previous shift to determine effectiveness of interventions and promote continuity of care. Nursing interventions should address the needs of the patient assessed.

3. Review of Patient #10's discharged medical record showed the patient was admitted to the facility's geriatric behavioral health inpatient unit on 03/20/11 for evaluation, treatment and crisis stabilization due to increased agitation, aggression and hallucinations. The record review showed the patient had become scared of reflections, climbing under the table, broke his/her glasses and was difficult to redirect. The patient's history included dementia with Alzheimer's type with psychosis. The patient was assessed on admission by nursing as a high fall risk and the physician admission orders included fall precautions.

4. Review of the patient's individual treatment plan initiated on 03/20/11 at 10:40 PM, showed the patient was confused/disoriented, had a history of previous falls (falls at home prior to admission) and an unsteady gait. A fall risk treatment plan was initiated and showed the following information:
- Long term goal: "Patient will have no injuries while in hospital by time of discharge";
- Short term goal (what the patient will do to reduce symptoms, in measurable terms): "Patient will have zero falls while in hospital"; and
- Nursing plan was to assess patient for fall risk potential each encounter; monitor gait and document each shift; place assistive devices such as walkers within reach; and identify and remove risk factors in the environment that may increase potential for falls.

5. Review of the multidisciplinary progress notes showed the following information:
- On 03/22/11 at 3:20 AM, the nursing assessment showed the patient as a fall risk, gait unsteady at times, up to the bathroom with assistance of two staff and will continue to monitor and work toward treatment goals.
- On 03/22/11 at 4:10 PM, the patient was found lying on the floor in the dayroom with half of his/her body under the table. The patient was assessed and no injuries were noted.
- On 03/22/11 at 5:45 PM, the patient's gait continued to be unsteady and the plan was to continue to assess the patient and work toward treatment goals.
- On 03/23/11 at 5:00 PM, the patient remained a high fall risk and staff encouraged patient to stay in wheelchair. The notes showed the patient attempted to walk by self at intervals and the plan was to continue to assess and work toward treatment goals.
- On 03/24/11 at 12:15 PM, the patient continued to hallucinate, reaching out into the air as if grabbing something. The patient was assessed with weakness in both lower legs and required transfer assistance of two staff from bed to recliner.
- On 03/26/11 at 2:30 PM, the patient was sitting in Geri-chair (a lounge type chair) with feet up, in the dayroom. Continued to hallucinate and pick things in the air. The notes showed the patient tried to get up from the chair several times without assistance. Nursing documented the patient "fell on the floor after lunch. No staff witnessed fall and the patient was found lying on left side. Had a very small skin tear on left knuckle and small spot of blood on left upper forehead, bump to back of head". The nurse's notes showed the patient "remained a great fall risk due to non-compliance with fall plan".
- On 03/27/11 at 2:40 PM, the patient was lying in recliner in hallway across from nurses desk and "talks to people that aren't there". The notes showed the patient fell before lunch at 11:50 AM in the dining room and no injuries were noted. The patient was in a wheelchair with a table in front of him/her before the fall. The patient complained of lower back pain, the physician was notified and X-rays were taken with no injury noted. The nurse documented the patient remained a great fall risk due to non-compliance and the plan was to continue to assess and work towards treatment goals.
- On 03/28/11 at 12:45 PM, the patient was sitting on the floor in dining room beside his/her wheelchair, very confused and whistling. The patient was assisted up by two staff and was unable to tell staff why he/she was sitting on floor, but continued to pick at things not there.
- On 03/28/11 at 6:15 AM, the patient was sitting in wheelchair at nurse's station and was observed standing up, then fell on the floor. Attempted to instruct patient to sit down in chair, however, the patient continued to stand up and staff was unable to redirect. Staff assisted the patient back into his/her chair and there was no apparent injury.
- On 03/29/11 at 11:00 AM, the patient was attempting to stand and ambulate, disregarding staff's attempt to redirect. The patient did not want to sit in chair, was verbally aggressive and pulled away from staff. Continued to reach downward to floor as if picking something up then placed hand in pocket. The patient continued with an unsteady gait and was unable to ambulate independently. The nursing notes showed "will continue to monitor and work toward treatment goals".

6. Review of the Interdisciplinary Treatment Plan Review dated 03/27/11 showed problem #4 Falls, progress toward goal unchanged and documented patient had fallen three times since admission.

7. Review of the Interdisciplinary Treatment Plan Review dated 03/29/11 showed problem #4 Falls, progress toward goal unchanged and documented patient continued to try and ambulate on his/her own and had fallen.

8. Review of the patient's individual treatment plan showed the goals that were initiated on 03/20/11 did not include specific interventions/instructions to direct staff regarding the individual patient's care needs; and the treatment goals/plan were not updated to reflect the changing needs of the patient following the falls (the goals/plan remained the same throughout the patient's hospital stay from 03/20/11 through discharge on 03/29/11).

9. Review of Patient # 6's current medical record showed the patient was admitted to the facility's geriatric behavioral health inpatient unit on 04/27/11 with the diagnosis of dementia and to receive treatment for recent hallucinations, paranoia, delusions and agitation.

10. Review of the patient's individual treatment plan initiated on 04/28/11 at 10:05 AM, showed the patient was confused/disoriented. A fall risk treatment plan was initiated and showed the following goals/plan:
- Long term goal: "Patient will have no falls that result in injury by discharge";
- Short term goals (what the patient will do to reduce symptoms, in measurable terms): "Patient will have no incidents of falls by day 3"; and "Patient will comply with staff's prompts/requests regarding safety and fall precautions" and
- Nursing plan was to assess patient for fall risk potential each encounter; monitor gait and document every shift; and identify and remove risk factors in the environment that may increase potential for falls.

11. Review of the multidisciplinary progress notes showed the following information:
- On 04/29/11 at 9:15 PM, the patient stood abruptly from chair and fell backward. A minor skin tear on the patient's right forearm was the only apparent injury.
- On 05/01/11 at 7:10 AM, the patient fell in his/her room and had abrasions on lower back.

12. Review of the Interdisciplinary Treatment Plan Review dated 05/05/11 showed patient has had falls on 04/29/11 and 05/01/11. The progress toward goals showed "Improved. Patient to continue to comply with staff's prompts/requests regarding safety and fall precautions".

13. Review of the patient's individual treatment plan showed the goals that were initiated on 04/28/11 did not include specific interventions/instructions to direct staff regarding the individual patient's care needs; the treatment goals/plan were not updated or changed following the patient falls (the goals/plan remained the same throughout the patient's hospital stay from 04/28/11 through 05/12/11).

14. During an interview on 05/10/11 at 1:45 PM, Staff E, Registered Nurse Program Director of the geriatric behavioral health inpatient unit stated that individualized interventions should be listed as part of the patient's care plan and should be found on the back side of the treatment plan. Staff E confirmed that there were no individualized interventions and/or updates listed for the two patients reviewed. Staff E stated that some of the interventions following a patient fall might include moving the patient in line of sight with staff, assist with transfers and the use of alarm devices to help alert staff of potential falls. Staff E stated that it was the staff's responsibility to prevent patient falls.

15. During an interview on 05/10/11 at 2:35 PM, Staff E stated that the interdisciplinary team meets two times a week to discuss the individual patient's care. Staff E stated that patient falls are reported and discussed during the team meetings and the treatment plans should be updated following the team discussions.

16. During an interview on 05/10/11 at 2:45 PM, Staff V, Registered Nurse stated that chair alarms are available if needed for patients, but did not remember if they were used for the two patients reviewed. Staff V confirmed that there was no documentation in the patient's record of chair alarms and stated they should be documented if used. Staff V also confirmed that the individualized treatment plans were not updated to reflect the falls and necessary interventions.

Based on interview, Missouri State Statute review, and personnel record review the facility failed to ensure individuals listed on the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) were not employed by the facility. Record review of seven (Staff B, E, J, P, R, S, and T) of eight personnel records reviewed showed the facility failed to compare the names of staff on a periodic/quarterly basis against the EDL. The facility census was 73.

Findings included:

1. Review of the Missouri State Statute RSMO 2003 Section 660.315 directed facilities licensed under Chapter 197 (hospitals) complete not only pre-employment EDL checks but also periodic checks of all currently employed staff against the quarterly updated EDL to ensure no current staff had been recently added to the EDL (The quarterly updated EDLs are available on the Missouri Department of Health and Senior Services web site).

2. Record review of Staff B's personnel file showed Staff B had been employed in the facility since approximately 01/12/76 and had never had verification that he/she was not on the EDL.

3. Record review of Staff E's personnel file showed Staff E had been employed in the facility since 06/22/10, had an initial pre-employment EDL check, but had never had verification that he/she was not on the EDL after the initial check.

4. Record review of Staff J's personnel record showed Staff J had been employed in the facility since 10/23/89 and had never had verification that he/she was not on the EDL.

5. Record review of Staff P's personnel record showed Staff P had been employed in the facility since 10/13/09, had an initial pre-employment EDL check but had never had verification that he/she was not on the EDL after the initial check.

6. Record review of Staff R's personnel record showed Staff R had been employed in the facility since 08/11/09, had an initial pre-employment EDL check but had never had verification that he/she was not on the EDL after the initial check.

7. Record review of Staff S's personnel record showed Staff S had been employed in the facility since 02/19/79 and had never had verification that he/she was not on the EDL.

8. Record review of Staff T's personnel record showed Staff T had been employed in the facility since 05/24/94 and had never had verification that he/she was not on the EDL.

9. During an interview on 05/12/11 at 11:00 AM, Staff BB, Senior Vice President, stated that the facility had never done periodic checks of all employees against the EDL.

Based on observation, interview and facility policy review staff in the outpatient rehabilitation clinic failed to ensure medical records of patients discharged from care were maintained in a manner to protect against unauthorized access. The facility census was 73.

Findings included:

1. Record review of the facility's policy titled, Release of Information, Policy Number 406, revised 09/30/01 showed the following direction:
-Any employee must not reveal any information of a medical nature except as outlined in these policies.
-Staff physicians may not give authorization to insurance companies or attorneys to secure copies of health information records from hospital personnel.
-The patient has the right to the contents of his/her health information record; the health information record in itself is the property of the hospital.
-Health Information Management (HIM) Records shall not be taken from any of the files to other parts of the hospital except as is necessary in the transaction of business of the hospital.

2. Observation on 05/11/11 at 2:20 PM, in the outpatient rehabilitation clinic showed staff maintained the following:
-A key locked room with floor to ceiling open shelving containing over twenty eight shelves of paper patient medical records.
-Fifteen cardboard boxes of paper medical records.
-The door to the room faced the outside door and was not in line-of-sight of staff in the rehabilitation gym or office.

3. During an interview on 05/11/11 at 2:35 PM, Staff K, Director of the Outpatient Rehabilitation Clinics, stated the following:
-The room off the gym area was storage for medical records of patients discharged from care.
-There were medical records dated from 2007 through present.
-The key for the room was kept in a desk drawer in the clinic office.
-All staff, including five part-time staff and three clerical staff had access to the key.
-The clinic was open for therapy Monday through Friday from 7:00 AM through 5:30 PM.
-Any staff person could enter the building and access medical records of discharged patients after hours, weekends and holidays without monitoring.
-He/she periodically sent out portions of patient medical records to attorneys who requested patient medical information.

4. During an interview on 05/11/11 at 2:58 PM, Staff L, Director of HIM, stated the following:
-Per facility policy, as HIM director he/she was responsible for all patient medical records including both current and discharged patients, and both inpatients and outpatients.
-He/she had paper medical records stored in three rooms in the facility and in off-site storage downtown.
-He/she thought the paper medical records of discharged outpatient rehabilitation patients were also stored downtown.
-He/she did not know that Staff K also maintained a room with paper medical records of discharged patients on premise.
-He/she was responsible for the facility release of information (ROI) process.
-ROI was tracked and processed through HIM.
-Staff K may be sending outpatient medical information to various requestors without his/her (Staff L's) knowledge.

Based on interview, record review, and policy review the facility failed to document in the medical record the date and time of notification to Centers for Medicare & Medicaid (CMS) of patient deaths associated with the use of restraints for one (#24) of one death records reviewed for restraints. The facility census was 73.

Findings included:

1. Record review of the facility's policy titled, "Restraints" showed direction to facility staff for the Nurse Manager to report to CMS any death that occurs while a patient is restrained, or within 24 hours after removal from restraint or seclusion, or where it is reasonable to assume a patient's death is a result of restraint.

2. Review of Patient #24's discharged medical record showed the patient expired on 04/15/11at 7:57 PM. The patient had bilateral soft wrist restraint ordered on 04/13/11 and at time of death, patient was in bilateral wrist restraints. The medical record contained no documentation of the date and time CMS was notified of the patient's death.

3. During an interview on 05/12/11 at 1:45 PM, Staff D, Vice President of Nursing, stated that patient deaths were reported to CMS, and confirmed staff did not document in the Patient #25's medical record the date and time the notification was made. Staff D stated that the facility policy did not direct staff to document reporting to CMS in the medical record.