HospitalInspections.org

Based on policy review, interview and record review the facility failed to ensure each patient and/or patient's representative was offered the opportunity to establish an advance directive for three patients (#9, #10 and #11) of 12 patients records reviewed for advance directives. The hospital census was 42.

Findings included:

1. Review of the facility policy titled Pemiscot Memorial Health Systems Patient Right's showed in part the following:
4. A patient has a right to formulate Advance Directives and expect health care providers to comply with these directives.

Review of facility policy titled Advanced Directives with a revised date of 08/2007 directs staff in part to:

POLICY:
All admitted patients or family member over 18 years of age will be instructed on Advance Directives, and asked to sign an Acknowledgement Form. If the patient is unable to understand the Advance Directive information, then this instruction will be given to a close relative. They will initial the appropriate blocks, and sign the form.
- 1. All patients will be instructed and given a copy of the Advance Directives during the initial admission process.
- 2. If the patient is not capable of receiving Advance Directive instructions, then this information will be given to a family member. The family member will acknowledge with their intials and signature.

2. Record review of Patient #9's record on 4/6/10 at 11:10 a.m. failed to document an advanced directive assessment by nursing staff.

During an interview on 4/6/10 at 2:00 p.m. Staff B, Program Director for Behavioral Health said, "I am unable to find Advance Directive information on the record."

3. Record review of Patient #10's record on 4/6/10 at 11:00 a.m. failed to document an advanced directive assessment by nursing staff.

During an interview on 4/6/10 at 2:00 p.m. Staff B, Program Director for Behavioral Health said, "I am unable to find Advance Directive information on the record."

4. Record review of Patient #11's record on 4/6/10 at 12:55 p.m. failed to document an advanced directive assessment by nursing staff.

During an interview on 4/6/10 at 2:00 p.m. Staff B, Program Director for Behavioral Health said, "I am unable to find Advance Directive information on the record."

Based on interview and facility policy review the facility failed to provide a policy related to the one hour face to face assessment after the initiation of restraints. The facility census was 42.

Findings include:

1. Review of Facility policy and procedure: Restraints for Acute Medical/Surgical with a revised date of 06/2008 reveals in part no policy and procedure for one hour face to face assessment after the initiation of restraints for the management of violent or self-destructive behavior.

During an interview on 4/6/10 at 2:30 p.m. Staff A, Director of Nursing, said we do not have a policy or procedure for the one-hour face to face assessment by the physician and/or trained staff. Staff A said checked with Behavioral Health and they do not have a policy for one-hour face to face assessment.

Based on interview and personnel file review, the facility failed to ensure all staff providing care for patients in restraints received basic first aid training related to restraint use. This failure impacts all patients placed in restraints. The facility census was 42.

Findings included:

1. During an interview on 4/6/10 at 2:30 P.M. Staff A, the Director of Nursing said basic First Aid training is not included in staff training for restraint usage.

2. Review of two personnel records for nursing revealed no first aid training.