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Based on interview and medical record review, it was determined the facility failed to report in a timely fashion a death following the use of restraints to the Center for Medicare and Medicaid Services (CMS) for one (1) out of four (4) patients reviewed.

The findings include:

06/13/23 at 10:34 am: The surveyor initiated the medical record review of four (4) patients with the assistance of Staff Member #1 (Director of Quality). Patient #4-who was selected from the facility's internal restraint log-was identified as an individual who died within twenty-four (24) hours of restraint use.

During review of the order set information, the surveyor found that Patient #4 was ordered a soft right ankle restraint due to the "interference with medical treatment" to include "pulling lines tubes dressing equipment" on 03/19/23 at 4:01 am.

Under the restraint flowsheet documentation, the medical record indicated that Patient #4 was placed on the restraint at 03/19/233 at 4:01 am. The same restraint flowsheet revealed that the patient continued to have the ankle restraint until 03/19/23 at 10:12 am when made into palliative "comfort" care.

The surveyor reviewed the provider's death note record of Staff Member #18 which read that the time of death of Patient #4 occurred on 03/19/23 at 10:17 am due to "Acute Liver Failure".

The surveyor was provided the facility policy titled, "Use of Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints" (with last effective date of 10/06/22) from Staff Member #1.

Under "Reporting" section of policy reads, "2. CMS requires reporting no later than the close of business on the next business day following knowledge of the patient's death of the following ...Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion".

The policy continues to read that such external reporting requirements could be exempt when "only 2-point soft wrist restraints were used" AND "the patient was not in seclusion within 24 hours of their death". The order set information confirmed that although Patient #4 was never ordered for seclusion, they had a restraint used outside of the wrist.

On page five (5) of same policy reads that the facility is "responsible for oversight and reporting requirements at 42 CFR 482.13 (g) ...1. Deaths must be reported to the Regional Office (RO) using electronic Form CMS-10455 ...".

In the afternoon of 06/13/23, the surveyor received verbal confirmation from Staff Member #1 that the external reporting to CMS surrounding Patient #4's ankle restraint and death was not performed.

In the morning of 06/14/23, Staff Member #1 informed the surveyor that CMS was notified on 06/14/23 at 9:18 am-approximately three (3) months following restraint event.

06/14/23 at 3:15 pm: Staff Member # (1, 2, 3, 5, 10) were made aware of the surveyor's findings.