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201 STATE STREET

ERIE, PA 16550

PATIENT RIGHTS: EXERCISE OF RIGHTS

Tag No.: A0129

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure patients rights were exercised for one of ten medical records reviewed. (MR1).

Findings include:

1. Review of the facility document "Patient Rights" effective March 2016, indicated, "At UPMC ... service to our patients and their families or representatives is our top priority. We are committed to making the hospital stay or outpatient service as please as possible ... for your plan of care, you have a right: ... to refuse any drugs, treatments or procedures offered by the facility. ... to the extent permitted by law, and a physician shall inform you of medical consequences of this refusal. ..."

2. Review, on February 26, 2018, at approximately 2:00 PM, of a facility process/algorithm used by physicians when placing a "Restricted to Hospital" order, revealed, "A patient may be Restricted to Hospital based on concerns for their decisional capacity if they have significant impairment in their ability to process information understand their medical condition, appreciate safety issues or communicate consistent decisions This order does not imply global impairment of capacity ... Common clinical impairments which may lead to Concern for Decisional Capacity include Altered level of consciousness (e.g. highly sedated following overdose ...) Limited attention and concentration (often related to delirium, substance intoxication or withdraw) Impairment in memory (related to dementia, other neurologic illness, or delirium.) Alteration in ability to process information and appreciate safety concerns (related to impairment of cognition or primary psychiatric issues such as severe depression, mania, or psychosis). ... Concern for Capacity - Restricted to Hospital - Pt Requests to leave AMA Or Attempts to Elope - Pt has regained Capacity and has no 302 grounds - Consider AMA Discharge - [or] Pt does not have Capacity and has no 302 grounds - [or] Continue to treat in hospital, Decision Maker - Pt does not have Capacity and has 302 grounds - Maintain in hospital Consult Psych to Consider 302 within 24 hrs ..."

3. Review, on February 26, 2018, at approximately 12:00 PM, of MR1's Trauma History and Physical report revealed, "...2/4/18 MVC restrained and airbag deployment LOC Taken to outside hospital ... February 4, 2018, CT head, face, cervical spine Right orbital fracture - consult plastic surgery and ophthalmology Concussion - consult ... General: Alert and oriented, No acute distress ... Neurologic: Alert & Oriented. ... Glasgow Coma Scale: Eye opening response (Spontaneous = 4) Motor Response. Psychiatric: Appropriate mood & affect, Normal judgement. ..."

4. Continued review, on February 26, 2018, at approximately 1:10 PM, of a Neuropsychological Evaluation Consult for MR1 indicated, "Addendum by [MD], ... February 5, 2018, 7:23 PM ... Before I left this afternoon, I told [Patient to MR1]... that I would come back and I also told [Patient to MR1] that it was my opinion that [Patient to MR1] did not currently have the cognitive capacity to rationally make decisions ... I stated that I did [sic] want [patient] to leave the hospital. symptoms including blurred vision ... dizziness, & intermittent diplopia. ... "

5. Review, at approximately 2:30 PM on February 26, 2018, of a physician order for MR1 dated February 5, 2018, 2:38 PM, revealed, "... Notify Who: Stat page security if patient attempts to elope and request that they detain patient. ... Order 2/5/2018, 2:38 Restricted to Hospital Reason for Restriction Concern for Decisional Capacity ... Special Instructions Patient not to leave the unit except for test and procedures and must be accompanied when off the unit. ..."

6. Review, on February 26, 2018, at approximately 2:45 PM, of a nursing note for MR1 revealed, " ... Patient attempting to leave [Against Medical Advice] AMA, instructed to go back to room. Patient became belligerent and combative. Security and trauma called. ..."

When asked for a policy for holding a patient in the hospital despite the patient's request for a discharge Against Medical Advice (AMA), EMP2 indicated that the facility did not have such a policy. EMP2 confirmed the above findings on February 26, 2,018, at approximately 2:30 PM.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0166

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that a restraint was in accordance with a written modification to the patient's plan of care for one of two violent restraint medical records reviewed (MR1).

Findings include:


1. Review of facility policy and procedure "Restraint and Seclusion" last revised June 23, 2017, revealed "... General Guidelines ... A written time limited order from a physician and documentation of the reason must accompany all episodes of restraint or seclusion. ... II Alternatives to Restraint or Seclusion or Seclusion Use ... Attempt to redirect agitated patients using diversionary activities and/or conversation such as: playing soothing music. Psychologist/psychiatrist consultation. ... Attempted use of alternative methods and the effectiveness of those methods must be present in the medical record. ... Documentation A. Appropriate documentation is to be made for each patient placed in restraint or seclusion as part of a modified plan of care. ... If the restraint or seclusion is no longer needed, a narrative note is to be written. ... D. Patient Plan of Care. 1. The use of restraint or seclusion will be addressed in the patient's plan of care and/or treatment plan. ..."

2. Review, on February 26, 2018, at approximately 2:45 PM, of a nursing note for MR1 revealed, " ... Patient attempting to leave [Against Medical Advice] AMA, instructed to go back to room. Patient became belligerent and combative. Security and trauma called. ..."

3. Review, on February 26, 2018, at approximately 2:45 PM, of a combative patient security report, revealed a narrative which indicated, "On 02/05/18 Sgt. [Sergeant] ... responded to a combative patient ... Handcuffs were applied for patient/officer safety. ... [MR1] was cuffed behind ... back, and cuffs were double locked ... per ... order [MR1] was placed in 4 way restraints. ... the subject was restrained. ... At approximately 1811 hrs ... dispatched again to assist medical staff ... Subject was still in restraints ... "

4. Review of the medical record for MR1 revealed that the patient's plan of care did not reflect the use of the restraint.

Interview with EMP6 on February 26, 2018, at approximately 3:00 PM confirmed the above findings and confirmed that the plan of care for MR1 did not reflect the use of the restraint.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0168

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that a restraint was applied in accordance with the order of a physician or other licensed independent practitioner for two of two violent restraint medical records reviewed (MR1 and MR2).

Findings include:

1. Review of facility policy and procedure "Restraint and Seclusion" last revised June 23, 2017, revealed "... General Guidelines ... A written time limited order from a physician and documentation of the reason must accompany all episodes of restraint or seclusion. ... II Alternatives to Restraint or Seclusion or Seclusion Use ... Attempt to redirect agitated patients using diversionary activities and/or conversation such as: playing soothing music. Psychologist/psychiatrist consultation. ... Attempted use of alternative methods and the effectiveness of those methods must be present in the medical record. ... Documentation A. Appropriate documentation is to be made for each patient placed in restraint or seclusion as part of a modified plan of care. ... If the restraint or seclusion is no longer needed, a narrative note is to be written. ... IX. Use of Restrain or Seclusion for Violent or Self-Destructive Behavior ... A Physician's Order .... A physician order, order of a CRNP or order of a PA is required for restraint or seclusion use. ..."

2. Review, on February 26, 2018, at approximately 2:45 PM, of a combative patient security report, revealed a narrative which indicated, "On 02/05/18 Sgt. [Sergeant] ... responded to a combative patient ... Handcuffs were applied for patient/officer safety. ... [MR1] was cuffed behind his back, and cuffs were double locked ... [MR1] was placed in 4 way restraints. ... the subject was restrained. ... At approximately 1811 hrs ... dispatched again to assist medical staff ... Subject was still in restraints ... "

3. Review of a facility document on February 26, 2018, revealed a "UPMC Police and Security Use of Force Form - Officer Report" which indicated, " ... Dispatched to Combative Patient ... Restraint Used: Yes ... Type of Restraint Used: 4 Pt Nylon ... 02/05/18 ..."

4. Review, on February 26, 2018, at approximately 2:45 PM, of a nursing note for MR1 revealed, " ... Patient attempting to leave [Against Medical Advice] AMA, instructed to go back to room. Patient became belligerent and combative. Security and trauma called. ..." There was no order for the use of restraints for MR1.

5. Review of MR2 on February 26, 2018, at approximately 2:15 PM, revealed a nursing note dated February 23, 2018, at 7:25 PM, that indicated that the patient was placed in four point restraints, mitts and four side rails.

6. An order dated February 23, 2018, at 4:46 PM indicated for the patient to MR2 to be placed in 4 point restraints and mitts. Continued review of MR2 revealed that there was order no for 4 side rails to be raised for MR2 on February 23, 2018.

Interview with EMP6 on February 26, 2018, at approximately 2:45 PM confirmed the above findings for MR1 and MR2.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0176

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that a physician had a working knowledge of the hospital policy regarding the use of restraint or seclusion for one of two credential files reviewed. (CF1)

Findings include:

1. Review of facility policy and procedure "Restraint and Seclusion" last revised June 23, 2017, revealed "... General Guidelines ... V. Education and Training 1. Physicians, CRNP's and PA's who order restraint or seclusion are to have a working knowledge of this policy. ..."

2. Review of a facility security document on February 26, 2018, revealed a narrative which indicated, "On 02/05/18 Sgt. [Sergeant] ... responded to a combative patient ... Handcuffs were applied for patient/officer safety. ... [MR1] was cuffed behind ... back, and cuffs were double locked ... [MR1] was placed in 4 way restraints. ... the subject was restrained. ... At approximately 1811 hrs ... dispatched again to assist medical staff ... Subject was still in restraints ... "

3. A consult report dated February 05, 2018, and timed 1830-1920, indicated, " ... I [CF1] was informed that [the patient to MR1] kicked and punched one of th e officers. ... We're again at that place. [the patient to MR1] wants [sic] get out of restraints and , I would like to accommodate that if, again, ... will give me assurances that [patient to MR1] will not try ot leave. ... [the patient to MR1] may need to be put in restraints once again.

4. A Nursing note for MR1 dated February 5, 2018, at approximately 1900 revealed, "[CF1] ... in to see pt & removed restraints. pt now out of hallway ..."

5. Review of the facility training revealed no evidence that the physician [CF1] received training on restraint application.

When asked for evidence that CF1 had a working knowledge of the facility restraint policy, EMP1 confirmed that there was no documention of restraint training or of the restraint policy review for CF1.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0179

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that the patient was seen face-to-face with in 1 hour after the initiation of the intervention to evaluate 1. The patient;s immediate situation; 2. The patient's reaction to the intervention; 3. The patient's medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion for two of two violent restraint medical records reviewed. (MR1 and MR2).

Findings include:

1. Review of facility policy and procedure "Restraint and Seclusion" last revised June 23, 2017, revealed "... General Guidelines ... A written time limited order from a physician and documentation of the reason much accompany all episodes of restraint or seclusion. ... II Alternatives to Restraint or Seclusion or Seclusion Use ... Attempt to redirect agitated patients using diversionary activities and/or conversation such as: playing soothing music. Psychologist/psychiatrist consultation. ... Attempted use of alternative methods and the effectiveness of those methods must be present in the medical record. ... Documentation A. Appropriate documentation is to be made for each patient placed in restraint or seclusion as part of a modified plan of care. ... 4. Verbal orders can be obtained from a physician, CRNP or PA to initiate restraint or seclusion. This does not replace a face-to-face physician, CRNP or PA evaluation which must occur within one hour after initiation of restraint or seclusion. The face-to-face -evaluation of the patient must be documented in the medical record. A registered nurse may conduct the in-person evaluation within one hour of the initiation of the restraint or seclusion when this individual is trained. ..."

2. Review, on February 26, 2018, at approximately 2:45 PM, of a combative patient security report, revealed a narrative which indicated, "On 02/05/18 Sgt. [Sergeant] ... responded to a combative patient ... Handcuffs were applied for patient/officer safety. ... [MR1] was cuffed behind his back, and cuffs were double locked ... [MR1] was placed in 4 way restraints. ... the subject was restrained. ... At approximately 1811 hrs ... dispatched again to assist medical staff ... Subject was still in restraints ..."

Continued review of MR1 on February 26, 2018, at approximately 3:00 PM revealed that there was no evidence of a face-to-face evaluation within one hour of the restraint intervention.

3. Review of MR2 on February 26, 2018, at approximately 2:15 PM, revealed a nursing note dated February 23, 2018, at 7:25 PM, that indicated that the patient was placed in four point restraints, mitts and four side rails.

4. An order dated February 23, 2018, at 4:46 PM indicated for the patient to MR2 to placed in restraints.

5. Continued review of MR2 revealed that there was no face-to-face evaluation completed for MR2 for this restraint intervention.

Interview with EMP6 on February 26, 2018, at approximately 2:45 PM confirmed the above findings for MR1 and MR2.