HospitalInspections.org

Based on the following patient rights deficiencies identified during a validation survey on 7/9/18 to 7/11/18, involving consents and restraints, it was determined that the hospital failed to protect the rights of patients and was out of compliance with the patient rights Condition of Participation.

Based on a review of the hospital policy, 38 open and 11 closed patient records, it was determined that the hospital failed to assess whether patient #18 lacked decision making capacity or to certify an incapacity prior to having multiple consents signed by patient #18's surrogate decision maker. In addition, one other patient (#32) was denied the right to refuse diagnostic testing in the emergency department.

Per hospital policy titled, "Consent, Informed" (revised 12/30/14) section D. "Treatment of a Patient Who is Incapable of Making Medical Decisions- Surrogate Decision Making" sub section "2. Certification by Physician," "Prior to providing, withholding, or withdrawing treatment or procedures on the basis of surrogate decision making, the attending physician and a second physician .... shall certify in writing that the patient is incapable of making an informed decision regarding the treatment. The certification shall be based on personal examination of the patient. If a patient is unconscious or unable to communicate by any means, the certification of a second physician is not required."
Patient #18 was a 60+ year old patient who was admitted to the hospital after being hit by a motor vehicle. Per trauma evaluation in the ED, patient #18 sustained multiple fractures but did not require acute surgical intervention. Patient was admitted to the surgical ICU. On the second day of patient #18's presentation to the hospital, patient #18 was cleared for surgery.

Review of patient #18's chart revealed 5 consents signed at 0740 and 0800 on this day (4 consents for orthopedic surgery and a consent for blood transfusion and/or blood component administration). Each consent had an element of a check box with the statement, "Patient lacks capacity (requires attending of record to coordinate documentation of incapacity in the medical record per (hospital) informed consent policy)." Each consent had the box checked which indicated patient #18 had an incapacity.

Per surgical daily progress note from earlier that day at 05:01, patient was "alert and oriented." Per Orthopedic Surgery Progress note at 05:58, patient was "alert and oriented to person, place and time." While patient #18 was found to be oriented to 3 spheres, all consents indicated an incapacity, and all consents were obtained by telephone from patient's surrogate. No actual assessment for certification of an incapacity was found in the record. A consent for anesthesia was also found for this day obtained verbally from the surrogate.

On the third day of patient #18's stay, a consent for anesthesia was found. Above the signature line for the patient to sign, it was written "verbal by patient." However, the patient's surrogate was called for a phone consent at 0930 AM. Per anesthesia pre-evaluation note at 10:46, "Pt seen and examine, Plan of care discussed with patient who agrees with plan for general anesthesia ... Patient unable to sign the consent and hence only verbal consent obtained from patient. (Surrogate) called and informed about the anesthetic plan or procedure."

On the seventh day of patient #18's stay patient was transferred to a floor unit. A consent was found for IV (intravenous) contrast. The consent was obtained from the patient's surrogate via the phone at 04:45. A consent for a chest tube was also found signed by the patient at 3:45. Per surgical daily progress note that day, patient was "alert and oriented."

On the 35th day of patient #18's stay, a consent for another surgical procedure was found. No check box was marked to indicate an incapacity, though the consent was obtained from the patient's surrogate via phone at 0824. A consent for anesthesia was also found that was obtained via phone. Per surgical daily progress note at 7:54, patient was "awake, disoriented." No recorded certification of incapacity was found.

In summary, the hospital failed to evaluate patient #18 for capacity and certify an incapacity prior to obtaining multiple consents from a surrogate. Based on this the hospital failed to honor the patient's right to make informed decisions about his or her care.

Patient #32 was an adult with a history of mental illness who presented to the emergency department (ED) in late April 2018 at 0041 on an emergency petition for an emergency psychiatric evaluation. Patient #1 had demonstrated behaviors in the community which indicated patient #32 was a danger to her/himself. Following a refusal of vital signs, patient #1 was escorted to the psychiatric portion of the ED with security at 0124. A nursing flow note of 0135 stated in part, " ...patient refused labs, refused to give urine ..."

A physician order of 0354 for "Short Term Physical Hold" revealed a rationale of "Violent/Imminent Harm to Others." However, nursing flow documentation of 0315 revealed the sole purpose of the Physical Hold was "needed for blood draw." A nursing note of 0338 stated, Labs obtained and sent. Patient remains uncooperative. Urine still needed."

Based on all documentation, the hospital took patient #32's blood forcibly after patient #32 expressly objected to giving that blood, which represented a failure to honor patient #32's right to refuse.

The hospital failed to ensure the safety of both patients and visitors within the emergency department to be free from injury resulting from unsecured needles, sharps, and intravenous IV equipment. During tour of this 36 bed emergency room, a supply cart containing needles and IV start materials in one of the triage rooms was noted to be unsecured and the drawers were able to be opened. An exam/treatment room was also checked revealing that the supply cart in this room was also unsecured and malfunctioning with staff unable to lock the cart at all.

In addition, while touring the ED, a visitor was witnessed going through the top drawers of the supply cart that was in a room with a patient. The top draws of the supply cart contained the majority of the needles and sharps equipment. Staff report that the carts usually are locked by the nurse prior to leaving the room and that the carts automatically lock after two minutes of inactivity, this was not found to be the case with the three randomly selected carts reviewed.

Based on a review of hospital policy for restraint use and review of 3 restraint records, it was determined that the hospital 1) restrained patient #32 in the emergency department for convenience while obtaining of a blood sample following patient #32 expressed refusal to give blood; and 2) patient #47 was restrained via a roll belt and enclosed bed without appropriate assessment and reassessment parameters.

Hospital Policies Restraints: Non-Violent/Non-Self Destructive and Violent/Self Destructive (approved 3/11/2015) both state in part, "The patient has the right to be restraint free from any form of restraint that is not medically necessary."

Patient #32 was an adult with a history of mental illness who presented to the emergency department (ED) in late April 2018 at 0041 on an emergency petition. Patient #32 had demonstrated behaviors in the community which indicated patient #32 was a danger to him/herself. Please refer to tag A-0131 related to a restraint used for staff convenience.

Patient #47 was a 60+ year old with progressive dementia who admitted to the hospital due to not sleeping, agitation and impulse control resulting in frequent falls in the community. A RN pre-admission note assessing the historic use of restraint, revealed "None" and that patient #47 had a history in part of increasing agitation at sundown, sliding to the floor out of a wheelchair, and a need for 1:1 staff monitoring to prevent falls.

The RN documented, "I discussed a Posey Bed and Belt with (surrogate) for safety and (surrogate) is in agreement." A Posey Bed (AKA Enclosed Bed/NetBed) is a bed which is enclosed by a rectangular netting spanning the width and length of the bed which stands approximately 3' off the surface of the bed. When in the enclosed bed, a patient may move about, but cannot exit the bed. An enclosed bed is a form of restraint requiring all regulatory elements to be met, including assessments for need, reassessments, and alternatives prior to use.

Rather than a real time assessment of the need for restraint, the RN documentation indicated that permission was obtained from the surrogate to utilize the enclosed bed and belt. The attempted use of alternatives to restraint use was not documented.

A physician History and Physical of 1312 on the day of admission revealed no reference to the utilization of a restraint bed in the management of patient #47. Under Assessment/Plan, the physician wrote in part, "(Patient #47) requires hospitalization due to need for 1:1 supervision in assisted living to manage impulsivity, sleep disorder, some agitation with personal care in setting of progressive degenerative neurologic disorder."

At 1556 on the day of admission, a Certified Registered Nurse Practitioner (CRNP) wrote an order for Enclosed Bed 7 PM to 7 AM and Roll belt/Soft belt from 7AM to 7 PM. Review of the order rationale revealed, "Prevent from removing therapeutic modalities." Patient #47 had no therapeutic modalities to remove which made the rationale of roll belt and the rationale for the later enclosed bed inaccurate. Patient #47 was placed into a roll belt due to being a high fall risk.

RN flow documentation revealed alternatives tried prior to application of the roll belt as "Distractions, repositioning." These were insufficient alternatives for a patient who was a high fall risk, and indicated that no appropriate alternative was tried, such as 1:1 monitoring. Please see tag A-0166.

Initial flow documentation described patient #47's behavior as "restless," which of itself did not justify restraining patient #47 to a chair via roll belt. Further, no flow documentation under "reason for continuation" and "describe behaviors: REQUIRED" was documented at the two hour assessment of 1757.

Patient #47 was placed into the enclosed bed at 1957 with behavior described only as "Impulsive." Alternatives to the use of the enclosed bed were documented by nursing as "Disguise equipment." This alternative was inappropriate for use of an enclosed bed.

A CRNP note on day 2 of admission at 0904 stated in part, " ...Nursing reports that the patient has been sleeping 8 hours per night ... Staff report that patient has been calm and cooperative but can hold onto staff members during care." No mention of enclosed bed restraint was found, nor was the need to reassess for use of the enclosed bed restraint with alternatives to the enclosed bed documented in the medical record.

Nursing flow documentation on day 2 of admission revealed that restraints were ongoing. However, no restraint order was found in the record. See tag A-0168. The reason for continuation of restraints on day 2 was noted in the nursing flow as, "Attempting to remove medical equipment/therapeutic modalities." As noted, pt. #47 had no therapeutic modalities.

The same behaviors and alternatives of day one and two of admission were similarly documented on day 3 through day 5. However, day 3 was noted to have no nursing flow "evaluations/outcome" assessment documentation for 4 of the two-hour assessment periods from 1149 through 1749. Additionally, no restraint care needs were documented every two hours for 1549 and 1749.

In summary, the hospital failed to justify restraint for patient #32 and patient #47. Additionally, for patient #47, the hospital failed to apply appropriate assessment parameters, failed to try appropriate alternatives to restraints, and failed to demonstrate a consistent assessment process.

Based on a review of patient #47's record, disparities were revealed related to the Interdisciplinary care plan and the nursing care plan related to the use of restraints.

Patient #47 was a 60+ year old with progressive dementia who admitted to the hospital due to not sleeping, agitation and impulse control resulting in frequent falls in the community. A RN pre-admission note assessing the historic use of restraint, revealed "None" and that patient #47 had a history in part of increasing agitation at sundown, sliding to the floor out of a wheelchair, and a need for 1:1 staff monitoring to prevent falls.

An Interdisciplinary Care Plan (ICP) initiated day one of admission did not note the potential intervention of an enclosed bed or belt in the prevention of falls. However, one potential intervention noted in the ICP under Safety/Falls in part, was, " ...Consider use of certified patient observer per hospital standards ..." A separate nursing care plan documented in the flows for both the enclosed bed and belt stated in part:

"Determine that alternatives or other, less restrictive measures have been tried or would not be effective before applying the restraint; Evaluate the patient's condition at the time of restraint application; Inform patient/family regarding the reason for restraint; Monitor per restraint policy for safety, psychosocial status, and comfort measures."

No documentation was found in the record indicating a rationale that a primary intervention such as 1:1 monitoring would not be an interventional option. Based on all documentation, a difference existed between ICP interventions and nursing care plans which appear to have excluded a potential alternative to restraint by using 1:1 monitoring.

Based on a review of patient #47's record, it was revealed that three prn orders for enclosed bed were written on days 1, 4, and 5 of admission.

Patient #47 was a 60+ year old with progressive dementia who admitted to the hospital due to not sleeping, agitation and impulse control resulting in frequent falls in the community. A RN pre-admission note assessing the historic use of restraint, revealed "None" and that patient #47 had a history in part of increasing agitation at sundown, sliding to the floor out of a wheelchair, and a need for 1:1 staff monitoring to prevent falls.

At 1556 on the day of admission, a Certified Registered Nurse Practitioner (CRNP) wrote an order in part for "Enclosed Bed 7 PM to 7 AM," which represented a prn (as needed) order for enclosed bed restraint. Similar orders were written for days 4, and 5 of admission. This meant that orders were obtained for restraint prior to any assessment of the need for restraint for patient #47 which represents PRN orders.

Based on life safety code deficiencies associated with fire safety identified during a validation survey on 7/9 and 7/10/18, it was determined that the hospital was out of complaince with the Condition of Participation for physicial environment.

Based on observation and staff interview, it was determined that food service areas were not maintained to ensure sanitary food service.
The findings include:

On July 10 and 11, 2018, the surveyor, accompanied by the Director of Environmental Health and Safety, Food Service Director and Vice President of Support Services, conducted an environmental tour of the food service areas of the facility. The following were observed and verified by facility staff:
1) At the loading dock, a door near the kitchen where supplies are delivered for food service, gaps were observed in the gaskets to the entry door and the main delivery door. These doors must be tightly sealed to prevent entry by pests. The concrete pad for the trash compacter was porous and not sealed to prevent absorption of spilled substances into the concrete.
2) Pans, turned upside down for storage, were observed on an open shelf rack. The bottom shelf was about nine inches from the floor. This created a risk for contaminating the cleaned pans from sweeping or mopping the floor near the shelf. Food contact surfaces must be protected from contamination, typically by being stored at least 18 inches from the floor.
3) A detergent dispenser was installed over a two-compartment sink. Dishwashing must be done in a three-compartment sink, to wash, rinse and sanitize. The two-compartment sink should be utilized for food preparation only. The dispenser created a risk of contaminating food with dish detergent.
4) A food digester, a large piece of equipment used to break down foods for disposal, was stored in the kitchen, near the dishwashing area. The dietary manager stated that the digester was not in use. Unused equipment may not be stored in the food service area, as it creates a risk for harborage of pests.
5) On July 11, 2018, in the Carol Ball Unit of the Burton building, at 1:00 PM, paper wrapped straws were stored adjacent to hand sinks, under the paper towel dispenser in the clean utility rooms in the A, B and C wings. This created a risk of contamination of the straws when employees washed and dried their hands.

Based on a review of 38 open and 11 closed medical records, no evidence was found the hospital provided a discharge evaluation in a timely manner for three of 38 open records reviewed.

Patient #28 (Pt# 28) was admitted for an elective surgical procedure to treat a brain aneurysm. Pt# 28 was admitted to the neuroscience intensive care unit post procedure due to surgical complications. On day 13 of Pt# 28's admission, no evidence was found a discharge planning evaluation had been completed.

Patient # 29 (Pt# 29) was transferred from an outside hospital for treatment of an acute stroke. Pt# 29 was admitted to the neuroscience intensive care unit. On day 10 of Pt# 29's admission, in-hospital transfer to the inpatient rehabilitation unit was arranged. Pt# 29's medical record revealed the discharge evaluation had been completed the same day of transfer.

Patient # 30 (Pt# 30) arrived to the Emergency Department with an elevated blood sugar level and was admitted for treatment. Three days after admission, review of Pt# 30's medical record revealed a discharge evaluation completed on the same day as the planned discharge.