HospitalInspections.org

Based on a review of the facility's patient information pamphlet entitled "Your Right to Decide," and the policy entitled "Statement of Patient Rights and Responsibilities," the hospital:
(a) failed to include the right to be free from abuse in the information pamphlet and the policy,
(b) added the word reasonable to the right to a safe environment,
(c) failed to assure telephone numbers for the the state agency were accurate,
(d) added a statement to the compliance statement relating to advance directives that changes, or makes unclear, the wording of this patient right, (e) failed to include information about resolution of patient grievances in the patient information pamphlet, and
(f) included a statement in the patient responsibilities (in the Your Right to Decide pamphlet) that documents patients are responsible for the behavior of visitors.
This deficient practice effected sixteen of sixteen (16 of 16) sampled patients and all patients at this facility.

Findings Include:

Eight alert and oriented patients (PI #2, #3, #4, #6, #7, #11, #12, #14) were observed and interviewed during tour 7/6/2011 (beginning at 10:50 AM). Each of these eight patients acknowledged receipt of the hospital's patient right and responsibility information.
Eight sampled patients (PI #1, #5, #8, #9, #10, #13, #15, #16)cognitively impaired, non-responsive, unavailable for interview (on tour), or discharged prior to the survey, had documented evidence, and or family members who verbally acknowledged receipt of the hospital's patient rights and responsibilities pamphlet.

A copy of the informational pamphlet entitled "YOUR RIGHT TO DECIDE INFORMATION ON ADVANCE DIRECTIVES AND YOUR RIGHTS AND RESPONSIBILITIES AS A PATIENT," was provided to the surveyor on 7/6/2011 by Employee Identifier (EI) #2. This tri-fold pamphlet is provided to patients on admission. There are four hospitals, in three Alabama counties, listed on the front of the pamphlet, including this facility.
The hospital policy, dated November 1994, and entitled: "Statement of Patient Rights and Responsibilities" lists the same patient rights and responsibilities as the patient information pamphlet.

The patient rights listed in the above documents includes:
"...[hospital name] respects the rights of our patients. We strive to provide care in a considerate and respectful manner based on each patient's individual needs. The following is a summary of your rights and responsibilities as a patient. Some of the rights and responsibilities listed may be limited by law or special circumstances. If you would like complete information on your rights and responsibilities, please contact a patient representative or a nurse.
Patient Rights
1. You, or someone on your behalf, have the right, by law, to request, accept, or refuse treatment.
2. Your have the right to make, review, and revise an advance directive and to have assistance in formulating an advance directive if you desire. You have the right to information about...[hospital name] policies on advance directives as listed in this brochure. Your choices concerning advanced directives will be placed in your medical record. However, access to and quality of care treatment, or services will be affected whether or not you have an advance directive. If you desire assistance or further information about advance directives, please contact a nurse or Patient Representative.
3. You have the right to expect that...[hospital name] will treat you if we offer the service and have the capacity.
4. You have the right to receive health care in a manner that respects your personal, religious, cultural and social preferences. Ask your nurse if you want counseling about or assistance with these issues.
5. You have the right to treatment or accommodations that you need regardless of your age, race, creed, national origin, religion, sex, disability, ability to pay, or how you pay your bill.
6. You have the right to know who is caring for you and what kind of professional they are. You also have the right to know what physician is primarily responsible for your care. This includes your right to know the professional relationship of the people who are treating you. You also have the right to know the relationship of any health care or educational institutions involved.
7. You have the right to complete information about your health status in terms you can understand. You, or someone you choose to represent you, have the right to make decisions about your health care and be included in the planning of your care.
8. You, or someone you choose to represent you, have the right to participate when ethical issues are considered about your care.
9. You have the right to have a family member (or someone you choose) and your own physician notified promptly of your admission to the hospital.
10. When you are admitted, you have the right to information about our patient rights policy and procedure to file complaints about the quality of care. Patients dissatisfied with the hospital internal complaint procedure / process may call the ...[the hotline telephone numbers for the state agency].
11. You have the right to appropriate assessment and management of pain.
12. You have the right to know if you are part of an experiment or other research / educational project that may affect your care or treatment. You have the right to refuse to be part of any such activity.
13. Your have the right to privacy concerning your medical program. Your medical information will be kept confidential as required by and within the limits of the law. You also have the right to receive information concerning (facility name) privacy practices. Detailed information about these practices can be found in the...Health System's Joint Notice of Privacy Practices.
14. You, or someone you choose, have the right to the information in your medical records as far as the law allows. We will provide access to you health information within a reasonable time frame.
15. You have the right to have your bill explained to you no matter how your bill will be paid.
16. You can expect to be reasonably safe at...[facility name].
17. You have th right to have visitors and communicate with people outside the hospital.
18. Your have the right to be free from the use of restraints (devices or medications used for the sole purpose of restricting freedom of movement) that are not medically necessary.
19. You have the right to personal privacy and dignity during all aspects of your care at...[facilty name] including bathing, dressing, toileting, and medical treatments.
20. You have the right to information about your care presented in a manner that you can understand. For example, interpretation services should be provided for non-English speaking patients, if they request it; An alternative communication techniques or aides should be provided for those who are deaf or blind, if the patient requests it.
21. You have the right to expect reasonable continuity of care. When it is time to leave the hospital, you have th right to know why you are being discharged. You also have the right to know what care or services you will need after discharge and how to get the services you need. You have the right to receive this information in a way that you understand. You, or someone you choose to represent you, have the right to be informed about the outcomes of your care, included unexpected outcomes.
22. You, or someone you choose to represent you, have the right to be informed about the outcomes of your care, including unexpected outcomes.
23. Your have the right to make your wishes known about organ donation and to have your wishes followed.

Patient Responsibilities
1. Your are responsible for giving the people who are taking care of you and your physician the most complete and correct information about present health problems and past medial history. You are responsible for telling your physician or other health care providers whether you understand your treatment plan or what you are to do as you participate in the plan.
2. You are responsible for following the treatment plan given to you by your physician. This may include following the instructions of nurses and other health care personnel as they carry out the plan of care. Also, your family members and other visitors must comply with the requests or direction from your caregivers. You are responsible for keeping appointments and, when you are unable to do so, for canceling and rescheduling those appointments.
3. You are responsible for your actions if you refuse treatments or do not follow instructions.
4. Your are responsible for seeing that your heath care bills are paid as quickly as possible.
5. You are responsible for following...[hospital name] policies. You also are responsible for the visitors, including their number and behavior. Your actions and those of your friends, relatives and visitors must be responsible and considerate of others while at ...[hospital name].
6. You are responsible for your belongings. You soul also be respectful of the property of others and of the hospital.
7. You are responsible for reporting any safety concerns you might have regarding your care to a member of the health care team or the Patient Representative.
8. If you have an advance directive, you are responsible for providing your advance directive information to the hospital..."

The facility policy includes: "Questions or concerns about quality of care or any other complaints or comments may be made by contacting your Patient Representative, Nurse, or Social Worker.
Questions, concerns or complaints may also be submitted in writing to the Patient Representative,...[address of the hospital]."

The Patient Rights pamphlet includes:
"Patient Questions, Concerns or Complaints
At...[hospital name] patients, family members, or their representatives with concerns or questions should contact the Patient Representative at...
After hours, contact the Nursing Supervisor through the hospital operator at... Questions, concerns or complaints may also be submitted in writing to the Patient Representative [hospital address / includes the contact information for all facilities listed on the front of the pamphlet]...If a patient is unable to resolve any concerns through above process, he / she or his / her representative may contact...[state agency name]..."
The telephone number for the state agency (SA) and the SA's toll free hotline are incorrect on the hospital policy and the Patient Rights and Responsibilities pamphlet.

On 7/8/2010, the facility provided a copy of a draft policy that includes the correct SA telephone numbers and additions or changes to the patient rights policy. This policy was pending review and approval by the hospital board and or governing body at the time of the survey.

Based on surveyor observations, review of the facility's restraint policy, and interviews, hospital staff failed to follow the facility "Restraint" policy, prior to or after physically restraining Patient Identifer (PI) #1 on 6/21/2011, and intermittently reapplying restraints between 6/21/2011 to 6/27/2011.
This deficient practice effected PI #1, one of sixteen ( 1 of 16) sampled patients.
Findings Include:

The hospital policy entitled "Restraints" has a revised date of 8/2010 and includes:
"I. PURPOSE
To guide the use of restraints in a manner congruent with...[hospital name] philosophy of restraint use.
II. PHILOSOPHY
A. Preventing, reducing, and striving to eliminate the use of restraint.
B. Preventing emergencies that may potentially lead to the use of restraint.
C. Using nonphysical interventions as the preferred interventions.
D. Using restraint only in emergencies in which there is an imminent risk of a patient physically harming himself or herself or anyone else.
E. Discontinuing each episode of restraint as soon as possible.
F. Raising the awareness of staff about how a patient may be physically and emotionally distressed when restraint is used.
G. Preserving the patient's safety and dignity when restrain is used.
H. The medical center does not permit restraint for any purpose such as coercion, discipline, convenience, or retaliation by staff.
I. The use of restraints is not based on a patient's restraint history or solely on a history of dangerous behavior.
III. POLICY
A. Definition of Scope
1. Behavioral restraint is used for violent and self destructive patiens.
2. Non-behavioral restraint is used for non-violent and non-self destructive patients.
B. Restraints are used only when less restrictive alternatives are inadequate to prevent a patient from harming self or others. Alternatives may include but not be limited to:
1. Assess and attend to physiological needs such as body temperature, hunger/thirst, toileting, and pain control.
2. Provide improved lighting.
3. Distract with TV, music, folding towels, or other safe activities...
4. Reassure with reality feedback for the non-demented, validation therapy for the demented.
5. Apply untied mittens.
6. Ask patient how to help him or her to maintain self-control.
7. Ask significant others how they calm patient at home and / or if they will stay with patient.
8. If possible, try ambulating, wheelchair ride, or rocking chair in hall.
9. Cover IV sites and other tubes.
10. If medically appropriate, ask physician to discontinue all tubes and to change feeding to bolus.
11. Upon physician order, consult Occupational Therapy to assist wit chronic or repetitive behaviors.
C. Restraint is clearly defined:
1. Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces that ability of a patient to move his or her arms, legs, body, or head freely. Examples include:
a. Chemical restraint - A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
b. Leather restraints - Used in Emergency Department and Intensive Care Units - control behavior with leather straps restricting movement of extremities.
[policy does not include c or d]
e. Soft restraints - Control of behavior with non-leather restrictive devices such as extremity ties, hand mittens, and body holder.
f. Bed enclosure - Fall prevention through enclosure of entire bed.
2. Not defined as restraints are some restrictive devices:
a. Usual and customary immobilization during medical, diagnostic, and surgical procedures.
b. Security devices used by law enforcement on forensic patients.
c. Adaptive or postural supports to compensate for musculoskeletal deficits.
d. Devices to prevent falls unrelated to cognitive or behavioral dysfunction.
D. Restrained patient may not smoke.
E. Restraint is discontinued when the patient no longer displays the behavior that necessitated the use of restraint.
1. Early release criteria may include but not be limited to:
a. Patient is alert, oriented, and able to follow commands consistently.
b. Patient is free of agitation/combative behavior.
c. Less restrictive interventions are effective.
d. Medical devices/tubes are removed, OR patient is not pulling at them.
2. If a patient was recently released from restraint and exhibits behavior that can only be handled by the reapplication of a restraint, a new order would be required. Staff cannot discontinue an order and then re-start it under the same order because that would constitute a PRN order. Each episode of restraint use must be initiated in accordance with the order of an MD or other LIP [abbreviations are not defined in policy]. However, a temporary release that occurs for the purpose of care for a patient's needs - for example toileting, feeding, range of motion, or therapy-is not considered a discontinuation of the intervention.
3. Only the MD, other LIP, or RN can determine when early release criteria is indicated.
F. Staff who care for restrained patients are educated regarding restraint reduction, application, utilization, and related care and observation needs during department orientation and periodically as part of departmental competency..."
IV. PROCEDURE
A. When less restrictive interventions are inadequate, a physician (or emergently for behavioral reasons a registered nurse) determines restraint is necessary and decides which form is appropriate.
B. Restraint order:
1. Behavioral Restraint Order form for behavioral restraint.
a. MD should co-sign order within 1 hour of initiation - after performing a "face to face" evaluation.
2. Non-Behavioral Restraint Order form for all other restraints.
a. Requires an order for restraint prior to the application of restraint. The need for a restraint intervention may occur so quickly that an order cannot be obtained prior to the application of restraints. In these emergency application situations, the order must be obtained either during the emergency application of the restraint or as soon as possible after the restraint has been applied.
b. MD should co-sign within 24 hours after performing "face to face" evaluation.
C. Try to gain patient's cooperation with use of restraint.
D Gather adequate number of staff to safely perform restraint (See Code Strong Policy.)
E. Allow patient to remain clothed but remove shoes, jewelry, constricting items or anything else the physician or registered nurse deems potentially dangerous.
Initial restraint.
1. Chemical restraint:
a. Oral medications are not given involuntarily.
b. IV or IM medications may be given involuntarily if a physician has determined and documented that the patient is medically incompetent to refuse treatment for that instance.
c. Monitor pulse, blood pressure, and respiration as indicated by symptoms of the patient.
2. Leather restraint:
a. The registered nurse directs 5 to 6 staff to:
1. Place the patient supine in bed with a pillow under head.
2. Hold patient's extremities down to mattress while other staff apply and lock restraints onto bed frame.
3. Empty pockets and remove shoes and socks.
b. The physician or registered nurse may decide to use a body net to protect patients who thrash while in leather restraints.
1) Place sheepskin neckline at patient's neck
2) Pull patient's arm through armholes.
3) Secure straps to bed frame with quick-release buckle or tie.
4) Secure arms at writs and above elbows with padded strips.
5) Secure ankles with padded strips.
3. Soft Restraints.
a. For extremity ties the registered nurse directs staff to:
1) Place the patient supine in bed with a pillow under head.
2) hold patient's extremities down to mattress while other staff apply a secure restraints to bed frame with quick release buckle or tie. Never restrain only a single limb, unilateral limbs, or both legs.
3) Pad underneath restraints if indicated to protect skin.
4). Remove hazardous items from patient's reach.
b. For Hand mittens the registered nurse directs staff to:
1) Place patient's hand into the mitten...
c. For Bodyholder:
1) Crisscross the bodyholder behind the patient...
...H. Monitoring Patient Status
1. Behavioral Restraint
a. Continuous in-person observation by a competent staff member.
2. Non-Behavioral Restraint
a. At least every two hours
I. Debriefing
1. Behavioral Restraint
a. Upon release, ascertain patient's and possibly significant other's perception of what could have prevented the need for the restraint...
V. Documentation
A. Interventions and/or why no alternatives were attempted.
B. Behavior necessitating use of restraint.
C. Type of restraint
D. Patient-family education/notification.
E. Care during restraint is assessed and documented at least every 2 hours for non-behavior restraint and every 15 minutes for behavioral restraint...

On 7/6/2011 at 10:50 AM, PI #1 was observed in his room, lying in bed. PI #1 was alert but could not recall the day, date, time, or where he was (in the hospital, etc).
When asked why he came to the hospital, PI# 1 answered, "It don't make no difference...to old to remember." PI # 1 stated he just wants to "be comfortable and be left alone, so he can rest and sleep all day till it gets dark in here."

Review of PI# 1's medical record revealed this elderly male patient was admitted to the hospital on 6/20/2011, with diagnoses that includes Left Epidural Hemorrhage and Hypertension. Staff documented that PI # 1 was incontinent of bladder and bowel (on admission) and a Foley (bladder) catheter was ordered and connected to a drainage bag.
On 6/21/2011 at 1540, the day after PI #1's admission, Employee Identifier (EI) #12 completed a "PATIENT ASSESSMENT" that includes: "...Apply Restraints, location TSICU [trauma surgical intensive care unit].
Type of Restraint Order: Medical Device Displacement.
Family Notification: Notified
Behaviors exhibited requiring restraints: Pulling @ medical Devices
Alternative attempted prior to restrain application [none documented]
ASSESS/REMOVE RESTRAINTS
Alert, oriented, able to follow commands consistently
Less restrictive interventions have proven effective
Medical Devices or tubes removed / pt [patient] leaves them alone Meets Early Release Criteria
Adjustment to medication (if any) has proven effective Restraints removed
Restraint Type Body Holder/ Vest
DOCUMENT CHANGES & FINDINGS IN NURSE ' S NOTES
Change Body Position of Patient * Yes
ROM To Restrained Extremities* Yes
Circulation to Restrained Extremities* Yes
Offer Elimination* Yes
Level of Distress & Agitation* Yes
Skin Integrity* Yes
Mental Status* Yes
Fluids/Meal Offered to Patient* Yes ...

On 6/20/2011 at 15:26, Employee Identifier (EI #12) documented:
Doctor # 3 "...AT BEDSIDE. NO NEW ORDERS RECEIVED."

On 6/21/2011 at 16:30, EI #12 documented:
"REASSESSMENT COMPLETE VSS [vital signs stable] AFEBRILE. PATIENT IS STILL ALERT AND ORIENTED x 4. PATIENT IS CONFUSED AT TIMES AND WILL TRY AND GET OUT OF BED. PATIENT STATES "I AM GETTING OUT OF THE BED AND GOING HOME. I HAVE BEEN HERE TO LONG... PATIENT CAN STATE HIS NAME, PLACE, TIME AND SITUATION. PUPILS RIGHT IS ...BOTH ARE BRISK. PATIENT STILL FOLLOWS ALL OTHER COMMANDS OTHER THAN TO STAY IN THE BED. BODY HOLD APPLIED AT THIS TIME. CALLED SON AND SON IS OK WITH THIS ...URINE OUTPUT IS MARGINAL. NO OTHER CHANGES NOTED FROM PREVIOUS ASSESSMENT. WILL CONTINUE TO MONITOR CLOSELY..."
At 1805, "...GOAL NOT MET. PATIENT HAVING MORE CONFUSION TODAY BUT IS STILL ORIENTED..."

On 6/21/2011 at 2000, EI #15 documented:
"...ASSUMING CARE OF PT [patient / PI #1] ...REMAINS IN BODY HOLDER AND WRIST RESTRAINTS DUE TO ATTEMPTS TO GET OOB [out of bed] WITHOUT ASSISTANCE. SUBDURAL DRAIN INTACT...
At 0000, "...BODY HOLDER IN PLACE. WILL CONT [continue] TO MONITOR."
At 2100, "... REMOVED BODY HOLDER AT THIS TIME. PT IS A/Ox4 [alert and oriented times four] FOLLOWING COMMANDS. I TOLD PT IF HE TRIED TO GET OOB I WOULD HAVE TO PUT THE BODY HOLDER BACK ON HIM. PT STATED 'I KNOW NOT TO GET OOB. I'M GOING TO GO TO SLEEP AND NOT GET UP.'"
At 2316, "PT ATTEMPTING TO GET OOB AGAIN. BODY HOLDER RE-APPLIED AT THIS TIME..."

On 6/22/2011 at 1115, EI #12 documented:
Doctor #5 "...AT BEDSIDE. NO NEW ORDERS RECEIVED."
At 1456, "...SUBDURAL DRAIN DC'D [discontinued]..."

On 6/23/2011 at 1248, EI #14 documented:
PI #1 "...CONFUSED AT TIMES EASY TO RE-ORIENTED. CAN TRANSFER BUT WAITING ON A SITTER..."
At 1426: "...CONTINUES TO PLAY WITH CATHETER. APPEARS TO BE CONFUSED. WHEN ASKED WHERE HE IS AT, HE STATED I DON'T KNOW. ASK HIS NAME, AND HE STATES I DON'T KNOW, ASKED WHAT IS YOUR SON'S NAME, I DON'T KNOW. WHEN ASKED IF HIS SON'S NAME IS LUCY, HE STATED NO. THEN GIVE HIM HIS SON'S NAME AND HE SAYS YES. THEN ASKED HIM WHAT HIS NAME IS...ASKED...WHERE HE IS AT AND HE STATED [name of hospital]..."
At 1600: "...WAITING FOR ESCORT TO COME GET PT. PT ORIENTED BUT WANTS TO PULL AT CATHETER STILL. MITTENS IN PLACE AT THIS TIME..."

On 6/23/2011, EI #16 documented:
PI #1 arrived "...TO FLOOR FROM TSICU AT 1640...PT IS FIDGETY HAS MITTS ON D/T [due to] TRYING TO GRAB MONITOR WIRES ETC, PT KEEPS SAYING HE WANTS TO GET OUT OF BED...BODY HOLDER IN PLACE. SITTER AT BEDSIDE..."

On 6/25/2011, Doctor # 1 ordered:
1) Keep Foley well secured to pt ' s (patient ' s) thigh (stat) lock and or tape,
2) Restrain to prevent self harm if he continues to pull at Foley
3) May irrigate Foley prn (as needed).

On 6/27/2011 at 1700, EI #13 documented:
"...REMOVED MITTEN RESTRAINTS PER PATIENT REQUEST. EXPLAINED TO Pt NOT TO PULL AT ANY OF HIS TUBING AS TO AVOID INJURY. PCA [patient care assistant] AT BEDSIDE WILL CALL IF HE NEEDS ASSISTANCE..."

On 6/28/2011, Doctor # 2 signed the "...NON BEHAVIORAL RESTRAINT ORDER PHYSICIAN PROGRESS NOTE AND RE-EVALUATION" form that includes:
"...CRITERIA FOR CONTINUED RESTRAINT USE ALTERNATIVES OR ATTEMPTS TO REGAIN CONTROL:
Interventions to regain control have been unsuccessful and patient has not met criteria for removal of restraints
Unsuccessful criteria:
Less restrictive interventions have not proven effective
Patient will not leave medical devices or tubes alone
Adjustments to medication (if any) has proven ineffective
RESTRAIN TYPE:
The type of restraint to be continued is:
Body Holder / Vest
PHYSICIAN TO SIGN, DATE, AND TIME FOR EVERY CALENDAR DAY CONTINUED RESTRAIN USE:
I have seen the patient, discussed with staff and agree with the lack of success to regain control, the type of devise selected and the CONTINUED indication and need for restraints..." There is no date or time documented on this form.

EI #8, one of the nurses on duty during the time PI #1 was restrained, was interviewed (on 7/8/2011 at 11:10 AM). EI #8 recalled PI #1 being restrained with untied mittens, while a sitter was at the bedside. When asked about the release of the PI #1's restraint, EI #8 was unsure if, or when, the bedside sitter released the restraints, but stated the patient was probably released during meal time. When asked about the facility policy for restraints, EI #8 stated that restraints are checked every two hours, but did not know the facility's policy relating to restraints being intermittently released, discontinued, and or re-ordered.