HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on a review of clinical records, interviews, and policy review for one (1) of ten (10) patients reviewed for care and services (Patient #15), the facility failed to ensure that an allegation of abuse was immediately and/or thoroughly investigated and/or that the patient was free from abuse.

Based on a review of clinical records, interview and policy review, for two (2) of three (3) patients reviewed for the use of restraints (Patient #24 and #25), the facility failed to ensure that an assessment was completed that warranted the use of restraints.



Please see A 145 and 165.

Based on a review of clinical records, interviews, and policy review for one (1) of ten (10) patients reviewed for care and services (Patient #15), the facility failed to ensure that an allegation of abuse was immediately and/or thoroughly investigated and/or that the patient was free from abuse. The finding includes the following:

Patient #15 was admitted on 1/9/19 with ventricular premature depolarization. The patient had a deep intraseptal paraHIsian PVC ablation completed followed by a dual chamber pacemaker implant.

Interview with RN #16 on 2/26/18 at 2:30 PM indicated that on 1/9/19 he was in the control room in the Electrophysiology (EP) lab and saw MD #15 with his hands raised to head/chest level and then MD #15 slammed his hands down on the mid abdomen of the patient. RN #16 indicated that the patient moaned.

Interview with RN #15 on 2/26/19 at 1:30 PM indicated that on 1/9/19 she had stepped out of the EP room and on her return to the control room heard a moan and asked RN #16 and 17 what the noise was, and was informed that MD #15 had just slammed his hands down on the patient and the noise was the patient moaning.

Interview with RN #17 on 2/27/19 at 10:45 AM indicated that on 1/9/19 he was in the control room of the EP lab and witnessed MD #15 slam both hands down on the magnetic mat which was on the patients abdominal area.

Interview with Scrub Tech #15 indicated that she was in the room with MD #15. ST #15 indicated that during the procedure MD #15 was holding the sheath cupped in his hands and lowered his hands to the magnetic mat. ST #15 indicated that the patient moaned.

Interview with MD #15 on 3/19/19 at 10:20 AM indicated that on 1/9/19 he performed an ablation and pacemaker insertion on Patient #15. MD #15 stated the procedure had been very lengthy and after finishing the ablation portion of the procedure, when the patient was awake, the next step was to place the patient in conscious sedation and perform the pace maker insertion. MD #15 stated that he was having a difficult time placing the guidewire and had been trying for a period of time when he realized it was not going to work. MD #15 removed the wire and sheath with two hands with the guidewire between his thumb and forefinger and upon removal, placed the sheath down with emphasis on the magnetic mat which was on the patient. MD #15 indicated that the patient grunted and the physician responded that he did not know the patient was awake. Patient #15 responded that he/she had been awake the entire time. MD #15 indicated that the patient never raised a concern or complaint following the incident. MD #15 indicated that there was no intent to harm the patient.

Interview with the Vice President of Medical Affairs (VPMA) on 2/26/19 at 12:30 PM indicated that he was notified that an internal complaint was filed regarding MD #15 and he interpreted the concern as a practitioner issue and not abuse, therefore, forwarded the concern to the Chief of Cardiology and the Chief of Electrophysiology. The VPMA indicated that no further follow-up had occurred and that the ball had been dropped.

Interview with the Chief of Electrophysiology on 2/28/19 at 2:50 PM identified that he was notified on the morning of 1/10/19 that there was a Quantros report (anonymous internal computerized reporting mechanism) regarding MD #15. He made an appointment with MD #15 for 1/15/19. At that meeting, MD #15 was notified that his reported behavior of slamming his hands down on Patient #15 was unprofessional. Another meeting with MD #15 occurred approximately two weeks later where professional behaviors were discussed.

Interview with the Chief of Cardiology on 2/26/19 at 1:11 PM identified that he met with MD #15 on 1/15/19 and discussed the incident. The Chief of Cardiology identified that he was in the process of stepping down as the Chief and thought that the in-coming Chief would be responsible for follow-up.

On 2/26/19 MD #15 voluntarily relinquished privileges at the hospital.

Review of the Medical Staff Professionalism policy failed to identify immediate actions that should occur when allegations of physical abuse are made.

Review of the Medical Staff Professionalism policy indicated communication, collegiality and collaboration are essential for the provision of safe and competent patient care. As such, all practitioners must treat others with respect, courtesy and dignity and conduct themselves in a professional cooperative manner.

Based on a review of clinical records, interview, and policy review, for two (2) of three (3) patients reviewed who utilized restraints (Patient #24 and #25), the facility failed to ensure that an assessment was conducted that warranted the use of restraints. The findings include the following:

a. Patient #24 was admitted on 4/1/19 with an inventricular tumor. Review of a physician's order dated 4/2/19 at 5:07 PM directed the use of bilateral wrist restraints for risk for self-injury. Review of the clinical record with the Informatics RN indicated that although the patient was monitored every two hours, the record failed to reflect an assessment that warranted the use of restraints.

b. Patient #25 was admitted to the hospital on 4/2/19 after a motor vehicle accident. The physician's order dated 4/2/19 at 6:24 PM directed the use of bilateral wrist restraints. Review of the record with the informatics RN and the Regulatory Director failed to reflect an assessment that warranted the use of restraints.

Review of the Restraint and Seclusion Policy indicated that comprehensive assessments and reassessments should be documented in the clinical record and include in part, the following, the patient's condition, symptoms, interventions, alternatives attempted, and clinical justification (reason or behavior requiring the restraint), least restrictive devise tried and patient's response.

Based on areview of the clinical record, interviews, and policy review, the facility failed to ensure that a mechanism was in place to ensure that a comprehensive investigation was completed after an allegation of patient abuse was made. The finding includes the following:

Patient #15 was admitted on 1/9/19 with ventricular premature depolarization. The patient had a deep intraseptal paraHIsian PVC ablation completed followed by a dual chamber pacemaker implant.

Interview with RN #16 on 2/26/18 at 2:30 PM indicated that on 1/9/19 he was in the control room in the Electrophysiology lab (EP) and saw MD #15 with his hands raised to head/chest level and then MD #15 slammed his hands down on the mid abdomen of the patient. RN #16 indicated that the patient moaned. RN #16 indicated that no one has interviewed him about the incident.

Interview with RN #15 on 2/26/19 at 1:30 PM indicated that on 1/9/19 she had stepped out of the EP room and on her return to the control room heard a moan and asked RN #16 and #17 what the noise was, and was informed that MD #15 had just slammed his hands down on the patient and the noise was the patient moaning.

Interview with RN #17 on 2/27/19 at 10:45 AM indicated that on 1/9/19 he was in the control room of the EP lab and witnessed MD #15 slam both hands down on the magnetic mat which was on Patient #15's abdominal area. RN #17 stated that no one has interviewed him about what happened on 1/9/19.

Interview with the EP Manager on 2/26/19 at 2:00 PM indicated on 1/10/19 he received a copy of an internal report staff had filed about an incident that happened on 1/9/19 that indicated that MD #15 slammed his hands on Patient #15's abdominal area. The Manager indicated that he talked to several staff about the incident and staff reported consistent stories. However, the manager did not conduct and/or document interviews or statements.

Interview with Scrub Tech (ST) #15 indicated that she was in the room with MD #15. ST #15 indicated that during the procedure MD #15 was holding the sheath cupped in his hands and lowered his hands to the magnetic mat and the patient moaned. ST #15 indicated that no one ever interviewed her about exactly what happened.

Interview with the Assistant Manager of the EP lab on 2/26/19 at 11:50 AM indicated that the incident was reported to her on 1/10/19 by RN #17 and she spoke with him and CST #15 about the incident but did not conduct and/or document interviews or statements.

Interview with the Vice President of Medical Affairs (VPMA) on 2/26/19 at 12:30 PM indicated that the report of the incident had been forwarded to him and he had forwarded it to the Chief of Cardiology and the Chief of Electrophysiology. The VPMA indicated that after that no further follow-up had occurred and that the ball had been dropped. Additionally, the VPMA identified that if there was an issue with patient safety or if a patient was harmed, the incident would be referred to the quality department, but in this case, it was not.

Interview with the Director of Regulatory Readiness on 2/26/19 at 12:10 PM indicated that staff are able to file anonymous reports via the computer system and these are reviewed daily to determine follow-up. In this case, the report was sent to the VPMA for review.

Review of the Medical Staff Professionalism policy indicated communication, collegiality and collaboration are essential for the provision of safe and competent patient care. As such, all practitioners must treat others with respect, courtesy and dignity and conduct themselves in a professional cooperative manner. Review of Medical Staff Professionalism policy indicated that based on interviews, discussions and consultations with medical staff leaders the VPMA will determine the next course of action. Additionally the policy failed to reflect time requirements when conducting the investigation.