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Based on observation, interview, and record review, the hospital failed to follow its policy and procedure (P&P) titled, "Advanced Healthcare Directive, Surrogate Decision Maker" (AD- legal document which outlines an individual's preferences for medical care if they are unable to communicate them) for three of four sampled patients (Patient 1, Patient 2, and Patient 3). This failure resulted in Patient 1's, Patient 2's, and Patient 3's Patient Rights not being honored and had the potential for their medical choices to not be honored.

Findings:

During a concurrent observation and interview on 11/25/24 at 10:12 a.m. with Patient Access Representative (PAR) 1, in Outpatient Registration, PAR 1 pre-registered Patient 1 for an outpatient procedure. PAR 1 asked Patient 1 if she had an "emergency contact" and if she had a person who could make medical decisions for her. Patient 1 stated she had a verbal agreement with her daughter but there were no legal documents regarding that agreement. PAR 1 did not ask Patient 1 if she wanted any information on how to formulate an AD. After the pre-registration process was completed, PAR 1 stated she did not ask patients who do not have an AD if they would like more information on how to execute an AD.

During an interview on 11/25/24 at 10:19 a.m. with Patient Access Supervisor (PAS), PAS stated she did not know patients who do not have an AD were supposed to be asked if they would like information on how to formulate an AD.

During a concurrent observation and interview on 11/25/24 at 10:39 a.m. with PAR 2, in Emergency Department (ED) Registration, PAR 2 registered Patient 2 to be seen in the ED. PAR 2 completed the full registration process and did not ask Patient 2 if she had an AD or wanted information on how to formulate one. PAR 2 stated she did not "typically" ask patients about ADs. PAR 2 stated sometimes she asked patients about ADs "if they are older."

During an interview on 11/25/24 at 11:01 a.m. with Patient 3, Patient 3 stated she had been admitted to the hospital the night before. Patient 3 stated during the registration process she was not asked if she had an AD or if she wanted information on how to formulate an AD.


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During an interview on 11/25/24 at 12 p.m. with Patient 2, Patient 2 stated when she was registered in the ED, PAR 2 did not ask her if she had an AD and if she wanted information on how to formulate an AD. Patient 2 stated she wanted more information on how to formulate an AD.

During a review of the hospital's "Patient Rights" (PR) dated April 2024, the PRs indicated, "You have the right to. . . 10. Formulate advance directives. This includes designating a decision maker if you become incapable of understanding a proposed treatment or become unable to communicate your wishes regarding care. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patients' rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf."

During a review of the hospital's P&P titled, "Advanced Healthcare Directive, Surrogate Decision Maker," dated 9/17/24, the P&P indicated, "The intent of this policy is to support a patient's right to formulate advance directives and to guide [The Hospital] staff and LIP's [sic] [Licensed Independent Practitioner] who provide care in complying with these directives. This includes the rights of a patient to make medical care decisions, the right to request or refuse treatment, the right to formulate an advance directive and the right to designate a surrogate [person acting on behalf of someone else or as a substitute] decision maker."

Based on interview and record review, the hospital failed to follow its policy and procedure (P&P) titled, "Restraint Management (Mechanical, Chemical, Seclusion)" for every 15-minute or every two-hour restraint use assessments for four of 18 sampled patients (Patient 6, Patient 9, Patient 4, and Patient 11). This failure had the potential for injuries and adverse health effects caused by use of restraints.

Findings:

During a concurrent interview and record review on 11/26/24 at 10:10 a.m. with Quality Business Intelligence Analyst (QBIA) and Risk and Regulatory Analyst (RRA) 1, Patient 6's "Restraint Apply: Non-Violent/Non-Self-Destructive" (RA) flowsheet dated 5/30/24 at 7:21 p.m. was reviewed. The RA indicated Patient 6 was placed in soft restraints on his right and left wrists because he "Engages in potential harmful behaviors." The "Clinical Data Flowsheet" (CDF) dated 5/30/24 and 5/31/24 was reviewed. The CDF indicated on 5/31/24 there was no every two-hour restraint use assessment at 12 a.m. QBIA and RRA 1 stated the assessment was not completed.

During a concurrent interview and record review on 11/26/24 at 11:50 a.m. with QBIA and RRA 1, Patient 9's RA flowsheet dated 5/5/24 at 3 p.m. was reviewed. QBIA stated Patient 9 was placed in soft restraints on his upper and lower extremities. The RA indicated Patient 9 was placed in restraints because he was a "Danger to self." The CDF dated 5/5/24 was reviewed. The CDF indicated on 5/5/24 every 15-minute restraint use assessments were not done at 5:15 p.m. or 5:30 p.m. QBIA and RRA 1 stated the assessments were not completed and or documented.


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During a concurrent interview and record review on 11/26/24 at 3:05 p.m. with RRA 2, Patient 4's "Order," dated 8/31/24 was reviewed. The "Order" indicated, "Restraints Apply: Non-Violent/Non Self-Destructive." RRA 2 stated Patient 4 had soft restraints on her right and left wrists because she was interfering with devices, tubes, and dressings.

During a review of Patient 4's "Order Plans" (OP), dated 8/31/24, the OP indicated, "Assess restraint use q [every] 2 hours."

During a concurrent interview and record review on 11/26/24 at 3:12 p.m. with RRA 2, Patient 4's "Restraint Group (RG - Restraint Flowsheet)," dated 11/26/24 was reviewed. The RG indicated on 9/1/24 there was no documentation of restraint use assessments at 12 p.m., 2 p.m., 4 p.m., or 6 p.m. RRA 2 stated the assessments were not done.

During a concurrent interview and record review on 11/26/24 at 3:39 p.m. with RRA 2, Patient 11's "Order," dated 9/26/24 was reviewed. The "Order" indicated, "Restraints Apply: Non-Violent/Non Self-Destructive." RRA 2 stated Patient 4 had soft restraints on her right and left wrists because she was interfering with devices, tubes, and dressings.

During a review of Patient 11's OP dated 9/28/24, the OP indicated, "Assess restraint use q 2 hours."

During a concurrent interview and record review on 11/26/24 at 3:44 p.m. with RRA 2, Patient 11's RG, dated 11/26/24 was reviewed. The RG indicated on 9/30/24 there was no restraint use assessment documented at 8 a.m. RRA 2 stated the assessment was not done.

During an interview on 11/26/24 at 12:13 p.m. with Registered Nurse (RN) 1, RN 1 stated patients with non-violent restraints were monitored every two hours.

During an interview on 11/26/24 at 12:26 p.m. with RN 2, RN 2 stated, "We check the patient [on restraints] every two hours. We try to go there more often to check for circulation."

During an interview on 11/26/24 at 12:38 p.m. with RN 3, RN 3 stated patients who were on non-violent restraints were monitored every two hours and the restraints were released every 15 minutes to check for circulation.

During a review of the hospital's P&P titled, "Restraint Management (Mechanical, Chemical, Seclusion)," dated 8/20/24, the P&P indicated, "Policy Summary/Intent: 5. Ongoing Monitoring/Documentation. a. Documentation of restraint and/or seclusion episode(s) to include, but not limited to: assessments/re-assessments, interventions, care plan/plan of care modifications, response to interventions, criteria met for discontinuation. i. Ongoing assessments/interventions are documented according to the frequency appropriate to the patients' condition; such as but not limited to vital signs, circulation, range of motion, hydration, elimination needs, injuries due to restraint(s), and skin integrity. . . 2. After the initial intervention, patients shall be seen face-to-face within 1 hour by a qualified LIP, registered nurse or physician assistant who has received education in accordance with requirements to evaluate: a. Patient's immediate situation b. Reaction to intervention c. Medical and behavioral condition d. Need to continue or terminate the restraint(s) or seclusion i. If responsible LIP changes at transfer, RN should notify accepting LIP of restraint use. 1. These types of restraint orders are used to protect the physical safety of non-violent or non-self-destructive patients. 2. Orders will be renewed every 3 days if continued restraint(s) are needed. 3. Assessment and monitoring will be conducted at minimum, every 2 hours. F. RESTRAINT CONSIDERATIONS - VIOLENT/SELF-DESTRUCTIVE 1. This type of restraint/seclusion order 1s used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others. 2. After the initial intervention, patients shall be seen face-to-face within 1 hour by a qualified LIP, registered nurse or physician assistant who has received education in accordance with requirements to evaluate: a. Patient's immediate situation b. Reaction to intervention c. Medical and behavioral condition d. Need to continue or terminate the restraint(s) or seclusion 3. If the face-to-face evaluation is conducted by a trained RN or physician assistant, that RN or physician assistant must consult the LIP responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to face evaluation. 4. Patients with violent/self-destructive behavior will be monitored every 15 minutes to include documentation of patient status and well-being."

Based on interview and record review, the hospital failed to follow its policy and procedure (P&P) titled, "Restraint Management (Mechanical, Chemical, Seclusion)" for conducting a face to face assessment (done by a trained physician, nurse practitioner, or registered nurse) within one hour of patient being placed in restraints, for four of 18 sampled patients (Patient 7, Patient 8, Patient 10, and Patient 5). This failure had the potential for injuries and adverse health effects caused by use of restraints.

Findings:

During a concurrent interview and record review on 11/26/24 at 11 a.m. with Quality Business Intelligence Analyst (QBIA) and Risk and Regulatory Analyst (RRA) 1, Patient 7's "Restraint Apply: Non-Violent/Non-Self-Destructive" (RA) flowsheet, dated 5/24/24 at 7 a.m. was reviewed. QBIA stated Patient 7 was placed in soft restraints on his right and left arms. The RA flowsheet indicated Patient 7 was placed in restraints because she, "Interferes w/ [with] devices [,] tubes [, and] dressings." The CDF dated 5/24/24 indicated no one-hour face to face evaluation was completed after Patient 7 was placed in restraints. QBIA stated she could not find the one-hour face to face evaluation.

During a concurrent interview and record review on 11/26/24 at 11:35 a.m. with QBIA and RRA 1, Patient 8's RA flowsheet, dated 8/1/24 at 10:03 p.m. was reviewed. QBIA stated Patient 8 was placed in bilateral upper extremities soft restraints. The RA flowsheet indicated Patient 8 was placed in restraints because he, "Interferes w/ devices [,] tubes [, and] dressings." The CDF dated 8/1/24 indicated no one-hour face to face evaluation was completed after Patient 8 was placed in restraints. QBIA stated she could not find the one-hour face to face evaluation.

During a concurrent interview and record review on 11/26/24 at 12:12 p.m. with QBIA and RRA 1, Patient 10's RA flowsheet, dated 7/31/24 at 5:49 p.m. was reviewed. QBIA stated Patient 10 was placed in soft restraints on both wrists. The RA flowsheet indicated Patient 10 was placed in restraints because he, "Interferes w/ devices [,] tubes [, and] dressings." The CDF dated 7/31/24 indicated no one-hour face to face evaluation was completed after Patient 10 was placed in restraints. QBIA stated she could not find the one-hour face to face evaluation.


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During a concurrent interview and record review on 11/26/24 at 3:16 p.m. with RRA 2, Patient 5's "Order," dated 7/22/24 was reviewed. The "Order" indicated, "Restraints Apply: Non-Violent/Non Self-Destructive." RRA 2 stated Patient 5 had soft restraints on her right and left wrists because she was interfering with devices, tubes, and dressings.

During a concurrent interview and record review on 11/26/24 at 3:20 p.m. with RRA 2, Patient 5's medical record (MR) was reviewed. The MR indicated there was no documentation of face-to-face evaluation within an hour after the application of restraints on 7/22/24. RRA 2 stated the face-to-face evaluation was not done.

During a review of the facility's P&P, titled "Standard Policy: Restraint Management (Mechanical, Chemical, Seclusion)," dated 8/20/24, the P&P indicated, "This organization recognizes that restraint use has the potential to produce serious consequences, such as physical and psychological harm, loss of dignity, violation of a patient's rights and even death. It is our intent to provide an environment that minimizes circumstances that give rise to use of restraint(s) and seclusion and maximizes safety when restraint or seclusion is used. . . 2. After the initial intervention [placement of restraints], patients shall be seen face-to-face within 1 hour by a qualified LIP [licensed provider], registered nurse or physician assistant who has received education in accordance with requirements to evaluate: a. Patient's immediate situation b. Reaction to intervention c. Medical and behavioral condition d. Need to continue or terminate the restraint(s) or seclusion."