HospitalInspections.org

This CONDITION is not met as evidenced by:

Based on observation, interview and record review the facility failed to protect patient's rights, placing all patients at risk for loss of their rights. Findings include:

---The facility failed to provide 4 current and 5 discharged patients with "An Important Message from Medicare." (A-0117)
---The facility failed to provide care in a safe setting to 21 of 21 patients on the Children's Unit on 10/15/13. (A-0144)
---The facility failed to ensure that physical restraints were applied in a safe manner for 1 of 1 current patients (#1) on the Children's Unit. (A-0167)
---The facility failed to ensure that a physician's order was obtained for restraints for 2 of 2 currents patients (#1 and #15). (A-0168)
---The facility failed to provide documented evidence of staffs' demonstrated competency for the application of restraints. (A-196)

Based on record review and interview the facility failed to provide 4 of 6 current patients (#11, #12, #18 and #19) and 5 of 6 discharged patients (#5, #6, #7, #8 and #9) with "An Important Message from Medicare resulting in the potential for all patients to be deprived of their rights under Medicare. Findings include:

Record Review:
1. On 10/16/13 from approximately 9:30 am- 9:45 am record review on the Adult Unit revealed that patients #11, #12, #18 and #19 did not have signed copies of "An Important Message from Medicare" in their records.

2. On 10/16/13 at approximately 1100-1200 a review of closed medical records for Patient #s 5, 6, 7, 8 and 9 revealed a lack of proper documentation for informing patients regarding an "Important Message from Medicare."

Interview:
1. On 10/16/13 from approximately 9:30 am- 9:45 am staff K confirmed that the facility could not provide evidence that patients #11, #12, #18 and #19, who had been at the facility for more than 2 calendar days, had received copies of "An Important Message from Medicare."
2. On 10/16/13 at approximately 12 noon staff L confirmed that discharged patients #5, #6 #7, #8 and #9 did not have documentation that "An Important Message from Medicare" had been provided at either admission or discharge.

Based of observation, interview and policy review the facility failed to provide care in a safe setting to 21 of 21 patients on the Children's Unit on 10/15/13. Findings include:

Observation:

On 10/15/13 at 10:50 am an unattended Housekeeping Cart was observed in a hallway on the Children's Unit. The Housekeeper (staff Q) could not be visualized from any angle while standing next to the cart. An unlocked cupboard on the cart contained Clorox Bleach and Green Earth Peroxide Cleaner. Staff C was present during these observations and verified that the Housekeeper could not be seen from the cart.

Interview:
Staff Q was asked if it was facility policy or procedure for Housekeepers to lock toxic substances or keep Housekeeping carts in their range of vision. Staff Q responded that he was unaware of requirements for either issue.

Policy Review:
An untitled policy revised 09/13 states:
-"Housekeeping and Maintenance carts are to be stored in locked areas on the Mental Health unit when not being directly attended by Housekeeping/Maintenance staff. Cleaning materials must be kept under lock within Housekeeping carts or in (locked) storage area."

Based on document review and interview the facility failed to ensure that physical restraints were applied in a safe manner and in keeping with hospital training for 1 of 1 (patient #1) current patients on the Children's Unit placing all patients at risk for unsafe restraint application. Findings include:

Policy Review:
Restraint and Seclusion, effective 7/83, states:
"Staff who are authorized to physically apply restraint or seclusion receive the training...and demonstrate competence in the safe use of restraints, including:
-The safe application and removal of types of restraints."

Secure: for Restraint, Seclusion Application and Documentation, revised 2007, (Module 3):
Mechanical Restraint Application states:
"Restrain with four points to avoid injury.
----Restrain one arm and the opposite leg when discontinuing restraints.
----Never restrain one arm and leg on one side."
-If a waist strap is applied. tighten so that two or three fingers can be placed between the strap and the patient. Ankle straps, when necessary, are applied to a fully extended leg..."

Record Review:
1. On 10/15/13 at 1100 review of the the "Restraint/Seclusion Physician Authorization/Order Form" for patient #1, an inpatient on the Children's Unit, revealed an order for "5-point (one extra across the legs)" mechanical restraint, dated 10/13/13 at 1407.
2. On 10/15/13 from approximately 1530-1600 the facility's training program for physical restraint application ("Secure: for Physical Intervention and Containment") was reviewed. The "Secure" Manual did not state where wrist/arm restraints were to be applied when mechanical restraints are used. No instructions to restrain patients with one arm raised and one arm down were noted.

Interview:
1. On 10/15/13 at approximately 1100 Nurse O stated that patient #1 was placed in 5-point restraints on 10/13/13 and that one strap was placed across the patient's legs. Nurse O stated that patient #1 was restrained with one arm up and one arm down. Nurse O stated that staff are trained to position patients in this manner in the facility's "Secure" training program.
2. On 10/15/13 from approximately 1500-1600 the staff trainer for the "Secure" program (staff J) was interviewed. Staff J confirmed that the training materials did not specify the location (on the patient's body) for applying each mechanical restraint when 5-point restraints are applied. Staff J stated that the fifth point in a 5 point restraint: "is a gait belt around the waist" but was unable to find this documented in training materials.
3. On 10/16/13 at approximately 1400 nurse K was asked if training in the use of 5-point restraints was provided to staff. Nurse K stated that she had not been trained to apply 5-point restraints as part of "Secure" or other facility training. Nurse K stated that 5-point restraints are not used on the Adult Unit.
4. On 10/16/13 at approximately 1500 Nurse G stated that during a 5-point restraint "the fifth strap goes across the patient's abdomen or chest."
4. On 10/16/13 from 1400-1500 nurses K and G stated that it is hospital protocol to physically restrain patient with one arm raised over the head and one arm at the patient's side and confirmed that "Secure" training manuals are not available on the Adult Unit.

Based on record review and interview the facility failed to ensure that a physician's order was obtained for application of chemical and physical restraints for 2 of 2 current patients (#1 and #15) increasing the risk of unauthorized restraint application for all patients. Findings include:

Policy Review:
Restraint and Seclusion, effective 7/83, states:
"A physician's order is time limited...It includes the specific behavior which constitutes the danger to self or others, and behavioral criteria for discontinuation. This order is dated, timed and signed by the physician."

Record Review:
1. On 10/15/13 at 1100 review of the the "Restraint/Seclusion Physician Authorization/Order Form" for patient #1, an inpatient on the Children's Unit, revealed an order for "5-point (one extra across the legs)" mechanical restraint, dated 10/13/13 at 1407. The same order form contained the following orders for "chemical restraint," Haldol 2.5 mg IM and Benadryl 25 mg. IM at 1400 and Zyprexa 10 mg. IM at 1435. There was only one notation of a telephone order being obtained for all three restraint orders, timed 1425. No physician's order for administration of Zyprexa (at 1435), listed as a chemical restraint on the order form, was noted.
2. On 10/16/13 at 1525 record review revealed a Progress Note for patient #15 stating: "Zyprexa 10 mg. given for loud yelling and very delusional conversation that he is going to take us all out to die after he takes himself hostage... had to be apprehended and taken to the QR (Quiet Room) for the IM (intramuscular) Zyprexa., and continued to yell loudly..." No order for physically restraining (apprehending and taking) the patient to the QR was obtained.

Interview:
1. On 10/15/13 at 1100 staff O confirmed that the above telephone order for use of Zyprexa as a chemical restraint (timed 1435) was timed after the time that the telephone order was obtained (at 1425).
2. On 10/15/13 from approximately 1500-1600 staff J, the designated staff trainer for the "Secure: for Physical Intervention and Containment," program was interviewed. Staff J confirmed that the training materials contained no information for applying 5-point restraints. Staff J stated that the 5 th point is a gait belt around the waist.
2. On 10/16/13 at 1525 Nurse K confirmed that patient #15's Progress Note on 10/12/13, stating that he was "apprehended" and "taken to the QR" sounds like physical restraint. Nurse K confirmed that no order for physical restraint was obtained.

Based on document review and interview, the facility failed to provide documented evidence of staffs' competency for 11 of 15 employees (AA-KK) in regards to the demonstration of the proper application of restraints resulting in the potential for harm to all patients at the facility that require behavioral management with the use of a mechanical restraint. Findings include:

On 10/16/2013 between 0830-1000, a review of staff files for education and demonstration of the application of restraints revealed that training sessions for staff using the "SECURE" program were held on 04/30/2013, 08/27/2013 and 09/24/2013. The "SECURE" program consist of three modules that contain a pre-test, post-test and competency, verification checklist for each. Module three relates to "Seclusion, Restraint and Documentation. The module three competency, verification checklist consist of two documents one for an initial certification and the other for a re-certification. The documentation reviewed revealed that on 04/30/2013 staff AA, BB, CC and DD all attended the "SECURE" training for module three, on 08/27/2013 staff EE, FF and GG attended another "SECURE" training session and on 09/27/2013 staff HH, II, JJ and KK attended a third "SECURE" training session. All of eleven (11) staff files lacked documentation (signature) by the trainer that the staff had demonstrated application of restraints for either initial certification or re-certification. The competency, verification checklist document reads "1. Demonstrates correct application of specific types of restraints. 2. Demonstrates a tie with quick release knot, securing it to bed frame or chair, out of patient's reach."The bottom of the document contains a statement that reads "The above named staff member has demonstrated satisfactory performance and understanding of the basic skills and knowledge required for understanding the use of seclusion and restraint module. SECURE trainer__________(signature) date (____)."

On 10/16/2013 at 1015, during an interview with staff C (Program Administrator) when asked to describe his job at the facility he stated "I work for (contracted service # 1), I am the Program Administrator at this facility." When asked what (contracted service # 1) was, he described it as "a contracted service that provides program administration oversite for facilities." He also stated that "the 'SECURE' program is a product of our company that provides staff education for the management of behavioral health clients. It is mainly taught only by (contracted service #1) employees who have been trained to do so."

When asked if staff education in regards to the "SECURE" program included demonstration of the application of restraints he stated "I think so but I am not for sure." Staff C later came back on 10/16/13 at 1200 and stated that he "had spoke to a 'SECURE' trainer on the phone and that staff are supposed to demonstrate the application of restraints but he did not think that they actually practiced placing restraints on a person and restraining them in a bed." When asked about the documents in the employee files being blank he stated "they are supposed to be signed by the trainer when staff complete the module/demonstration." When asked if there was any further documentation he could provide for staff competency in regards to the training for the application of restraints he stated "No."