HospitalInspections.org

Based on observation, document review and interview, it was determined for 4 of 4 (Pts #11, #12, #13, #14) patients who presented to the ED (Emergency Department), the Hospital failed to ensure patients and/or the patient's representative(s) were informed of their patient rights prior to receiving care. This has the potential to affect all patients receiving services by the ED.
Findings include:
1. During an observational tour of the ED on 6/21/16 at approximately 10:15 AM, the patient waiting room, triage assessment room, 23 treatment rooms and hallways lacked any posting of Patient Rights.
2. The clinical record of Pt #11 was reviewed on 6/22/16 at approximately 1:00 PM. Pt #11 was admitted to the ED on 5/25/16 for complaints of abdominal pain. The record lacked documentation Pt #11 was informed of the Patient's Rights.
3. The clinical record of Pt #12 was reviewed on 6/22/16 at approximately 1:15 PM. Pt #12 was admitted to the ED on 6/2/16 for complaints of rectal bleeding. The record lacked documentation Pt #12 was informed of the Patient's Rights.
4. The clinical record of Pt #13 was reviewed on 6/22/16 at approximately 1:30 PM. Pt #13 was admitted to the ED on 6/6/16 for complaints of low back pain. The record lacked documentation Pt #13 was informed of the Patient's Rights.
5. The clinical record of Pt #14 was reviewed on 6/22/16 at approximately 1:45 PM. Pt #14 was admitted to the ED on 6/6/16 for complaints of headache. The record lacked documentation Pt #14 was informed of the Patient's Rights.
6. During an interview on 6/21/16 at approximately 10:15 AM, the Director of Emergency Services (E#5) stated that once a patient's insurance is determined, a handout specific to that insurance (Medicare/Medicaid, Private insurance and/or no insurance) which describes the Hospital's Financial Assistance Policy and Patient Rights is offered to the patient. E#5 stated "It's the patient's choice to take it or not. "

Based on document review and interview, it was determined in 4 of 4 (Pts #11, #12, #13, #14) patient's clinical records who presented to the ED (Emergency Department), the Hospital failed to ensure the patient, or the patient's representative, were assessed for communication barriers and the ability to understand consent for treatment in order to make an informed decisions prior to the reception of care and services. This has the potential to affect all patients being served by the ED.

Findings include:

1. The clinical record of Pt #11 was reviewed on 6/22/16 at approximately 1:00 PM. The informed consent was signed by Pt #11 on 5/25/16 at 7:56 PM. The Emergency Department (ED) log noted Pt #11 was registered as a patient requesting a medical screening exam for complaints of abdominal pain on 5/25/16 at 7:58 PM, after the informed consent was signed.
2. The clinical record of Pt #12 was reviewed on 6/22/16 at approximately 1:15 PM. The informed consent was signed by Pt #12 on 6/2/16 at 4:00 AM. The ED log noted Pt #12 was registered as a patient requesting a medical screening exam for complaints of rectal bleeding on 6/2/16 at 4:02 AM, after the informed consent was signed.
3. The clinical record of Pt #13 was reviewed on 6/22/16 at approximately 1:30 PM. The informed consent was signed by Pt #13 on 8:15 AM. The ED log noted Pt #13 was registered as a patient requesting a medical screening exam for complaints of low back pain on 6/6/16 at 8:16 AM, after the informed consent was signed.
4. The clinical record of Pt #14 was reviewed on 6/22/16 at approximately 1:45 PM. The informed consent was signed by Pt #14 on 6/6/16 at 9:45 PM. The ED log noted Pt #14 was registered as a patient requesting a medical screening exam for complaints of headache on 6/6/16 at 9:46 PM, after the informed consent was signed.
5. During an observational tour of the ED waiting room on 6/21/16 at approximately 10:15 AM with E#5 (Director of Emergency Services), the receptionist demonstrated the patient arrival process. The receptionist stated when a patient presented to the ED waiting room window, the receptionist would ask for the patient's name and symptoms, then give the patient an informed consent form to sign and a demographic sheet to complete. The receptionist stated the patients were then entered into the system (computer) and the nurse was notified a patient needed to be triaged. E#5 verbally agreed that patients are not assessed as to their level of education, communication barriers or understanding of the consent form prior to the patients signing the form. E#5 verbally agreed the informed consent should not be obtained prior to the registration and/or triage assessment.

Based on document review and interview, it was determined in 2 of 2 (Pt #4, #5) records reviewed of restrained patients for violent behavior, the Hospital failed to provide continuous monitoring per policy. This has the potential to affect all patients that require restraint use.
Findings include:
1. The policy titled "Utilization of Restraint and Seclusion" (template date 5/15/14) was reviewed on 6/22/16. The policy required " D. Restraint and Seclusion for Violent or Self Destructive Behavior ... 2. Assessment and Monitoring a) Continuous in-person observation (1) Monitoring of a patient ... is done through continuous in-person observation ... "
2. The clinical record of Pt #4 was reviewed on 6/21/16 at approximately 1:00 PM. Pt #4 was admitted to the ED (Emergency Department) on 5/6/16 for intoxication and a psychological evaluation. Pt #4 was placed into locked cuffed restraints for violent behavior on 5/6/16 at 11:53 PM. The ED Summary report, authored by E#10 (ED Registered Nurse), noted "Continual Observation Provided By Person documenting" on 5/7/16 at 12:00 AM, 12:15 AM and 12:30 AM. The ED Summary report authored by E#10 noted a restraint assessment and interventions was completed by E#10 on 5/7/16 at 12:30 AM.
The clinical record of Pt #17 was reviewed (focused) on 6/22/16 at approximately 12:30 PM. Pt #17 was admitted to the ED on 5/7/16 for intentional overdose. The ED Summary report noted an Admission Assessment, contraband check and Risk Assessments were completed by E#10 on 5/7/16 at 12:00 AM and "Continual Observation Provided By Person documenting" on 5/7/16 at 12:30 AM.
The clinical records reviewed of Pt #4 and Pt #7 noted E#10 conducted cares on both patients at the same time and did not provide continuous observation per policy.
3. The clinical record of Pt #5 was reviewed on 6/21/16 at approximately 2:00 PM. Pt # 5 was admitted to the ED on 6/12/16 for Acute Psychosis/Psychiatric evaluation. The ED Summary report noted a Behavioral assessment was completed and "Continual Observation Provided By Person documenting" by E#11 (ED Registered Nurse) at 3:15 AM on 6/13/16
The clinical record of Pt #18 was reviewed on 6/22/16 at approximately:00 PM. Pt#18 was admitted for Psychiatric Evaluation. The ED Summary Report noted an Admission Assessment and ED Psychiatric Assessment was completed by E#11 at 3:15 AM on 6/13/16.
The clinical records reviewed of Pt #5 and Pt #18 noted E#11 conducted cares on both patients at the same time and did not provide continuous observation per policy.
4. During an interview on 6/22/16 at approximately 1:30 PM, E#1 (Regulatory Compliance) verbally agreed continuous observation was not provided for Pt #4 and #5 and should have been.

Based on document review and interview, it was determined for 7 of 7 (MD#1, MD#2, MD#3, MD#4, MD#5, MD#6, and MD#7) physicians who order restraints, the Hospital failed to ensure the physicians were knowledgeable of, and in compliance with, the Hospital's restraint policy. This has the potential to affect all patients who would require the use of restraints.

Findings include:

1. The Hospital policy titled "Utilization of Restraint and Seclusion" (template date 5/15/14) was reviewed on 6/22/16 at approximately 1:00 PM. The policy stated "IV. Procedure H. Associate and Physician Training 1. Physicians a) Physicians... who order restraint or seclusion will receive information... at the time of initial appointment to the medical staff, and at the time of each subsequent reappointment. This information will include: (1) Time frames for initial and subsequent orders... (5) Documentation standards..."

2. The Physician credential files were reviewed on 6/22/16 at approximately 3:30 PM with the Manager Medical Affairs (E#12) and the Medical Affairs Assistant (E#13). Quality Resource Management (E#2) was also present. Seven of seven physician files lacked documentation of the physician knowledge of and agreement to comply with the Hospital's restraint policy as follows:
a. MD#1 was reappointed to the Medical Staff (Critical Care) on 9/30/15.
b. MD#2 was reappointed to the Medical Staff (Critical Care) on 3/31/16.
c. MD#3 was reappointed to the Medical Staff (Emergency Department- ED) on 3/31/15.
d. MD#4 is currently in the reappointment process (ED).
e. MD#5 was appointed to the Medical Staff (ED) on 3/31/15.
f. MD#6 was appointed to the Medical Staff (ED) on 7/14/14.
g. MD#7 was appointed to the Medical Staff (Psychiatry) on 7/23/14.

3. An interview was conducted with E#12, E#13, and E#2 during the physician credential file review. E#12 stated all initial and reappointments are now completed via email since 2015 with a link for the Restraint and Seclusion policy attached to the email. When asked how the Hospital ensures the physician has read, understands, and agrees to follow the Hospital's restraint policy, E#13 stated "We can't track that. We would have to get each of their passwords to see if they opened the link. We don't have them sign anything saying they have read and agree to follow the policy." When asked how the process worked prior to 2015, E#13 stated "We mailed it (the Restraint information) to them with their applications. We don't have any way to show that any of them have read it (the restraint information) or agree to follow it."