HospitalInspections.org

Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility failed to substantially comply with this condition.

Findings:

The following standards were cited and showed a significant nature of non-compliance with regards to Patient Rights as follows:

482.13(c)(2) Tag 0144 Patient Rights: Care in Safe Setting:
The information reviewed during the survey provided evidence the facility failed to ensure the safety of mental health patients petitioned under an involuntary hold (302 status), as the facility failed to place mental health patients on 1:1 observation per policy in six of seven applicable medical records reviewed (MR1, MR27, MR29, MR30, MR31 and MR33); and failed to perform a suicide risk assessment in one of seven applicable medical records reviewed. (MR1)

482.13(e)(5) Tag 0168 Patient Rights: Restraint or Seclusion:
The information reviewed during the survey provided evidence the facility failed to obtain an order for the use of physical restraints in two of four applicable medical records reviewed. (MR5 and MR7)

482.13(e)(10) Tag 0175 Patient Rights: Restraint or Seclusion
The information reviewed during the survey provided evidence the facility failed to perform restraint reassessments in one of four applicable medical records reviewed. (MR7)

Based on review of facility policy, medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure the safety of mental health patients petitioned under an involuntary hold (302 status), as the facility failed to place mental health patients on 1:1 observation as per policy in six of seven applicable medical records reviewed (MR1, MR27, MR29, MR30, MR31 and MR33); and failed to perform a suicide risk assessment in one of seven applicable medical records reviewed (MR1).

Findings include:

Review on July 25, 2019, of facility policy "Elopements," last reviewed by the facility November 2018, revealed "...Definition:...Outpatient Elopement: Any time an outpatient undergoing treatment at the facility cannot b[sic] located, which places the patient's health, safety or welfare at risk...Procedure: Patients at Risk for Elopement: 1. It is the policy of Lehigh Valley Hospital - Schuylkill to provide healthcare services in an environment that priorities patient dignity, autonomy, and safety. With this policy in mind, staff may employ any one of the following interventions designed to reduce the risk of elopements...D. Notify the patient's attending that 1:1 observation may be indicated..."

Review on July 25, 2019, of facility policy, "Suicide Assessment and Prevention," last reviewed by the facility October 2018 revealed "...Policy It is the policy of Lehigh Valley Hospital - Schuylkill to create an environment of care that will foster the accurate identification and successful management of patients who are at an increased risk for suicide or self-destructive behaviors...All patients admitted to the hospital will be screened for their risk of self-harm using the [name of screening tool]...Procedure Initial suicide risk assessments must be performed by the registered nurse or designated members of the clinical team as part...of each discipline specific admission assessment..."

Review on August 22, 2019, of facility policy "Patient Rights and Responsibilities," last reviewed by the facility October 2018 revealed "Policy: All patients should receive quality health care, according to need... Procedure: 1. The patient's rights and responsibilities are posted in a prominent place in outpatient departments. ... Care Delivery. Receive care in a safe setting..."

Review on August 22, 2019, of Emergency Department (ED) facility policy "Admission to a Psychiatric Unit," last reviewed by the facility December 2018 revealed "... Involuntary admissions A. The patient should be placed in an examination room which will provide confidentiality for the patient and provide for adequate protection of the patient... J. All 302 patients are to be on a 1:1 status. This means the Security officer; NA (nurse aide)/Orderly or Nursing Staff will be within arm's length distance of the patient..."

Review of MR1 on July 24, 2019, revealed MR1 was brought to the ED by police on July 21, 2019, at 2043 under a 302 petition/warrant for a psychiatric evaluation. MR1 was non-compliant with medications, had poor hygiene and made statements to family that patient wanted to kill self. During triage MR1 was assigned an ESI (Emergency Severity Index) Triage Level 2 (a patient who should not wait because of a high-risk situation). MR1 returned to the ED waiting room following triage. At 2120 nursing staff noted MR1 had left the ED.

Review on July 24, 2019, of MR1 revealed MR1 was returned to the ED by police on July 22, 2019, at 0113. Triage notes at 0120 reveal MR1 was here earlier last evening under 302 petition/warrant and eloped. The 302 and an order for inpatient admission were signed by the physician at 0500 on July 22, 2019. MR1 was not ordered 1:1 observation and at 0810 on July 23, 2019, MR1 ran out of the emergency department. Further review of MR1's July 22, 2019, admission revealed a suicide risk assessment was not completed during this admission.

Interview with EMP2 on July 25, 2019, at 1425 confirmed any patient that has previously eloped is considered an elopement risk. EMP 1 confirmed 1:1 observation was not ordered by the physician during MR1's July 22, 2019, emergency department admission. EMP2 further confirmed a suicide risk assessment was not completed during MR1's July 22, 2019, admission.

Review of MR27 on August 22, 2019, at approximately 1100 revealed this patient was brought to the ED by police on August 20, 2019, at 1539 under a 302 petition/warrant for a psychiatric evaluation. This patient refused to have a medical exam completed and left the ED at 1650. Continued review of MR27 at 1310 revealed no documentation 1:1 supervision was ordered and provided for this patient.

Interview with EMP1 on August 22, 2019, at approximately 1315 confirmed MR27 revealed this patient was brought to the ED by police on August 20, 2019, at 1539 under a 302 petition/warrant for a psychiatric evaluation and there is no documentation in MR27 that 1:1 supervision was ordered and provided.

Review of MR29 on August 22, 2019, at approximately 1130 revealed this patient was brought to the ED by police on August 4, 2019, at 2024 under a 302 petition/warrant for a psychiatric evaluation. This patient was combative and resistive to care. Continued review of MR29 at 1320 revealed no documentation 1:1 supervision was ordered and provided for this patient.

Interview with EMP1 on August 22, 2019, at approximately 1320 confirmed MR29 was brought to the ED by police on August 20, 2019, at 1539 under a 302 petition/warrant for a psychiatric evaluation and there is no documentation in MR29 that 1:1 supervision was ordered and provided.

Review of MR30 on August 22, 2019, at approximately 1145 revealed this patient was brought to the ED by police on August 19, 2019, at 2208 under a 302 petition/warrant for a psychiatric evaluation. Continued review of MR30 at 1330 revealed no documentation 1:1 supervision was ordered and provided for this patient.

Interview with EMP1 on August 22, 2019, at approximately 1330 confirmed MR30 was brought to the ED by police on August 20, 2019, at 1539 under a 302 petition/warrant for a psychiatric evaluation and there was no documentation in MR30 that 1:1 supervision was ordered and provided.

Review of MR31 on August 22, 2019, at approximately 1200 revealed this patient was brought to the ED by police on August 17, 2019, at 1732 under a 302 petition/warrant for a psychiatric evaluation. Continued review of MR31 at 1340 revealed this patient was not ordered and provided 1:1 supervision until August 18, 2019 at 1730.

Interview with EMP1 on August 22, 2019, at approximately 1340 confirmed MR31 was brought to the ED by police on August 20, 2019, at 1539 under a 302 petition/warrant for a psychiatric evaluation and this patient was not ordered and provided 1:1 supervision until August 18, 2019 at 1730.

Review of MR33 on August 22, 2019, at approximately 1315 revealed this patient was brought to the ED by prison guards on August 7, 2019, at 1528 after documented suicide attempts. A 302 petition/warrant for a psychiatric evaluation was upheld after examination by the provider at 2100. Provider documentation on August 7, 2019, at 2145 revealed that the provider discussed with nursing that the plan for the patient was to have 1:1 supervision. Nursing documentation at 2200 revealed the nursing staff was aware the prison guards left the patient's bedside. There was no documentation that 1:1 supervision was provided. Documentation at 2240 revealed the patient had left the premises and the police were notified.

Interview with EMP2 on August 22, 2019, at approximately 1330 confirmed MR33 was brought to the ED by prison guards on August 7, 2019, at 1528 after documented suicide attempts under a 302 petition/warrant and that the patient was not provided 1:1 supervision and eloped from the facility.

Based on review of facility policy, medical records (MR) and staff (EMP) interview, it was determined the facility failed to obtain an order for the use of restraint in two of four medical records (MR5 and MR7).

Findings include:

Review on July 25, 2019, of facility "Restraint and Seclusion Policy," last revised by the facility December 2017 revealed "...C. Restraint and Seclusion or Seclusion Orders for Violent and Self-Destructive Behavior...2.) The physician is responsible to issue a time-limited order for restraint, however, due to the emergent nature of this type of restraint, a qualified RN or PA may apply restraint prior to obtaining the physician order..."

Review of MR5 on July 25, 2019, revealed restraints for violent behavior were applied on May 30, 2019, at 2145 and removed at 2230. No order for the use of restraint was located in MR5.

Review of MR7 on July 25, 2019, revealed restraints were applied for violent behavior on May 6, 2019, at 1500 and removed at 1620. No order for the use of restraint was located in MR7.

Interview with EMP1 on July 25, 2019, at 1410 confirmed there was no order for the use of restraint in MR7.

Interview with EMP1 on July 25, 2019, at 1430 confirmed there was no order for the use of restraint in MR5.

Based on review of review of facility policies, medical records (MR), and staff (EMP) interview, it was determined the facility failed to perform restraint reassessments for one of four medical records (MR7) reviewed.

Findings include:

Review on July 25, 2019, of facility "Restraint and Seclusion Policy," last revised by the facility December 2017 revealed..."E. Monitoring and Care ... 3.) Monitoring and care activities are implemented and recorded on the Restraint Seclusion Flow Sheet by a trained and competent staff member at the initiation of restraint or seclusion and every 15 minutes thereafter..."

Review of MR7 on July 25, 2019, revealed restraints were applied to MR7 May 6, 2019, at 1500 and removed at 1620. Restraint monitoring was not documented from 1530 to 1600.

Interview on July 25, 2019, with EMP1 confirmed that restraint monitoring must occur every 15 minutes while a patient is restrained. EMP1 further confirmed restraint monitoring for MR7 was not completed as per policy.

Based on review of facility policies, review of medical records (MR), and staff (EMP) interview, it was determined the facility failed to ensure all medical record entries were dated in three of three medical records (MR1, MR2 and MR7).

Findings include:

Review on July 26, 2019, of facility policy "Medical Record Management," last reviewed by the facility January 2016, revealed" ... Policy ... 6. All entries in the medical record are dated, timed, and authenticated by the author ..."

Review on July 25, 2019, of MR1 revealed no dates were documented on the following forms in this medical record: the Foreign Travel Screen, Emergency Department Report Sheet, Medication Administration, Vital Signs, Patient Personal Item Tracking Record, Downtime Form Coagulation, Emergency Department Nurses Notes, four Nursing Note Supplements and two 1 :1 Observation Forms.

Review of MR2 on July 25, 2019, revealed no dates were documented on the following medical record forms: Foreign Travel Screen, Emergency Department Adult Triage Past Medical History, ER Assessment Adult, Emergency Department Nursing Notes and Medication Administration.

Review of MR7 on July 25, 2019, revealed no date was recorded on a 1:1 Observation Form.

Interview on July 25, 2019, at 1020 with EMP1 confirmed the documents above in MR1 and MR2 were not dated.

Interview on July 25, 2019, at 1430 with EMP1 confirmed the document above in MR7 was not dated.