HospitalInspections.org

Bringing transparency to federal inspections

200 EAST STATE STREET

ALLIANCE, OH 44601

PATIENT RIGHTS

Tag No.: A0115

Based on record review, observation and staff interviews, the facility failed to inform patients of their rights (A117); failed to provide the patients with contact information to file a grievance and/or the state agency (A118); failed to ensure patients received care in a safe setting (A144); and failed to ensure the use of seclusion was implemented in accordance with facility policy. (A167) The cumulative effect of these practices resulted in a risk to the health and safety of all facility patients.

PATIENT RIGHTS: NOTICE OF RIGHTS

Tag No.: A0117

Based on record review, observation and staff interview, the facility failed to inform nine of nine emergency department patients whose medical records were reviewed of their Patient Rights. (Patients' #1 through #9) The census was 47.

Findings include:

Review of Patient #1's medical record revealed no documented evidence he/she was informed of his/her rights, either verbally or in writing, while in the ED on 08/28/19.

Review of Patient #2's medical record revealed no documented evidence he/she was informed of his/her rights, either verbally or in writing, while in the ED on 08/28/19.

Review of Patient #3's medical record revealed no documented evidence he/she was informed of his/her rights, either verbally or in writing, while in the ED on 08/04/19.

Review of Patient #4's medical record revealed no documented evidence he/she was informed of his/her rights, either verbally or in writing, while in the ED on 08/22/19

Review of Patient #5's medical record revealed no documented evidence he/she was informed of his/her rights, either verbally or in writing, while in the ED on 08/30/19.

Review of Patient #6's medical record revealed no documented evidence he/she was informed of his/her rights, either verbally or in writing, while in the ED on 08/13/19.

Review of Patient #7's medical record revealed no documented evidence he/she was informed of his/her rights, either verbally or in writing, while in the ED on 09/11/19.

Review of Patient #8's medical record revealed no documented evidence he/she was informed of his/her rights, either verbally or in writing, while in the ED on 09/14/19.

Review of Patient #9's medical record revealed no documented evidence he/she was informed of his/her rights, either verbally or in writing, while in the ED on 09/23/19.

Observation during tour of the emergency department revealed Patient Rights information was not posted.

Staff J confirmed this finding during interview on 09/23/19 at 10:47 AM.

PATIENT RIGHTS: GRIEVANCES

Tag No.: A0118

Based on document review and staff interview, the facility failed to provide the patients with contact information to file a grievance and/or the state agency. This affected all current patients. The census was 47.

Findings include:

Review of the facility's "Patient Resource Information", under the heading of "Patient Rights and Responsibilities", was contact information for the following entities if a patient had a concern, complaint or grievance: the facility, Medicare, and KEPRO. There was no contact information for the state agency.

Tour of the facility, including the ED (emergency department) and inpatient units, confirmed there were also no postings which contained information on how to file a grievance with the state agency.

Staff B was made aware of and confirmed these findings on 09/25/19 at 4:46 PM.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on document review and staff interviews, the facility failed to ensure the patient received care in a safe setting. This affected one of 10 patients whose medical record was reviewed, Patient #1. The census was 47.

Findings include:

Review of the facility's Emergency Department (ED) log revealed Patient #1 was brought to the ED by ambulance on 08/28/19 at 2:43 PM with chief complaint of Suicidal Ideation (SI), history of Mental Retardation and Developmental Disabilities (MRDD), upset with thoughts of returning to workshop, stated thoughts of suicidal and homicidal ideation, history of suicide attempts, calm and cooperative at this time. Diagnoses are listed in the medical record as unspecified intellectual disabilities, suicidal ideation, homicidal ideation and hyperglycemia.

The documented RN assessment completed at 2:47 PM revealed Patient #1 had "thoughts of suicide" and "thoughts of harming" self. Patient #1's suicide plan was to "walk into traffic." Patient #1 was screened using the Columbia Suicidal Risk Assessment and received a score of 12 (high risk). The following interventions were to be initiated based on the score: immediate notification of the ED provider; Behavioral Health Consult; room safety measures; and 1:1 sitter. There was no documented evidence of a Behavioral Health Consult or a 1:1 sitter.

At 3:04 PM Staff F (RN) documented he/she informed security and the nursing supervisor Patient #1 scored high risk and "triggered a 1:1." Staff F was informed there was "no additional staff available at this time."

At 3:15 PM Staff F documented in a note he/she had spoken with Patient #1's group home administrator. The administrator informed Staff F that Patient #1 had "eloped last night". Also noted Patient #1 never had any previous suicidal or homicidal tendency or attempts.

Sixty five (65) minutes after Patient #1 was first identified at high risk for suicide and in need of a 1:1 sitter for his/her personal safety, Staff F documented in a note at 3:52 PM the physician stated there was "no need for 1:1."

Patient #1 was seen by the physician sometime between 2:56 PM and 4:19 PM, at which time the physician completed a Discharge Screen and noted Patient #1's disposition as "home/self care."

At 4:20 PM the signature page of the discharge instructions was printed out and signed by Patient #1 and Staff G. Documentation revealed Staff G gave Patient #1 a 1 (one) mg dose of Ativan at 4:29 PM, and the Discharge Assessment was completed at 4:30 PM. Patient #1 was discharged to home/self care in "good" condition.

At 4:41 PM a Code Brown (Missing or Wandering Person) was initiated after it was discovered Patient #1 was missing.

Staff A confirmed the above findings on 09/24/19 at 8:33 AM.

Staff G (RN) was interviewed on 09/24/19 at 2:25 PM. Staff G stated he/she was just beginning shift when taking over the care of Patient #1 on 08/28/19. Staff G stated he/she was the charge nurse and asked to discharge Patient #1. Staff G stated he/she didn't know Patient #1 was MRDD. Staff G stated he/she reviewed the discharge instructions with Patient #1 and he/she responded appropriately.

Staff G stated he/she asked another RN to show Patient #1 where the ED waiting room was. Staff G stated that RN took Patient #1 to the waiting room and returned without incident. Staff G stated a few moments later Staff F informed him/her Patient #1 wasn't in the waiting room. Staff G walked out and confirmed Patient #1 wasn't in the waiting room. Staff G stated she called a Code Brown and the local police department. Staff G stated they continued searching until Patient #1 was found.

Staff G was asked if he/she would have done anything differently regarding the care of Patient #1 and stated yes. Staff G stated he/she probably would have assigned a sitter, made Patient #1 a 1:1 for observation. Staff G stated he/she also would not have set Patient #1 in the lobby to wait after discharge. Staff G stated he/she would have kept Patient #1 in his/her ED room while waiting. Staff G was asked if he/she received or participated in any education/re-education following this incident and replied no. Staff G stated there was some informal discussion with his/her supervisor.

Staff F (RN) was interviewed on 09/24/19 at 2:59 PM regarding Patient #1 and the Code Brown. Staff F was Patient #1's RN in the ED on 08/28/19. Staff F stated he/she was present when Patient #1 arrived in the ED at 2:43 PM, but Staff F's shift ended prior to Patient #1 being discharged. Staff F stated he/she clocked out at the end of shift and was heading out the back ED door(s) when he/she saw Patient #1 heading out the same doors(s).

Staff F redirected Patient #1 back into the ED waiting area and asked Patient #1 to sit and wait, explaining his/her ride wasn't here yet. Staff F then turned around and proceeded to the triage area to let staff know what had just happened. Staff F stated when he/she turned back around, Patient #1 was gone. Staff F stated other people in the ED waiting room reported seeing Patient #1 run out the door(s) and Staff F subsequently ran out looking for the patient. Staff F stated he/she didn't see Patient #1, so he/she called the hospital operator and informed the operator of a Code Brown. Staff F then notified the nursing supervisor of the situation and continued searching the hospital grounds for Patient #1.

Staff F was asked if he/she received or participated in any education/re-education following this incident and replied no.

Patient #1 was found approximately six (6) hours later in a neighboring city. Patient #1 was returned to the ED by ambulance and remained there until being transferred to an inpatient hospital with psychiatric services on 08/30/19 at 6:37 PM.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0167

Based on record review, policy review and staff interview, the facility failed to ensure the use of seclusion was implemented in accordance with their policy. This affected one of one patients placed in seclusion, Patient #1. A total of 10 medical records were reviewed. The census was 47.

Findings include:

Facility policy Restraint/Seclusion, Utilization Guidelines (revised 08/2017) was reviewed. Seclusion was defined as "the involuntary confinement of a person alone in a room or area from which the person is physically prevented from leaving." Seclusion was only permitted "to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff members, or others."

The order for restraint or seclusion (for adults 18 and older) must be renewed every four (4) hours, up to a total of 24 hours. The policy also specified "assessment, evaluation, and documentation" was to be done every two (2) hours at a minimum.

Patient #1 was returned to the emergency department (ED) via ambulance on 08/28/19 at 11:42 PM and was immediately placed in ED Room #17 (seclusion room). The initial assessment by the RN revealed Patient #1 was suicidal, with a plan to slit his/her throat. Patient #1 was alert to self and paranoid. Patient #1 was screened using the Columbia Suicidal Risk Assessment and received a score of 12 (high risk). The following interventions were to be initiated based on the score: immediate notification of the ED provider; Behavioral Health Consult; room safety measures; and 1:1 sitter.

There was a verbal order read back (VORB) for seclusion on 08/29/19 at 8:56 AM. ED Restraint Alternatives/Flow Sheet documentation revealed nursing staff performed an initial assessment related to the use of seclusion at 9:16 AM on 08/29/19. The restraint type was "seclusion" and the clinical justification was threatening behavior, dangerous behavior, safety/instruction, and protection. The Flow Sheet noted "Documentation MUST be completed every 15 minutes for Chemical/Leather/Behavioral restraints."

Documentation was not completed again until 12:45 AM on 08/30/19, approximately 15.5 hours later. At 3:43 PM the RN documented in a note, Patient #1 "remains in monitored room with security at nursing station monitoring."

There was no documented evidence staff completed the required 15 minute checks or renewed the order for seclusion every four (4) hours.

Patient #1 remained in seclusion (ED Room #17) until he/she was transferred to another facility on 08/30/19 at 6:37 PM.

Staff E confirmed these findings on 09/23/19 at 4:13 PM.