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Based on interview, policy review, and interview, the facility failed to include the patient's family in planning for their social and discharge needs, failed to post notice of complete patient rights in the emergency department, failed to communicate to the patient the right to appeal to a grievance committee, failed to identify the use of a hand mitt as a restraint, failed to employ less restrictive measures in the form of patient companions before applying a restraint. The cumulative effect of these sytemic practices resulted in the facility's inability to protect patient's rights.

Findings:

Refer to A117, A130, A154, and A161.

Based on observation and interview, the facility failed to inform each patient in the emergency department of their rights and failed to notify complainants of the existence of a complaint committee that can further review their complaints. This has the potential to affect each patient that visits the emergency department and each patient or family that files a grievance against the hospital. The emergency department's average daily census is 169 patients per day and the facility's census was 368 patients.

Findings include:

On 08/28/12 at 1:30 P.M. a tour of the emergency department's waiting room and treatment area was completed. In the waiting area a poster was observed which described patient rights for health insurance portability and accountability act, however, the poster did not provide the state agency's complaint hotline number or describe the patient's additional rights.
On 08/28/12 during the tour Staff A and Staff E confirmed the observation.

Review of the facility's complete patient rights was completed on 08/30/12. The review revealed it contained the state agency's complaint hotline number and revealed the patient had the right to be involved in care decisions and to receive information about their rights.

On 08/28/12 at 2:00 P.M. Patient #17 stated in an interview in the treatment area that he/she had not received his/her patient rights.

On 08/28/12 at 2:00 P.M. Patient #18 stated in an interview in the treatment area that he/she has been to the department before and usually gets patient rights when discharged.

On 08/28/12 at 2:00 P.M. Patient #19 stated he/she did get patient rights before coming into the treatment area of emergency department.

On 08/28/12 at 2:10 P.M. Staff I, in an interview, stated he patients rights are given. Staff I produced a booklet on rights under the health insurance portability and accountability act and no additional rights.

A review of the administrative policy entitled "Patient Complaint-Grievance", last revised on 10/10, was completed on 08/30/12. The review of the policy revealed the committee is required to meet if the patient or patient's representative is not satisfied with the resolution of the grievance.

On 08/30/12 a review of Patient #20's family complaint file was completed. The review of the complaint file revealed the family complained about the medical care the patient received on 05/23/12. The review revealed a letter responding to the complaint dated 05/18/12. The review revealed a letter was sent to the family on 05/25/12. The letter stated the facility would not discuss the patient's care without the patient's release. The letter did not inform the complainant of the existence of a grievance committee if the paitient wanted to pursue the matter further.

On 08/30/12 a review of Patient #21's complaint file was completed. The review revealed the patient complained about treatment by staff in writing on 06/21/12. The review revealed a note dated 08/16/12 that stated the case was still pending because of inability to connect with patient. The review revealed a note dated 08/29/12 that stated the complainant's allegations were unfounded. The review did not reveal a letter that informed the complainant of the existence of a grievance committee if the paitient wanted to pursue the matter further.
On 08/29/12 at 4:00 P.M. in an interview Staff D said the grievance committee doesn't meet to discuss complaints/grievances. Staff D said each complaint/grievance is sent to the department mentioned in the complaint and the manager of the department addresses it. Staff D said the patient isn't informed of the committee.
On 08/29/12 at 4:30 P.M. in an interview Staff B said to Staff D that he/she thought the committee was mentioned in the letter. Staff D said it wasn't.

Based on interview, policy review, and clinical record review, the facility failed to include the family of Patient #22 in the development of the plan of care. Patient #22 suffered a fatal gunshot to the head by the spouse during visiting hours. The census was 368 patients, and the sample size was 22 patients.

Findings:

The clinical record review for Patient #22 was completed on 08/30/12. The clinical record review for Patient #22 was completed on 08/30/12. The clinical record review revealed an operative report for four-vessel angiography dictated on 07/28/12 that stated the patient was admitted on 07/28/12 and had postoperative diagnoses of ruptured aneurysms, left posterior communicating artery aneurysm, left internal carotid artery summit aneurysm, and anterior communicating artery aneurysm.


The clinical record review revealed neurology consult dated 07/28/12 that stated when patient came to the emergency department patient complained of a severe headache, nausea, and vomiting. The consult stated patient was alert, oriented to person, place, and time, had reasonably good judgment, and fluent, articulate speech.


The clinical record review revealed an operative report dictated 08/08/12 that stated the patient received a coiling procedure (a procedure whereby tiny coils are packed into the aneurysm to promote blood clotting and close off the aneurysm to stop in from bleeding more) to all three aneurysms. The note did not indicate any untoward issues arose during the procedure.

(The note did not indicate a date of service; however a physician progress note dated 07/31/12 at 8:07 A.M. stated 07/31/12 was post coiling day three. Therefore, the date of the coiling procedure was on 07/28/12.)

The clinical record review revealed a neurosurgery physician progress note dated 08/01/12 at 7:15 A.M. that stated the patient opened her/his eyes minimally with noxious stimuli, was not following commands, and had occasional spontaneous semi purposeful movement.

The clinical record review revealed a physician progress note dated 08/01/12 at 8:02 A.M. that stated the patient would only moan and did not move her/his arms or legs to command.

A neurosurgery physician progress note dated 08/03/12 at 8:30 A.M. stated the patient opened her/his eyes briefly and intermittently to voice. The note described her/his as nonverbal and not following commands.


The clinical record review revealed a physician progress note dated 08/04/12 at 9:56 P.M. that stated a loud noise was heard, the husband was observed in the room holding a gun, and stated "Please tell me he/she's dead." The note stated a diagnosis of gunshot wound to the brain was made.

The clinical record review revealed a consult note dated 08/04/12 at 9:06 P.M. that stated a male "(prob. Husband) having pulled a firearm and shoot the patient on the left side of her/his head. "

The clinical record review revealed upon admission an advance directive questionnaire was completed and, being unable to ascertain whether the patient had any advance directives, social work was contacted on 07/29/12. The clinical record review revealed the patient's next of kin was her/his spouse.

On 08/29/12 at 9:00 A.M. in an interview Staff F stated he/she received the consult, but didn't do it because he/she has 24 hours to respond. So he/she left it with the department secretary to tell another social worker to visit the patient.


On 08/29/12 at 9:00 A.M. in an interview, Staff D stated the secretary-and not the department management-assigns who completes uncompleted work assignments. Staff D confirmed a social worker never contacted the patient's spouse.


The clinical record review did not reveal where social work contacted the patient or family regarding advance directives.


A review of policy number 19, section H, Initial Screening Assessment for Interdisciplinary Referrals, last revised 2008, was completed on 08/30/12. The review revealed an Initial Screening Assessment For Interdisciplinary Referrals form is to be completed by a registered nurse within 24 hours of admission. Review of the form revealed a screening for social work. The form read "notify social work if any item noted" and these items included, among other things, information on advance directives, new onset dimension, and cerebral vascular accident.


The clinical record review revealed the patient had had a cerebral vascular accident with diagnoses of ruptured aneurysms, left posterior communicating artery aneurysm, left internal carotid artery summit aneurysm, and anterior communicating artery aneurysm. Review of the clinical record in its electronic form did not reveal where the Initial Screening Assessment for Interdisciplinary Referrals form was completed.

The clinical record review revealed social work never contacted the family between the patient's arrival on 07/28/12 and the shooting on 08/04/12.

On 08/30/12 at 12:00 P.M. Staff A confirmed the form was not completed.

The clinical record review revealed on 07/30/12 at 1:21 P.M. an update was given to the husband. On 08/01/12 at 2:00 P.M. the clinical record review revealed a nursing note that stated the spouse was updated. The clinical record review did not reveal what all "updated" entailed.

On 08/30/12 at 10:50 A.M. in an interview, Staff K, who wrote the 07/30/12, 1:21 P.M. note, stated by "updated" he/she had spoken with the husband and told him his spouse's condition had neither improved or declined. He stated his spouse was his caregiver and he said he was frail himself.

The clinical record review revealed a nursing note dated 08/01/12 at 2:00 P.M. that stated the husband was "updated" by phone, and nothing more, such as what the "update" was and how he reacted to it.

The clinical record review did not reveal any documentation of discharge planning between arrival on 07/28/12 and the patient being shot on 08/04/12. The clinical record review did not reveal any discharge planning for the patient given that the spouse was in need of care himself based on the interview with Staff K.

On 08/30/12 at 1:11 P.M. in an interview Staff L stated when discharge planning begins is a judgment call. Staff L said the topic can add more stress to the family, and so they sometimes wait. Staff L said when discharge needs become more evident, the process is then begun. Staff L confirmed a case manager did not contact the spouse at any time between the patient's arrival on 07/28/12 and being shot on 08/04/12.

Based on clinical record review, policy review and staff interview, it was determined the hospital failed to utilize a bedside caregiver, a less restrictive intervention, in lieu of restraints for Patient #6 and #7. At the time of the survey the census was 368. Six clinical records with restraint use were reviewed and 13 current patients were restrained at the time of the survey.

Findings include:

The clinical record review for Patient #6 was completed on 08/30/12. This patient was admitted to the hospital on 08/22/12 at 10:07 A.M. with diagnoses that included dementia and seizure disorder. The patient was transferred to the hospital from a nursing home whom had identifed the patient as a fall risk. On admission to the hospital, the nursing assessment identifed the patient as a fall risk with a score of 50 , according to the Morse Fall Scale used by the hospital. A score greater than 45 identifies the patient as a fall risk.

The nursing documentation dated 08/22/12 in the patient's clinical record revealed the patient was agitated and was pulling at tubes repeatedly. Bilateral soft wrist restaints were ordered on 08/22/12 at 10:00 P.M. and applied at that time. The restraints remained on until 08/24/12 at 11:45 A.M. at which time the nursing documentation revealed the patient was calm. On 08/25/12 at 12:30 A.M. the wrist restraints were reordered and reapplied because the patient had pulled both of his peripheral intravenous lines out.

A hospital policy for the role of a bedside caregiver was reviewed on 08/30/12. As part of the policy, the registered nurse is to utilize the Patient Safety Assessment Tool (PSAT) to determine the need for a bedside caregiver. The first of twenty bullet points with strategies to enhance patient safety is "avoid restraints". A bedside caregiver is not indicated for a score that is less than four points. If the PSAT had been done the patient's score would have been at least a seven, which would indicate the need for a bedside caregiver.

During review of the electronic clinical record with Staff J on 08/30/12 at 12:15 P.M., no documentation was found indicating the registered nurse had used the PSAT for Patient #6.


The clinical record review for Patient #7 was completed on 08/30/12. This patient was admitted to the hospital on 08/26/12 at 4:44 A.M. with a diagnosis of tachycardia. The patient was brought to the hospital after being found at home on the floor after a fall. On admission to the hospital, the nursing assessment identifed the patient as a fall risk with a score of 75.

The nursing documentation dated 08/26/12 in the patient's clinical record revealed the patient was agitated at 10:30 P.M. and was trying to get out of bed at 11:00 P.M.. Bilateral soft wrist restaints were ordered on 08/26/12 at 11:00 P.M. and applied at that time. On 08/27/12 at 2:36 A.M. in addition to the wrist restraints, bilateral ankle restraints were also ordered. According to the nursing documentation, these four restraints remained on until 8:00 A.M. on 08/27/12 at which time the patient was off the unit for various tests, returning to the unit at approximately 4:00 P.M.. At 7:30 P.M. on 08/27/12 the nursing documentation reveals the patient is argumentative. On 08/27/12 at 10:00 P.M. all four restraints were reapplied and remained on until approximately 5:00 A.M. the next morning (08/28/12). They remained off until at least the time the patient was interviewed on 08/29/12 at 3:10 P.M..

A hospital policy for the role of a bedside caregiver was reviewed on 08/30/12. As part of the policy, the registered nurse is to utilize the Patient Safety Assessment Tool (PSAT) to determine the need for a bedside caregiver. The first of twenty bullet points with strategies to enhance patient safety is "avoid restraints". A bedside caregiver is not indicated for a score that is less than four points. If the PSAT had been done the patient's score would have been at least a seven, which would indicate the need for a bedside caregiver.

Interviews with Staff B were conducted on three occasions to discuss the use of bedside caregivers at this hospital. On 08/29/12 at 3:20 P.M. Staff B revealed, "we use sitters (bedside caregivers) here, but then that takes staff away from other units." Interview with Staff B on 08/30/12 at 11:00 A.M. revealed, "we're trying to get away from using sitters here and do what's best for the patient."

A final interview with Staff B on 08/30/12 at 1:37 P.M. confirmed the nursing staff did not utilize the PSAT for either Patient 6 or 7 because the physician ordered the restraints so there was no need to determine the need for a bedside caregiver.

Based on observation, staff interview, policy and procedure it was determined the facility failed to identify a restraining device for one patient (#8) of 6 patients reviewed for restraint usage out of 13 patients identified as having restraints. The hospital census was 368.

Findings included:

Patient # 8 was admitted to the hospital on 08/27/12 with diagnoses of hypkokalemia (low blood levels of potassium), dementia, urinary tract infection, left eye blindness, hypertension and history of ischemic stroke. Review of the electronic clinical record was completed on 08/30/12 and revealed the patient was alert and oriented with some confusion, was able to move all extremities and required assist for bathing, grooming and hygiene needs. The clinical record revealed the patient had intravenous (IV) access for the administration of IV medications and fluids. The clinical record also revealed the patient had removed the IV access device on two occasions, on 08/28/12 at 5:04 A.M. and again at 10:50 A.M. The documentation revealed that following the second time the patient had removed her IV access device she was placed in bilateral hand mittens.

Review of the clinic record revealed there were no other least restrictive or alternative methods attempted prior to the implementation of bilateral hand mittens. The hospital was unable to provide a physician's order for the use of this device.

Interview with Staff H on 08/29/12 at 2:09 P.M. when asked if they had any restraints on this hospital unit, Staff H replied that Patient #8 had bilateral hand mittens on but that hand mittens were not restraints. When interviewed at this time the staff indicated a restraint was any type device or medication that would prevent or hinder movement.

Interview on 08/29/12 at 4:15 P.M. with Staff B revealed the hospital had done extensive research and the hospital deemed the hand mittens did not meet the criteria of a wrist restraint and therefore did not require physician's orders, restraint assessment, and associated plan of care, despite the guidance in the Centers for Medicare and Medicaid regulation at 161 documentation "mittens so bulky that the patient's ability to use their hands is significantly reduced, that this would be considered a restraint and the requirements would apply."
Interview with Staff G on 08/30/12 at 9:50 A.M. revealed she had provided care for Patient #8 during the hospital stay. Staff G verbalized that Patient #8 was able to transfer herself from the bed to the bathroom with minimal assist of staff, the patient was also able to feed herself as well after set up, as well as able to use the call bell device if it was next to her. When asked by the surveyor how the patient would use the call bell or grasp utensils with bilateral hand mittens, Staff G failed to answer the question and verbalized that the patient was only in hand mittens because she " had IV's and would pull them out and that the mittens prevented her from pulling them (IV's) out. "
Observation of the mitten on 08/29/12 at 10:00 A.M. revealed the device was a light- bulb shaped full pocket mitten without finger separators. It measured 11 inches long from top to the wrist portion and eight and one-half inch wide at the widest portion. The palm portion of the device was filled with light weight beading. The mitten was manufactured of a light weight rubberized coated fabric. When donned by surveyors and staff, the mitten prohibited the ability to utilize the thumb and fingers for grasping of most devices or utensils of daily living such as call bell device, drinking or eating utensils, or telephone or the adjustment of clothing or bed linens.

Review of the 2009 manufactures guidelines for their mitten product revealed, the device was classified as a limb restraining device and required a physician's prescriptive order and was for use in healthcare facility only. The manufacturer's guideline further directed staff to make a complete assessment of the patient to ensure restraint use was appropriate. This printed directive instructed to use a restraint when all other options had failed and that patient's had a right to be free from restraint. The printed directive further instructed to use in accordance with a patient's individualized care plan.

Review of the hospital's policy and procedure entitled Restraints and Seclusion with a most recent revision date of 04/12 directed that the decision to use a restraint was based on an assessment of the patient by a physician,licensed independent practitioner, or a registered nurse and that less restrictive interventions must be determined by staff to be ineffective to protect the patient or others from harm. Appendix B of this policy and procedure provided examples of less restrictive interventions prior to initiating restraints which included working with MD (physician) to remove tubes, lines, dressings, as soon as possible, or the use of protective dressing over IV/tube sites and to provide distractions or request family to sit with patients.

Interview with Staff A on 08/30/12 at 12:35 P.M. verified the manufacture directive classified this device as a limb restraint and therefore its usage would require a physician's order, assessment and plan of care to reflect the restraint usage. Staff A verified she was unable to perform simple finger and thumb grasps of commonly used items when the mitten was donned.