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Based on the review of 15 closed medical records, it was determined that 1 out of 15 closed records revealed that the patient's POA was not allowed to participate in the development of her sister's care plan.

Patient #1 presented to the ED on 8/18/2012 complaining of high fever, hypotension and tachycardia. The patient had a MOLST form from the nursing home which identified the patient's sister as her surrogate decision maker and to attempt CPR. No other areas of the MOLST (Maryland Medical Orders for Life-Sustaining Treatment) form were completed. Upon the patient's entrance into the Emergency Department, the physician documented his contact with the patient's POA (power of attorney). The progress note read as follows: the physician documented on 8/18/12 at 7:31 am under assessment/plan #5 the POA updated(power of attorney). Patient remains a full code. States patient follows commands but has not recently asked patient if she wants aggressive care.

On 8/20/12 at 6:15pm the patient was evaluated by vascular service regarding dialysis access catheter. The note indicated that the patient was known to the physician from prior care and that her chart was reviewed. The progress note stated "will remove Permacath port dialysis if that's the opinion of all physician and family but would suggest a hospice consult and ethics consult to clarify our plan." In the column for documentation of date and time the physician wrote discuss with KC who will discuss with the critical care management team in am and arrange hospice consult.

On 8/21/12 there is a note by critical care reviewing the patient's condition, assessment and plan. Under #9 of this note code status , "spoke to patient's sister, POA (Power of attorney) via telephone. The physician discussed the patient's poor/deteriorating clinical status, severe sepsis, CLABI (Central Line Acquired Blood Infection), poor likelihood to treat. New dialysis access would be possible if Permacath discontinued. Patient is now full DNR (Do Not Resuscitate), no further dialysis, and Permacath to be discontinued. Continue IV antibiotics, tube feeding, and other medications." The hospital completed the MOLST form to correspond with the note. Again it appears that the conversation was not documented as witnessed.

Review of patient # 1's medical record revealed that the suggestion for hospice and ethics consultation were not acted upon by the critical care management team nor was the patient's power of attorney involved in the decision. The patient's POA was not informed of all the available options and services for the patient, therefore the POA was not proactively involved in the development of the patient ' s plan of care.

Based on the review of 15 closed medical records, it was determined that 1 out of 15 closed records lack documentation of appropriate acquired informed consent from the patient's power of attorney.

Patient #1 presented to the ED on 8/18/2012 complaining of high fever, hypotension and tachycardia. The patient had a MOLST form from the nursing home which identified the patient's sister as her surrogate decision maker and to attempt CPR. No other areas of the MOLST (Maryland Medical Orders for Life-Sustaining Treatment) form were completed. Upon the patient's entrance into the Emergency Department, the physician documented his contact with the patient's POA (power of attorney). The progress note read as follows: the physician documented on 8/18/12 at 7:31 am under assessment/plan #5 Mary Stroupe updated POA (power of attorney). Patient remains a full code. States patient follows commands but has not recently asked patient if she wants aggressive care. Per the hospital policy the physician will perform the witnessed discussion with the POA or guardian and document the discussion in the patient ' s medical record.

In addition, on 8/21/12 there is a note by critical care reviewing the patient's condition, assessment and plan. Under #9 of this note code status - spoke to patient's sister, Mary Jane Stroupe via telephone. The physician discussed the patient's poor/deteriorating clinical status, severe sepsis, CLABI (Central Line Acquired Blood Infection), poor likelihood to treat. New dialysis access would be possible if Permacath discontinued. Patient is now full DNR (Do Not Resuscitate), no further dialysis, and Permacath to be discontinued. Continue IV antibiotics, tube feeding, and other medications. The hospital completed the MOLST form to correspond with the note. Again it appears that the conversation was not documented as witnessed.

Based on review of 15 closed medical records, it was determined that 1 out of 15 closed records lacked revision/modification to the patients care plans after seclusion/restraint.

Patient #3 was admitted through the Emergency Department for assaulting a sibling at home with continued aggressive behavior towards others. The patient's behavior continued to escalate with patient placement into seclusion on 9/25/12 at 9:30 am. The seclusion was discontinued at 10:15am, 45 minutes later. Review of the medical record revealed the patient's care plan had been revised on 9/23/12, two days before he was secluded but no revision occurred following the use of seclusion on 9/25/12.

Based on review of 15 closed medical records, it was determined that 1 out of 15 closed records lacked the face-to-face documentation.

Patient #3 was admitted through the Emergency Department for assaulting a sibling at home with continued aggressive behavior towards others. The patient's behavior continued to escalate with patient placement into seclusion on 9/25/12 at 9:30 am. The seclusion was discontinued at 10:15 am, 45 minutes later. Review of the medical record revealed no face-to-face was performed on this patient. Although the seclusion was discontinued before the practitioner arrived to perform the face-to-face, the practitioner is still required to see the patient face-to-face and conduct the evaluation within 1 hour after the initiation of the seclusion.

Based on review of data collection related to seclusion/restraint episodes in other locations of the hospital besides the Emergency Department and inpatient psychiatric unit and complaint/grievance data, it was determined that data was not documented in these areas and therefore not integrated into the hospital's quality process. Therefore the hospital lacks an integrated plan of improvement as evidenced by:

During this Federal survey the surveyor was informed by the Associate Vice President of Quality & Clinical Effectiveness that the hospital maintains logs regarding seclusion and restraints for patients in the Emergency Department and the inpatient psychiatric unit only. When asked about the patients on the critical care and medical-surgical units, the surveyor was told that the units have not been monitoring restraint use in several months but this would be an easy fix since the staff can go back to monitoring immediately. Again the hospital was not collecting the data, submitting the data for review and incorporating into the quality process. Therefore, the hospital lacks an integrated plan for improvement. During the survey, a list of restraint and seclusion use in all areas of the hospital was requested from July 2012 to September 2012. The hospital could produce a list for the Emergency Department and inpatient psychiatric unit only. There was no data to review for the other inpatient units of the hospital. The AVP of Quality & Effectiveness stated that the employee responsible for collection of the data choice not to collect data for the other inpatient units like critical care and medical surgical units. The restraints were being monitored up to several months ago. The hospital did have a monitoring tool and stated they would resume monitoring restraints on all other units effective immediately. The hospital policy under performance improvement states:

1. AHC (Adventist Health Care identifies, collects, complies and analyze each episode of restraint usage identify levels of performance, patterns, trends, and variations in the use of restraints and/or seclusion. From this data, opportunities to reduce risks associated with restraint and seclusion use through preventative strategies, alternatives and process improvement, if identified, will be prioritized. AHC uses the PDC methodology for PI.

2. In accordance with behavioral health accreditation standards, data on restraint and seclusion episodes are collected from and classified for all setting and locations.

The hospital failed to monitor or measure quality indicators for restraint and/or seclusion in all locations of the hospital.

In addition, the hospital was unable to provide information to the surveyors regarding complaints and grievances. The hospital could not provide a complaint log or documentation on the complaints or grievances submitted to the hospital in the last several months. The surveyors were unable to determine if the hospital is in compliance with the complaint and grievance process since we were not provided documentation regarding the complaints. The hospital's patient complaints management policy and procedure under procedure C, #6 states documentation of complaints will be maintained. This will provide a basis for the identifying patterns of problems/trends for preventive action. The AVP of Quality & Clinical Effectiveness informed the surveyors she could not produce a log or complaint files of the most recent complaints/grievances but stated she could provide the letters regarding the investigation results since these are formatted letters. During a prior survey it was revealed that the hospital had the same concern and that the hospital was hiring staff to fill positions including staff to monitor and maintain the complaint/grievance process. The hospital has the required staff but they are still in the process of orienting staff. The projected time frame for the complaint/grievance process to be fully implemented is by December 2012.

Based on review of 15 closed medical records, it was determined that 5 out of 15 records lacked signed discharge/transfer summaries at the time of the survey on 10/5/12.

Patient #5 was admitted on 7/12/12 with angina/coronary artery disease with stents. The patient was discharged on 7/14/12 and the discharge summary dictated and transcribed on 7/14/12. The discharge summary was not signed in a closed medical record on 10/5/12, over three months after the patient was discharged.

Patient #7 was admitted on 7/13/12 homicidal ideation toward the mother's husband. The patient was discharged on 7/18/12. The discharge summary was not signed in a closed medical record on 10/5/12, over three months after the patient was discharged.

Patient #8 was admitted on 7/10/12 with hyperkalemia (elevated potassium level) and fluid overload after missing 2 last dialysis sessions. The transfer summary was incomplete with blank spaces and no signature on the summary that was dictated and transcribed on 7/18/12. The transfer summary was not signed in a closed medical record on 10/5/12, over three months after the patient was discharged.

Patient #9 was admitted on 9/4/12 and discharged on 9/11/12. The discharge summary was dictated on 9/28/12 and transcribed on 9/30/12. The discharge summary was not signed in a closed medical record on 10/5/12.

Patient #10 was admitted to the facility on 9/3/12 and discharged on 9/6/12. The patient's discharge summary was dictated and transcribed on 9/12/12. As of 10/5/12, a review of the medical record revealed that the physician had not signed the discharge summary.

Based on review of 15 closed medical records, it was determined that 1 out 0f 15 closed medical records was not completed within 30 days of discharge.

Patient #2 was admitted 8/23/11 and discharged on 8/24/11, the physician dictated a discharge summary on 9/30/11 and the summary was transcribed on 10/1/12. The discharge summary in a closed medical record was dictated, transcribed over one month after the patient was discharged, and signed by the physician on 10/4/12.