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Based on medical record review, staff interview, and a review of facility policy, it was determined that the facility failed to ensure that the "Informed Consent for Surgery/Procedure" policy was implemented in one (1) out of three (3) medical records reviewed for hemodialysis consent (Medical Record #3).

Findings include:

Reference: Facility policy, Informed Consent, states, "... Every patient has a right to receive information, in terms he/she understands, regarding his/her medical condition, recommended treatment, risk(s) of the treatment, expected results, and reasonable medical alternatives, including risks of refusing treatment. ... 3. The Informed Consent Form ... c) The attending physician, resident or other appropriately credentialed practitioner who has had the informed consent discussion shall obtain the informed consent of the patient ... g) The Informed Consent Form shall include the name of the physician or appropriately credentialed practitioner who has obtained the informed consent. The name must be printed legibly on the form and the physician or appropriately credentialed practitioner must date, time, and sign the form. ... 5. Patients with Communication Problems. a) Patient who do not speak or understand English. ... [bullet] ... Language translation services/phones are available ... [bullet] The use of the language translation service/phone shall be documented in the medical record."

1. A review of Medical Record #3 revealed the following:

a. In the Learning Assessment section of Medical Record #3, there was documented evidence dated 8/11/18 that the preferred language of Patient #1 was Spanish.

b. Medical Record #3 contained a Consent For Procedure/Treatment Form dated 8/10/18 for Hemodialysis.

(i) The Consent form was written in English.

(ii) There was no evidence that the language translation service/phone was used to discuss and obtain Patient #3's consent for hemodialysis.

(iii) Section 1 of the consent form, "(Explain in lay terms)", was left blank. The Consent form lacked evidence that Patient #3's medical condition was explained in terms that Patient #3 could understand.

(iv) The Consent form lacked evidence that the physician explained the procedure, the risks and benefits, alternatives and consequences of treatment and non-treatment to Patient #3. Section #7, the Physician's Attestation, was left blank.

2. On 1/9/18 at 1:45 PM, the above findings were confirmed by Staff #1.

Based on review of hospital policies and procedures and tours of three (3) patient care units, it was determined that the facility failed to provide patients with care in a safe setting.

Findings include:

Reference #1: Facility policy and procedure, Regulated Medical Waste, states, "Regulated Medical Waste (RMW), is a category of waste generated at health care facilities, as well as medical research facilities and laboratories that is the portion of the waste stream that may be contaminated by blood, body fluids or other potentially infectious materials, which includes any sharps or sharps material. ... Sharps * All syringes, used or unused, with or without needles (includes oral and irrigation syringes) ... Discard to designated Sharps Collector ..."

Reference #2: Facility policy and procedure, Crash Cart and Lifepak 15 Check Procedure, states, "CRASH CART CHECKS: This procedure is to be followed by all nursing units and procedural areas with crash carts for their daily and weekly crash cart checks. ONCE DAILY: ALL AREAS- ... * Document the Crash Cart Check, Therapy cable and Standard Paddle and Passing of (Auto) User Test on the Crash Cart Monitoring and Defibrillator Check flow sheet. ..."

1. A tour of the emergency department on 1/9/19 revealed:

a. In the Amber Zone: Two (2) 10 ml (milliliter) syringes and 2 (two) 3 ml syringes were observed in a regular trash bag in the nurses station.

2. A tour of the emergency department on 1/10/19 revealed:

a. In the Purple Zone: The CRASH CART MONITORING AND DEFIBRILLATOR CHECK sheet for the month of January 2019 did not have entries made on the 9th day of the month to indicate that the required checks were done.

b. A "Pediatric code box checks January 2019" and a "Pediatric Cart Checklist Daily Lock Check" for the month of January 2019 did not have entries made on the 4th day of the month to indicate that the required checks were done.

Based on tours of two of three patient care units and an interview with administrative staff, it was determined that patient clinical information was not maintained in a confidential manner on two (2) of three (3) units.

Findings include:

1. On 1/9/19, a tour of the Amber Zone Nurses Station in the Emergency Department revealed:

a. The presence of two (2) stickers containing the name, date of service (12/27/18), account number, medical record number, date of birth, age, and gender of Patient #8 in a drawer.

b. The presence of 4 sheets of paper containing the name, date of birth, date of visit (20-Jul-2018), and pacemaker tracking information of Patient #12 under a piece of equipment, on top of a cart, in the Refrigerator / Supply Area.

c. On 1/9/19, Administrator #11 stated that documents containing confidential patient information should be placed in the shredder bins which are in the nurses stations.

2. On 1/9/19, fifteen (15) stickers containing the name, date of birth, medical record number, and account number of Patient #5 were observed in a regular waste paper basket in the MICU (Medical Intensive Care Unit).

A. Based on review a hospital policy and procedure, review of the medical record (MR #14) of a patient who was placed in seclusion, and interview with administrative staff, it was determined that the use of seclusion was not in accordance with the order of a physician or other licensed independent practitioner authorized to order seclusion by hospital policy.

Findings include:

Reference: Facility policy and procedure, Restraints and Seclusion, states, "Purpose: The purpose of this policy is to establish a process for the appropriate use of restraints and seclusion in accordance with CMS (Centers for Medicare & Medicaid Services), NJDOH (New Jersey Department of Health), and Joint Commission standards and to ensure that the use of restraints and seclusion is limited to clinically appropriate and adequately justified situations.
... 3. Management of Patients in Restraints or Seclusion ... Patients Demonstrating Violent/Self-Destructive Behavior
1. In an emergency situation a restraint may be applied by a Registered Nurse. 2. The attending physician must be consulted as soon as possible to order the restraint or seclusion. When the attending physician is unavailable, responsibility for the patient must be delegated to another physician. ..."

1. The "Violent or Self-Destructive Restraints" section of a "Default Flowsheet Data (12/28/18 0000--01/03/19 2359)" form in the medical record of Patient #14 included entries made by nursing staff that the patient was placed in "Seclusion (V)" (violent) at 1445 (2:45 PM) on 12/30/18. There was no written order for the use of seclusion in the medical record.

2. On 2/28/19 at 2:25 PM, Administrator #28 agreed with the findings during a telephone conversation.

B. Based on review of the medical record of 2 (two) of 2 (two) patients (Medical Records #13, and #14) physically restrained for behavior management and staff interview, it was determined that the use of restraint was not in accordance with the order of a physician or other licensed independent practitioner authorized to order restraint.

Findings include:

1. Review of the medical record of Patient #14 revealed:

a. The "Violent or Self-Destructive Restraints" section of a "Default Flowsheet Data (12/28/18 0000--01/03/19 2359)" form included entries made by nursing staff that the patient was placed in:
"Therapeutic Locked Restraint R (Right) Wrist (V)" (violent);
"Therapeutic Locked Restraint L (Left) Wrist (V)";
"Therapeutic Locked Restraint R Ankle (V)"; and
"Therapeutic Locked Restraint L Ankle (V)" at 1445 (2:45 PM) on 12/30/18.

b. The "Restraints violent or self-destructive adult (age 18 and older) (Order 85899317)" did not include the number of limbs to be restrained.

2. Review of the medical record of Patient #13 revealed:

a. The "Violent or Self-Destructive Restraints" section of a "Default Flowsheet Data (12/25/18 0000--12/31/18 2359)" form included entries made by nursing staff that the patient was placed in:
"Therapeutic Locked Restraint R (Right) Wrist (V)" (violent);
"Therapeutic Locked Restraint L (Left) Wrist (V)";
"Therapeutic Locked Restraint R Ankle (V)"; and
"Therapeutic Locked Restraint L Ankle (V)" at 0900 (9:00 AM) on 12/30/18.

b. The "Restraints violent or self-destructive adult (age 18 and older) (Order 85721207)" did not include the number of limbs to be restrained or the type of restraints to be utilized.

3. On 2/26/19, Administrator #28 agreed with the findings during a telephone conversation.

Based on review of hospital policy and procedure, interview with administrative staff, and medical record review of 1 (one) of 2 (two) (MR# 14) adult patients who were physically restrained for the management of violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, a staff member, or others, it was determined that each order for restraint was not limited to four hours.

Findings include:

Reference: Facility policy and procedure, Restraints and Seclusion, states, "... 3. Management of Patients in Restraints or Seclusion ... Patients Demonstrating Violent/Self-Destructive Behavior 1. In an emergency situation a restraint may be applied by a Registered Nurse. 2. The attending physician must be consulted as soon as possible to order the restraint or seclusion. When the attending physician is unavailable, responsibility for the patient must be delegated to another physician. ... 4. Each order for restraint or seclusion for management of the Violent/Self-destructive behavioral management: a. 4 hours for adults 18 years of age or older; ..."

1. Review of Medical Record #14 revealed:

a. The "Process Instructions" section of a "Restraints violent or self-destructive adult (age 18 and older) (Order 85899317)" order stated: "The duration should not exceed 4 hours. Please set the start time to be the time the restraints are initiated. ..." Other sections of the order indicated that at 1515 (3:15 PM), a licensed independent Practitioner ordered an undocumented number of limbs to be retrained with "Therapeutic Locked Restraint " for 4 hours. There was no written order to place the patient in seclusion.

b. The "Violent or Self-Destructive Restraints" section of a "Default Flowsheet Data (12/28/18 0000--01/03/19 2359)" form included an entries made by nursing staff that the patient was placed in:
"Therapeutic Locked Restraint R (Right) Wrist (V)" (violent);
"Therapeutic Locked Restraint L (Left) Wrist (V)";
"Therapeutic Locked Restraint R Ankle (V)";
"Therapeutic Locked Restraint L Ankle (V); and
"Seclusion (V)" at 1445 (2:45 PM) on 12/30/18.

c. Documentation indicated that the patient who had already been in 4-point locked restraints was ordered to be in restraints for an additional 4 (four) hours, effectively ordering the patient to be in restraints for up to 4.5 hours.

2. On 2/28/19 at 2:25 PM, Administrator #28 agreed with the findings during a telephone conversation.

Based on review of medical records, review of facility policies and procedures, and staff interviews, it was determined that the governing body failed to ensure that its discharge planning process applies to all patients.

Findings include:

1. The facility failed to include all necessary discharge instructions, specific for the patient's needs post hospital care (Cross Refer to Tag A-0820).

Based on a review of three (3) out of six (6) medical records (MR #3, #7, #10), staff interview, and a review of facility policy, it was determined that the facility failed to include all necessary discharge instructions, specific for the patient's needs post hospital care.

Findings include:
Reference: Facility policy, Referrals for Post Discharge Continuing Care Providers, states, "... 5. The patient and family or significant other shall receive upon discharge written instructions about follow-up care and medications, if relevant, and the telephone number of a contact person to call in case there are any questions after discharge. ..."

1. A review of Medical Record #3 revealed the following:

a. The discharge instructions, dated 9/8/18, lacked evidence that Patient #3 was given written instructions related to end stage renal disease, renal diet, hemodialysis, signs and symptoms of complications of not receiving hemodialysis, and when to seek medical attention related to hemodialysis upon discharge.

(i) On 1/9/19 at 12:55 PM, the above findings were confirmed by Staff #1.

b. Upon interview on 1/9/19 at 10:55 AM, Staff #6 stated that patient's who are receiving dialysis and are going to need dialysis after discharge should receive the instructions for end stage kidney disease, hemodialysis, and a dialysis diet with their discharge instruction paperwork.

2. A review of Medical Record #7 revealed the following:

a. The physician's discharge summary, dated 11/21/18, contained documented evidence that stated "Her follow-up will require GI [Gastroenterology], Cardiology, Pulmonology, Endocrinology, and primary care."

b. The discharge instructions, dated 11/21/18, lacked evidence that Patient #7 was notified of the required follow-up with GI, Cardiology, Pulmonology, Endocrinology, and to primary care.

(i) The section titled "What's next" states, "You currently have no upcoming appointments scheduled."

(ii) During interview on 1/10/19 at 1:44 PM, Staff #1 confirmed the above finding and stated that if a patient was referred for a follow-up with specialist as an outpatient, the information would be listed in the "What's next" section of the discharge instructions.

c. The discharge instructions, dated 11/21/18, lacked evidence that Patient #7 was given written discharge instructions upon discharge.

(i) The signature area for the acknowledgment that the registered nurse provided discharge instructions was left blank by the registered nurse.

(ii) The signature area for the acknowledgment that Patient #7 received and understood his/her discharge instructions was left blank.

(iii) On 1/10/19 at 1:45 PM, Staff #1 confirmed the above findings and stated that the registered nurse should sign the discharge instructions after educating the patient, and the patient is to sign the discharge instructions acknowledging that they received the instructions and understand them.

3. A review of Medical Record #10 revealed the following:

a. A physicians discharge summary, dated 11/21/18, contained documented evidence that stated, "... Patient was also found to have a positive QuantiFERON TB gold test and will require outpatient follow-up in TB [tuberculosis] Clinic and ID [Infectious Disease] will arrange. ..."

(i) On 2/5/19, Staff #1 provided laboratory results, dated 6/29/18, that indicated Patient #10 had a Positive QuantiFERON TB gold test.

(ii) On 2/5/19 at 10:25 AM, Staff #1 stated that the 6/29/18 results were the only QuantiFERON TB gold test results in Medical Record #10.

b. Medical Record #10 lacked evidence that the ID arranged a follow up appointment for Patient #10's positive QuantiFERON TB gold test, as requested by the physician.

c. The discharge instructions, dated 11/21/18, lacked evidence that Patient #10 was informed of the required follow-up with the TB clinic.

(i) There was no evidence of the Infectious Disease physician name or contact phone number listed on the discharge instructions.

(ii) There was no evidence of the contact phone number of the TB clinic on the discharge instructions.

d. On 11/21/18, Patient #10 was transferred back to his/her group home with no documentation on his/her discharge instructions or the Universal Transfer form that a follow-up with the TB clinic was required for a positive QuantiFERON TB gold test.

e. On 1/10/19 at 1:55 PM, Staff #1 confirmed the above findings and stated that the discharge instructions lacked evidence that Patient #10 was notified of the need for follow-up at the TB clinic.