HospitalInspections.org

Based on documnet review and interview, it was determined that for 1 of 1 (Pt. #1) patient records reviewed for notification of rights to the guardian, the Hospital failed to ensure that the patient's guardian was notified before discontinuation of services or discharge from the Hospital.

Findings include:

1. On 11/29/2021, the Hospital's policy titled, "Patient Rights and Respnsibilities" revised by the Hospital 1/2019 was reviewed. The policy required, "...The exercise of Patient's Rights provides for...the process to inform each patient or, when appropriate, teh patient's representative (as allowed under state law) of patient's right in advance of furnishing or discontinuing patient care whenever possible..."

2. On 11/29/2021, Pt. #1's clinical record was reviewed. Pt. #1 presented to the Emergency Department (ED) on 10/27/2021 at 4:52 PM, from a nursing home via ambulance, and was discharged to self on 10/27/2021 at 6:56 PM. The patient information record from the nursing home included documentation of Pt #1's guardian's name and contact information.

-The ED nursing note, dated 10/27/2021 at 7:29 PM, authored by a Registered Nurse (E #2), included, " ...brought to er [emergency room] for psych [psychiatric] evaluation with petition [for psychiatric evaluation] from nursing home ..."

-The Physician order, dated 10/27/2021 at 8:39 PM, signed by MD #1, included an order to discharge home independently.

-The clinical record lacked documentation of state guardian notification related to Pt. #1's ED visit and discharge.

3. On 11/29/2021 at 1:38 PM, an interview was conducted with an Emergency Department Physician (MD #1). MD #1 stated that he was not made aware Pt. #1 was from a nursing home with a petition for a psychiatric evaluation. MD #1 stated that he was not made aware that Pt. #1 had a guardian until today (11/29/2021). MD #1 stated that it is the responsibility of the Emergency Department staff to review the patient record when a patient comes from another Facility.

Based on document review and interview, it was determined that for 1 of 3 patients (Pt. #2) clinical records reviewed for restraints, the Hospital failed to ensure each order for restraint included the time limit the restraint was permitted.

Findings include:

1. On 11/29/2021, the Hospital's policy titled, "Restraint and Seclusion," approved 6/15/2017, was reviewed. The policy required, "V. Procedure... B. Authorization and Ordering Restraints... 1.b... Restraint orders must be dated when signed by physician and include... reason for restraint... and specific duration of restraint order."

2. Pt. #2's clinical record was reviewed on 11/29/2021. Pt. #2 was brought to the Emergency Department (ED) on 10/4/2021, for a mental health evaluation. On 10/4/2021 at 11:18 PM, a physician's order for full leather restraints was written because Pt. #2 was "severely agitated". The physician's order lacked a duration/time limit for restraints. The restraints were removed on 10/5/2021 at 12:01 AM.

3. On 11/29/2021 at 11:15 AM, an interview was conducted with the ED Manager (E #1). E #1 stated that the physician's order should include a time limit for restraints.