HospitalInspections.org

Based on document review, medical record review and staff interview, the hospital failed to protect and promote each patient's rights. The hospital failed to ensure: the patient has the right to be notified of their patient's rights prior to the start of care, (refer to A-117); patients had the right to participate in their care planning, (refer to A-130); patients had the right to be free of restraints, (refer to A-154); patients had the right to be restrained only when less restrictive interventions have been determined to be ineffective, (refer to A-164); patients had the least restrictive type of restraint used , (refer to A-165); restraints were used in accordance with the patient's plan of care, (refer to A-166); restraints were used only upon physician's/practitioner's order, (refer to A-168); restraint orders were renewed every 24 hours, (refer to A-172); restraints were used in accordance with hospital policy, (refer to A-173); restraints were discontinued at the earliest time possible, (refer to A-174); alternatives and less restrictive devices were considered, (refer to A-186); and failed to assess and document the patient's response to the restraint, (refer to A-188).


The hospital's systemic failure to protect and promote each patient's rights including notification of their patient's rights prior to the start of care, to participate in their care planning, to be free of restraints, to be restrained only when less restrictive interventions have been determined to be ineffective, to use the least restrictive type of restraint, to use restraints in accordance with the patient's plan of care, to restraint patients only upon physician's/practitioner's order, restraint orders were renewed every 24 hours, to use restraints in accordance with hospital policy, restraints will be discontinued at the earliest time possible, alternatives and less restrictive devices were considered, and to assess and document the patient's response to the restraint resulted in the hospital's inability to provide care in a safe effective manner.

Based on medical record review, staff interview and document review, the hospital failed to: evaluate patients discharge needs in a timely manner and coordinate services (refer to A-081), failed to provide ongoing evaluation of discharge planning (refer to A-0811), failed to provide discharge instructions and discharge education (refer to A-0820), and failed to reassess and update discharge plans (refer to A-0821).

The cumulative effect of the systematic failure to ensure the hospital evaluate patients discharge needs in a timely manner and coordinate services, to provide ongoing evaluation of discharge planning, provide discharge instructions and education, and to reassess and update discharge plans resulted in the hospitals inability to provide care in a safe and effective manner.

The hospital reported a current census of 15 patients with average daily census of 17 patients. Based on document review, medical record review, and staff interview, the hospital failed to inform two of 21 patients and/or their representatives with records reviewed of the patient's rights in advance of providing care (patient #'s 16 and 17). The hospital's failure placed the patients and/or their representatives at risk of not knowing their patient's rights.

Findings include:

- The hospital document titled "Wichita AMG Speciality Hospital Conditions of Admission and Consent for Medical Treatment" required the patient's and/or their representative's signature, the date and time the document is signed and a hospital representative's signature, date and time.

- The hospital policy titled "I.C.3.06 Referrals/Admissions", reviewed on 4/3/14 at 12:15pm, revealed "13. Admission forms and patient information packets will be prepared and on the day of admission. These include: A. Consent for Admission/Consent to treat".

- Patient #16's medical record revealed an admission date of 12/24/13 with diagnoses including post-operative care. The "Admission and Consent for Medical Treatment", signed by the patient on 12/31/13, -seven days after patient #16's admission. The hospital failed to notify the patient and/or their representative of the patient's right in advance of starting the patient's care.

- Patient #17's medical record revealed an admission date of 2/25/14 with diagnoses including a wound. The "Admission and Consent for Medical Treatment", signed by the patient's representative on 3/3/14, -six days after patient #17's admission. The hospital failed to notify the patient and/or their representative of the patient's right in advance of starting the patient's care.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on document review, medical record review and staff interview, the hospital failed to include seven of 21 patients with medical records reviewed in the development and implementation of the patient's care planning (patient #'s 1, 5, 6, 7, 8, 9, and 21). The hospital's failure to include the patient and/or patient's representative in the planning of the patient's care placed the patients at risk for inadequate care.

Findings include:


- The hospital Policy titled "II.I.9.02 Plan of Care", reviewed on 4/3/14 at 12:15pm, revealed "B. Planning: 2. ...the nursing goals and expected patient outcomes mare made with the patient and/or his/her significant other". The policy directs "3. The care plan will be reviewed each shift and revised as necessary..." and "D. Evaluation 3. All nurses are responsible for updating care plans with specific changes in the patient's condition, as new orders are written and as treatment changes."


-Patient #1 admitted on 10/4/13 and discharged on 1/3/14 with diagnoses including intestinal fistula (an abnormal opening from a body part to the skin), chronic stomach ulcers, blood infection, and bacteremia (a blood infection). The medical record review between 3/31/14 to 4/3/14 revealed Continued Stay Review Forms, the form used for interdisciplinary care planning, indicating the group met on 10/9/13, 10/16/13, 10/23/14, 10/30/13, 11/5/13, 11/13/13, 11/20/13, 12/4/13, and 12/18/13 for care planning for Patient #1. The medical record lacked documentation the patient had been included in care planning.
-Patient #5 admitted on 11/29/13 and discharged on 12/31/13 with diagnoses of left lower extremity cellulitis (an infection under the skin) and possible osteomyelitis (a bone inflammation). Medical record review on 4/1/14 revealed Continued Stay Review Forms, the form used for interdisciplinary care planning, indicating the group met on 12/4/13, 12/11/13, and 12/18/13 for care planning for patient #5. The medical record lacked documentation the patient had been included in care planning.
-Patient #6 admitted on 9/23/13 and discharged on 10/18/13 with diagnoses of post-operative infection and sepsis (a bacterial infection). Medical record review on 4/1/14 revealed Continued Stay Review Forms, the form used for interdisciplinary care planning, indicating the group met on 9/25/13, 10/2/13, and 10/16/13 for care planning for patient #6. The medical record lacked documentation the patient had been included in care planning.

-Patient #7 admitted on 11/15/13 and discharged on 12/24/13 with a diagnosis of sepsis (a bacterial infection) due to wound infection. Medical record review on 4/1/14 revealed Continued Stay Review Forms, the form used for interdisciplinary care planning, indicating the group met on 11/20/13, 12/4/13, and 12/18/13 for care planning for patient #7. The medical record lacked documentation the patient had been included in care planning.

-Patient #8 admitted on 10/7/13 and discharged on 10/31/13 with a diagnosis of status post colectomy (removal of part of the bowel) and sepsis (a bacterial infection). Medical record review on 4/1/14 revealed Continued Stay Review Forms, the form used for interdisciplinary care planning, indicating the group met on 10/9/13, 10/16/13, 10/23/13, and 10/31/13 for care planning for patient #8. The medical record lacked documentation the patient had been included in care planning.

-Patient #9 admitted on 11/7/13 and discharged on 11/29/13 with diagnoses of right hand cellulitis (an infection under the skin) and lower extremity lymphedema (abnormal swelling due to fluids). Medical record review on 4/1/14 revealed Continued Stay Review Forms, the form used for interdisciplinary care planning, indicating the group met on 11/8/13 and 11/13/13 for care planning for patient #9. The medical record lacked documentation the patient had been included in care planning.

-Patient #10 admitted on 11/8/13 and discharged on 11/18/13 with a diagnosis of amputation of left second toe with osteomyelitis (a bone infection). Medical record review on 4/1/14 revealed Continued Stay Review Forms, the form used for interdisciplinary care planning, indicating the group met on 11/8/13 and 11/13/13 for care planning for patient #10. The medical record lacked documentation the patient had been included in care planning.


- Patient #21 admitted on 2/11/14 and discharge on 3/27/14 with diagnoses of sepsis (a bacterial infection). Medical record review on 4/2/14 Continued Stay Review Form, the form used for interdisciplinary care planning, indicated the group met on 2/12/14, 2/19/14, 2/26/14,3/5/143/12/14 and 3/19/14 for care planning for patient #21. The medical record lacked documentation the patient had been included in care planning.

The hospital reported a current census of15 patients with an average daily census of 17 patients. Based on document review, medical record review and staff interview, the hospital failed to ensure patients have the right to be free from physical restraints and ensure restraints are used only for the patient's physical safety and are discontinued at the earliest possible time for two of two patients with restraints (patient #'s 18 and 21). The hospital's lack of complete documentation for restraints placed the patient at risk for inappropriate restraint use.

Findings include:

- The hospital policy titled "II.K.11.07 Restraints", reviewed on 4/2/14 at 9:50am, revealed "I. F. Restraint use will only be imposed upon receipt of appropriate physician orders, when need to ensure the immediate physical safety of the patient... and will be discontinued at the earliest time possible.", " II. Procedure A. Orders: Restraint use will be initiated upon the order of a physician....The order for restraint will include the type and site(s) of restraint to be applied and the specific actions or conditions that indicate restraint" and "Continuation of Restraint Orders: The physician... will perform in-person assessments of the restrained patient at least one every 24 hours, at which time restraint will either be reordered or discontinued as indicated" and "d) Documentation: The following will be documented in the medical record whenever medical restraint is applied:
a. A description of the patient's actions or condition that indicated the initial and/or continued use of restraint. Document on Restraint Order Sheet.
b. The alternative or less restrictive interventions attempted. Document on Restraint Order Sheet.
c. Physician orders for restraint. Use Restraint Order Sheet."


- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record contained a "Restraint Order Sheet", reviewed on 4/2/14, lacked the patient's name, the date and time the restraint initiated, the date and time the order expired, the nurse responsible for the orders, the "High Risk Criteria/Behaviors Present" as an indication for the need for the restraint, the "Alternatives to Restraints Tried", the "Invasive Interventions that Apply to Patient" and evidence the restraint procedure was followed.

Administrative staff B, interviewed on 4/2/14 at 9:05am, acknowledged the physician signed orders for the continued restraint use on an incomplete form.

The medical record revealed mittens (a hand-covering restraint) were applied on 3/22/14 and 3/23/14. The medical record lacked evidence of the least restrictive methods used to avoid placing the restraint on the patient, lacked evidence of physician notification and orders for the use of the restraint, lacked evidence of the patient's plan of care updated with the use of the restraint, lacked evidence of the required at least every two hour checks of the patient while the restraint is in place, lacked evidence the restraint was released every two hours, and lacked evidence the restraint was discontinued at the earliest possible time.


- Patient #21's medical record, reviewed on 4/2/14, revealed an admission date of 2/11/14 with diagnoses including sepsis (a systemic infection), aspiration pneumonia (an infection caused by foreign material in the respiratory tract).

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/11/14 at 2:00pm to expire 2/12/14 at 6:00am for left and right wrist restraints, signed by Physician H on 2/12/14 at 9:00am, 19 hours after the restraint was initiated and 3 hours after the restraint orders expired. The "High Risk Criteria/Behavior Present" was "Confusion/Inability to follow direction". The document lacked evidence of the nurse responsible for the orders, "The Alternatives to Restraint Tried", "Invasive Interventions That Apply to Patient" and evidence the hospital staff following the policy and procedures.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/15/14 at 6:00am and expiring 2/16/14 at 6:00am for left and right wrist restraints. Physician H signed the document on 2/17/14 at 9:20am, more than three hours after the orders expired. The hospital failed to document Criteria/Behaviors present, alternatives, invasive interventions and procedure for the continued use of wrist restraints.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/16/14 at 6:00am and expiring 2/17/14 at 6:00am for left and right wrist restraints. Physician H signed the document on 2/17/14 at 9:00am, three hours after the orders expired. The hospital failed to document the alternative to restraint that were tried.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/17/14 at 6:00am and expiring 2/18/14 at 6:00am for left and right wrist restraints. The hospital failed to document the alternatives to restraint that were tried.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/25/14 at 4:00pm. The order sheet lacked the date the order expired and the name of the nurse responsible for the orders. Physician H signed the order on 2/24/14, but failed to document the time signed.

Patient #21's medical record contained a "Restraint Order Sheet" dated 3/1/14 at 6:00am and expiring on 3/2/14 at 6:00am for left and right wrist restraints. Physician H signed the order on 3/3/14 at 11:00am, more than two days after the restraints were ordered.

Patient #21's medical record contained a "Restraint Order Sheet" dated 3/2/14 at 6:00am and expiring 3/3/14 at 6:00am. Physician H signed the order on 3/3/14 at 11:00am, more than a day after the restraints were ordered.

- Administrative staff B, interviewed on 4/2/14 at 9:05am acknowledged the hospital failed to follow the hospital's policies and procedures for the use of the restraints for patient #'s 18 and 21.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on document review, medical record review and staff interview, the hospital failed to ensure restraints are used only when less restrictive interventions have been determine to be ineffective to protect the patient for two of two patients with restraints (patient #'s 18 and 21). The hospital's lack of complete documentation for restraints placed the patient at risk for inappropriate restraint use.

Findings include:

- The hospital policy titled "II.K.11.07 Restraints", reviewed on 4/2/14 at 9:50am, revealed "I. Policy F. Restraint use will only be imposed upon receipt of appropriate physician orders, when need to ensure the immediate physical safety of the patient... and will be discontinued at the earliest time possible.", " II. Procedure A. Orders: Restraint use will be initiated upon the order of a physician....The order for restraint will include the type and site(s) of restraint to be applied and the specific actions or conditions that indicate restraint" and "Continuation of Restraint Orders: The physician... will perform in-person assessments of the restrained patient at least one every 24 hours, at which time restraint will either be reordered or discontinued as indicated" and "d) Documentation: The following will be documented in the medical record whenever medical restraint is applied:
a. A description of the patient's actions or condition that indicated the initial and/or continued use of restraint. Document on Restraint Order Sheet.
b. The alternative or less restrictive interventions attempted. Document on Restraint Order Sheet".


- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record contained a "Restraint Order Sheet", reviewed on 4/2/14, lacked the patient's name, the date and time the restraint initiated, the date and time the order expired, the nurse responsible for the orders, the "High Risk Criteria/Behaviors Present" as an indication for the need for the restraint, the "Alternatives to Restraints Tried", the "Invasive Interventions that Apply to Patient" and evidence the restraint procedure was followed.

Administrative staff B, interviewed on 4/2/14 at 9:05am, acknowledged the physician signed orders for the continued restraint use on an incomplete form.

The medical record revealed mittens (a hand-covering restraint) were applied on 3/22/14 and 3/23/14. The medical record lacked evidence of the least restrictive methods used to avoid placing the restraint on the patient, lacked evidence of physician notification and orders for the use of the restraint, lacked evidence of the patient's plan of care updated with the use of the restraint, lacked evidence of the required at least every two hour checks of the patient while the restraint is in place, lacked evidence the restraint was released every two hours, and lacked evidence the restraint was discontinued at the earliest possible time.

- Patient #21's medical record, reviewed on 4/2/14, revealed an admission date of 2/11/14 with diagnoses including sepsis (a systemic infection), aspiration pneumonia (an infection caused by foreign material in the respiratory tract).

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/11/14 at 2:00pm to expire 2/12/14 at 6:00am for left and right wrist restraints. The order sheet lacked evidence of "The Alternatives to Restraint Tried" for the continued use of wrist restraints.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/15/14 at 6:00am and expiring 2/16/14 at 6:00am for left and right wrist restraints. The hospital failed to document Criteria/Behaviors present, and the alternatives tried for the continued use of wrist restraints.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/16/14 at 6:00am and expiring 2/17/14 at 6:00am for left and right wrist restraints. The hospital failed to document the alternative to restraint that were tried.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/17/14 at 6:00am and expiring 2/18/14 at 6:00am for left and right wrist restraints. The hospital failed to document the alternatives to restraint that were tried.


- Administrative staff B, interviewed on 4/2/14 at 9:05am acknowledged the hospital failed to follow the hospital's policies and procedures for the use of the restraints for patient #'s 18 and 21.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on document review, medical record review and staff interview, the hospital failed to ensure the type of restraint is the least restrictive intervention to protect the patient from harm for two of two patients with restraints (patient #'s 18 and 21). The hospital's lack of complete documentation for restraints placed the patient at risk for inappropriate restraint use.

Findings include:

- The hospital policy titled "II.K.11.07 Restraints", reviewed on 4/2/14 at 9:50am, revealed "I. Policy F. Restraint use will only be imposed upon receipt of appropriate physician orders, when need to ensure the immediate physical safety of the patient... and will be discontinued at the earliest time possible.", " II. Procedure A. Orders: Restraint use will be initiated upon the order of a physician....The order for restraint will include the type and site(s) of restraint to be applied and the specific actions or conditions that indicate restraint" and "d) Documentation: The following will be documented in the medical record whenever medical restraint is applied:
a. A description of the patient's actions or condition that indicated the initial and/or continued use of restraint. Document on Restraint Order Sheet.
b. The alternative or less restrictive interventions attempted. Document on Restraint Order Sheet.
c. Physician orders for restraint. Use Restraint Order Sheet."


- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record contained a "Restraint Order Sheet", reviewed on 4/2/14, lacked the patient's name, the date and time the restraint initiated, the date and time the order expired, the nurse responsible for the orders, the "High Risk Criteria/Behaviors Present" as an indication for the need for the restraint, the "Alternatives to Restraints Tried", the "Invasive Interventions that Apply to Patient" and evidence the restraint procedure was followed.

Administrative staff B, interviewed on 4/2/14 at 9:05am, acknowledged the physician signed orders for the continued restraint use on an incomplete form.

Patient #18's medical record revealed mittens (a hand-covering restraint) were applied on 3/22/14 and 3/23/14. The medical record lacked evidence of the least restrictive methods used to avoid placing the restraint on the patient, lacked evidence of physician notification and orders for the use of the restraint, lacked evidence of the patient's plan of care updated with the use of the restraint, and lacked evidence the type of restraint was the least restrictive intervention to protect the patient.


- Patient #21's medical record, reviewed on 4/2/14, revealed an admission date of 2/11/14 with diagnoses including sepsis (a systemic infection), aspiration pneumonia (an infection caused by foreign material in the respiratory tract).

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/11/14 at 2:00pm to expire 2/12/14 at 6:00am for left and right wrist restraints, signed by Physician H on 2/12/14 at 9:00am, 19 hours after the restraint was initiated and 3 hours after the restraint orders expired. The "High Risk Criteria/Behavior Present" was "Confusion/Inability to follow direction". The document lacked evidence of the nurse responsible for the orders, "The Alternatives to Restraint Tried", "Invasive Interventions That Apply to Patient" and evidence the hospital staff following the policy and procedures and used the least restrictive, protective intervention.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/15/14 at 6:00am and expiring 2/16/14 at 6:00am for left and right wrist restraints. Physician H signed the document on 2/17/14 at 9:20am, more than three hours after the orders expired. The hospital failed to document Criteria/Behaviors present and least restrictive, protective interventions for the patient included the use of wrist restraints.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/16/14 at 6:00am and expiring 2/17/14 at 6:00am for left and right wrist restraints. Physician H signed the document on 2/17/14 at 9:00am, three hours after the orders expired. The hospital failed to document the least restrictive, protective interventions included the use of wrist restraints.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/17/14 at 6:00am and expiring 2/18/14 at 6:00am for left and right wrist restraints. The hospital failed to document the least restrictive interventions to restraint that were tried.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/25/14 at 4:00pm. The order sheet lacked the date the order expired and the name of the nurse responsible for the orders. Physician H signed the order on 2/24/14, but failed to document the time signed.

Patient #21's medical record contained a "Restraint Order Sheet" dated 3/1/14 at 6:00am and expiring on 3/2/14 at 6:00am for left and right wrist restraints. Physician H signed the order on 3/3/14 at 11:00am, more than two days after the restraints were ordered.

Patient #21's medical record contained a "Restraint Order Sheet" dated 3/2/14 at 6:00am and expiring 3/3/14 at 6:00am. Physician H signed the order on 3/3/14 at 11:00am, more than a day after the restraints were ordered.

- Administrative staff B, interviewed on 4/2/14 at 9:05am acknowledged the hospital failed to follow the hospital's policies and procedures for the use of the restraints for patient #'s 18 and 21.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on document review, medical record review and staff interview, the hospital failed to ensure the use of restraints is in accordance with the patient's plan of care for one of two patients with restraints used (patient #18). The hospital's lack of complete documentation for restraints placed the patient at risk for inappropriate restraint use.

Findings include:

- The hospital policy titled "II.K.11.07 Restraints", reviewed on 4/2/14 at 9:50am, revealed "II. Procedure: A. d) f. An updated care plan that addresses restraint episode".


- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record revealed mittens (a hand-covering restraint) were applied on 3/22/14 and 3/23/14. The medical record lacked evidence of the patient's plan of care updated with the use of the restraint.

Administrative staff B, interviewed on 4/2/14 at 9:05am, acknowledged the hospital failed to update patient #18's plan of care to include the use of the restraint and failed to follow the hospital's policies and procedures for the use of the restraints for patient # 18.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on document review, medical record review and staff interview, the hospital failed to ensure patients have the right to be free from physical restraints and ensure restraints are used only with a physician's/practitioner's order for one of two patients with restraints (patient #18). The hospital's lack of orders for restraints placed the patient at risk for inappropriate restraint use.

Findings include:

- The hospital policy titled "II.K.11.07 Restraints", reviewed on 4/2/14 at 9:50am, revealed "I. Policy F. Restraint use will only be imposed upon receipt of appropriate physician orders, when need to ensure the immediate physical safety of the patient... and will be discontinued at the earliest time possible.", " II. Procedure A. Orders: Restraint use will be initiated upon the order of a physician....The order for restraint will include the type and site(s) of restraint to be applied and the specific actions or conditions that indicate restraint" and "Continuation of Restraint Orders: The physician... will perform in-person assessments of the restrained patient at least one every 24 hours, at which time restraint will either be reordered or discontinued as indicated" and "d) Documentation: The following will be documented in the medical record whenever medical restraint is applied:
a. A description of the patient's actions or condition that indicated the initial and/or continued use of restraint. Document on Restraint Order Sheet.
c. Physician orders for restraint. Use Restraint Order Sheet."


- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record contained a "Restraint Order Sheet", reviewed on 4/2/14, lacked the patient's name, the date and time the restraint initiated, the date and time the order expired, the nurse responsible for the orders, the "High Risk Criteria/Behaviors Present" as an indication for the need for the restraint, the "Alternatives to Restraints Tried", the "Invasive Interventions that Apply to Patient" and evidence the restraint procedure was followed.

Administrative staff B, interviewed on 4/2/14 at 9:05am, acknowledged the physician signed orders for the continued restraint use on an incomplete form.

The medical record revealed mittens (a hand-covering restraint) were applied on 3/22/14 and 3/23/14. The medical record lacked evidence of the least restrictive methods used to avoid placing the restraint on the patient, lacked evidence of physician notification and orders for the use of the restraint.

- Administrative staff B, interviewed on 4/2/14 at 9:05am acknowledged the hospital failed to ensure the patient's medical record contained physician's/practitioner's orders for restraint and failed to follow the hospital's policies and procedures for restraints for patient #18.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on document review, medical record review and staff interview, the hospital failed to ensure a physician/practitioner sees and assesses the patient before writing a new order for a restraint for two of two restrained patients with records reviewed (patient #'s 18 and 21). The hospital's lack of complete documentation for restraints placed the patient at risk for inappropriate restraint use.

Findings include:

- The hospital policy titled "II.K.11.07 Restraints", reviewed on 4/2/14 at 9:50am, revealed "I. Policy F. Restraint use will only be imposed upon receipt of appropriate physician orders, when need to ensure the immediate physical safety of the patient... and will be discontinued at the earliest time possible.", " II. Procedure A. Orders: Restraint use will be initiated upon the order of a physician....The order for restraint will include the type and site(s) of restraint to be applied and the specific actions or conditions that indicate restraint" and "Continuation of Restraint Orders: The physician... will perform in-person assessments of the restrained patient at least one every 24 hours, at which time restraint will either be reordered or discontinued as indicated" and "d) Documentation: The following will be documented in the medical record whenever medical restraint is applied:
a. A description of the patient's actions or condition that indicated the initial and/or continued use of restraint. Document on Restraint Order Sheet.
b. The alternative or less restrictive interventions attempted. Document on Restraint Order Sheet.
c. Physician orders for restraint. Use Restraint Order Sheet."


- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record contained a "Restraint Order Sheet", reviewed on 4/2/14, lacked the patient's name, the date and time the restraint initiated, the date and time the order expired, the nurse responsible for the orders, the "High Risk Criteria/Behaviors Present" as an indication for the need for the restraint, the "Alternatives to Restraints Tried", the "Invasive Interventions that Apply to Patient" and evidence the restraint procedure was followed.

Administrative staff B, interviewed on 4/2/14 at 9:05am, acknowledged the physician signed orders for the continued restraint use on an incomplete form and lacked evidence the physician saw and assessed the patient.

The medical record revealed mittens (a hand-covering restraint) were applied on 3/22/14 and 3/23/14. The medical record lacked evidence of a physician assessment for the need of the restraints upon application of the devises. The medical record lacked evidence the physician saw and assessed the patient at least every 24 hours to assess for the continued need for the restraints.


- Patient #21's medical record, reviewed on 4/2/14, revealed an admission date of 2/11/14 with diagnoses including sepsis (a systemic infection), aspiration pneumonia (an infection caused by foreign material in the respiratory tract).

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/11/14 at 2:00pm to expire 2/12/14 at 6:00am for left and right wrist restraints, signed by Physician H on 2/12/14 at 9:00am, 19 hours after the restraint was initiated and 3 hours after the restraint orders expired. The "High Risk Criteria/Behavior Present" was "Confusion/Inability to follow direction". The document lacked evidence of the nurse responsible for the orders, "The Alternatives to Restraint Tried", "Invasive Interventions That Apply to Patient" and evidence the hospital staff following the policy and procedures. The hospital failed to ensure a physician saw and assessed the patient for the need of the restraint.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/15/14 at 6:00am and expiring 2/16/14 at 6:00am for left and right wrist restraints. Physician H signed the document on 2/17/14 at 9:20am, more than three hours after the orders expired. The hospital failed to document Criteria/Behaviors present, alternatives, invasive interventions and procedure for the continued use of wrist restraints. The hospital failed to ensure a physician saw and assessed the patient every 24 hours for the continued need for the restraints.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/16/14 at 6:00am and expiring 2/17/14 at 6:00am for left and right wrist restraints. Physician H signed the document on 2/17/14 at 9:00am, three hours after the orders expired. The hospital failed to ensure a physician saw and assessed the patient every 24 hours for the continued need for the restraints.


Patient #21's medical record contained a "Restraint Order Sheet" dated 2/17/14 at 6:00am and expiring 2/18/14 at 6:00am for left and right wrist restraints. The hospital failed to ensure a physician saw and assessed the patient every 24 hours for the continued need for the restraints.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/25/14 at 4:00pm. The order sheet lacked the date the order expired and the name of the nurse responsible for the orders. Physician H signed the order on 2/24/14, but failed to document the time signed. The hospital failed to ensure a physician saw and assessed the patient every 24 hours for the continued need for restraints.

Patient #21's medical record contained a "Restraint Order Sheet" dated 3/1/14 at 6:00am and expiring on 3/2/14 at 6:00am for left and right wrist restraints. Physician H signed the order on 3/3/14 at 11:00am, more than two days after the restraints were ordered. The hospital failed to ensure a physician saw and assessed the patient every 24 hours for the continued need for restraints.

Patient #21's medical record contained a "Restraint Order Sheet" dated 3/2/14 at 6:00am and expiring 3/3/14 at 6:00am. Physician H signed the order on 3/3/14 at 11:00am, more than a day after the restraints were ordered. The hospital failed to ensure a physician saw and assessed the patient every 24 hours for the continued need for restraints.


- Administrative staff B, interviewed on 4/2/14 at 9:05am acknowledged the hospital failed to follow the hospital's policies and procedures for the use of the restraints for patient #'s 18 and 21.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on document review, medical record review and staff interview, the hospital failed to ensure patients have the right to be free from physical restraints and ensure restraints are used only for the patient's physical safety for two of two restrained patients with records reviewed (patient #'s 18 and 21). The hospital's lack of complete documentation for restraints placed the patient at risk for inappropriate restraint use.

Findings include:

- The hospital policy titled "II.K.11.07 Restraints", reviewed on 4/2/14 at 9:50am, revealed "I. Policy F. Restraint use will only be imposed upon receipt of appropriate physician orders, when need to ensure the immediate physical safety of the patient..."


- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record contained a "Restraint Order Sheet", reviewed on 4/2/14, lacked the indication for the need for the restraint and evidence the restraint procedure was followed.

Administrative staff B, interviewed on 4/2/14 at 9:05am, acknowledged the physician signed orders for the continued restraint use on an incomplete form.

The medical record revealed mittens (a hand-covering restraint) were applied on 3/22/14 and 3/23/14. The medical record lacked evidence of the restraint was used for patient safety.


- Patient #21's medical record, reviewed on 4/2/14, revealed an admission date of 2/11/14 with diagnoses including sepsis (a systemic infection), aspiration pneumonia (an infection caused by foreign material in the respiratory tract).

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/15/14 at 6:00am and expiring 2/16/14 at 6:00am for left and right wrist restraints. The hospital lacked evidence the restraint was used for patient safety. The hospital failed following their policy and procedures.

- Administrative staff B, interviewed on 4/2/14 at 9:05am acknowledged the medical records lacked evidence the restraints were used for patient safety and confirmed the hospital failed to follow the hospital's policies and procedures for the use of the restraints for patient #'s 18 and 21.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on document review, medical record review and staff interview, the hospital failed to ensure patients have the right to be free from physical restraints and are discontinued at the earliest possible time for two of two restrained patients with records reviewed (patient #'s 18 and 21). The hospital's lack of complete documentation for restraints placed the patient at risk for inappropriate restraint use.

Findings include:

- The hospital policy titled "II.K.11.07 Restraints", reviewed on 4/2/14 at 9:50am, revealed "I. Policy F. Restraint use will only be imposed upon receipt of appropriate physician orders, when need to ensure the immediate physical safety of the patient... and will be discontinued at the earliest time possible.", " II. Procedure A. Early discontinuation of restraint: restraint will be discontinued as soon as it is not longer indicated by the patient's actions or the nature of the patient's treatment plan.


- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record contained a "Restraint Order Sheet",
The medical record revealed mittens (a hand-covering restraint) were applied on 3/22/14 and 3/23/14. The medical record lacked evidence the restraint was discontinued at the earliest possible time.


- Patient #21's medical record, reviewed on 4/2/14, revealed an admission date of 2/11/14 with diagnoses including sepsis (a systemic infection), aspiration pneumonia (an infection caused by foreign material in the respiratory tract).

Patient #21's medical record contained "Restraint Order Sheet" documents dated 2/11/14 to 3/4/14. The medical record lacked evidence of the continued need for the restraint on 2/11/14, 2/15/14, 2/16/14 and 2/17/14. The medical record lacked evidence the restraint was required. The hospital failed to ensure the restraints were discontinued at the earliest possible time.

- Administrative staff B, interviewed on 4/2/14 at 9:05am acknowledged the hospital failed to follow the hospital's policies and procedures to ensure restraints were discontinued at the earliest time possible.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on document review, medical record review and staff interview, the hospital failed to ensure patients had alternatives or less restrictive restraints are attempted to avoid restraints for two of two patients with restraints (patient #'s 18 and 21). The hospital's lack of complete documentation for restraints placed the patient at risk for inappropriate restraint use.

Findings include:

- The hospital policy titled "II.K.11.07 Restraints", reviewed on 4/2/14 at 9:50am, revealed "I. Policy E. Restraints will only be used when less restrictive interventions have been determined to be ineffective to protect the patient...".

" II. Procedure A. d) Documentation: The following will be documented in the medical record whenever medical restraint is applied:
a. A description of the patient's actions or condition that indicated the initial and/or continued use of restraint. Document on Restraint Order Sheet.
b. The alternative or less restrictive interventions attempted. Document on Restraint Order Sheet.



- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record contained a "Restraint Order Sheet", reviewed on 4/2/14, lacked the patient's name, nurse responsible for the orders, the "High Risk Criteria/Behaviors Present" as an indication for the need for the restraint, the "Alternatives to Restraints Tried" and evidence the hospital's restraint procedure was followed.

Administrative staff B, interviewed on 4/2/14 at 9:05am, acknowledged the physician signed orders for the continued restraint use on an incomplete form.

The medical record revealed mittens (a hand-covering restraint) were applied on 3/22/14 and 3/23/14. The medical record lacked evidence of alternatives or less restrictive methods attempted to avoid placing the mitten restraint on the patient.


- Patient #21's medical record, reviewed on 4/2/14, revealed an admission date of 2/11/14 with diagnoses including sepsis (a systemic infection), aspiration pneumonia (an infection caused by foreign material in the respiratory tract).

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/11/14 at 2:00pm to expire 2/12/14 at 6:00am for left and right wrist restraints, signed by Physician H on 2/12/14 at 9:00am, The medical record lacked evidence of "The Alternatives to Restraint Tried" and evidence the hospital staff followed the policy and procedures.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/15/14 at 6:00am and expiring 2/16/14 at 6:00am for left and right wrist restraints. The medical record lacked evidence of "The Alternatives to Restraint Tried" and evidence the hospital staff followed the policy and procedures.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/16/14 at 6:00am and expiring 2/17/14 at 6:00am for left and right wrist restraints. The medical record lacked evidence of "The Alternatives to Restraint Tried" and evidence the hospital staff followed the policy and procedures.

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/17/14 at 6:00am and expiring 2/18/14 at 6:00am for left and right wrist restraints. The medical record lacked evidence of "The Alternatives to Restraint Tried" and evidence the hospital staff followed the policy and procedures

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/25/14 at 4:00pm. The medical record lacked evidence of "The Alternatives to Restraint Tried" and evidence the hospital staff followed the policy and procedures.

Patient #21's medical record contained a "Restraint Order Sheet" dated 3/1/14 at 6:00am and expiring on 3/2/14 at 6:00am for left and right wrist restraints. The medical record lacked evidence of "The Alternatives to Restraint Tried" and evidence the hospital staff followed the policy and procedures.

Patient #21's medical record contained a "Restraint Order Sheet" dated 3/2/14 at 6:00am and expiring 3/3/14 at 6:00am. The medical record lacked evidence of "The Alternatives to Restraint Tried" and evidence the hospital staff followed the policy and procedures

- Administrative staff B, interviewed on 4/2/14 at 9:05am acknowledged the hospital failed to follow the hospital's policies and procedures for the use of the restraints for patient #'s 18 and 21.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on document review, medical record review and staff interview, the hospital failed to document the patient's response to the restraint for two of two patients with restraints (patient #'s 18 and 21). The hospital's lack of complete documentation for restraints placed the patient at risk for inappropriate restraint use.

Findings include:

- The hospital policy titled "II.K.11.07 Restraints", reviewed on 4/2/14 at 9:50am, directed staff to "II Procedure A. d) h. Documentation: Patient's response to the interventions used..."


- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record revealed mittens (a hand-covering restraint) were applied on 3/22/14 and 3/23/14. The medical record lacked evidence of the patient's response to the restraint.


- Patient #21's medical record, reviewed on 4/2/14, revealed an admission date of 2/11/14 with diagnoses including sepsis (a systemic infection), aspiration pneumonia (an infection caused by foreign material in the respiratory tract).

Patient #21's medical record contained a "Restraint Order Sheet" dated 2/11/14 to 3/3/14 for left and right wrist restraints. The medical record lacked evidence of the patient's response to the restraint.

- Administrative staff B, interviewed on 4/2/14 at 9:05am acknowledged the hospital failed to follow the hospital's policies and procedures for the use of the restraints for patient #'s 18 and 21.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on medical record review, policy review, and interviews a RN (Registered Nurse) failed to a) consistently implement established hospital policies, protocols and procedures to prevent development of pressure ulcers; b) to evaluate the nursing care provided and; c) to evaluate the patient's response to interventions for two of twenty one sampled patients (Patient #1 and #18). This deficient practice places all patients at risk for in adequate care.

Findings include:

- The hospital's policy for skin care protocol, reviewed on 4/3/14 at 11:50am directed, "...all patients have an integumentary assessment completed upon admission and daily...Braden Scale is completed at time of admission and daily...Braden Scale Protocol...less than 16 at risk...inspect skin for signs and symptoms of breakdown at each patient repositioning; note any changes...at risk...place on a pressure reduction or pressure relief device...provide pressure relief to heels while patient in bed..."


- The hospital's policy for pressure ulcer prevention, reviewed on 4/3/14 at 11:50am directed, "...To provide guidelines for the prediction and prevention of pressure ulcers...use pressure reduction device on the bed...reposition every two hours...elevate heels off bed surfaces and use pillows between knees..."

- The hospital's policy for position chart, reviewed on 4/3/14 at 11:50am directed, "...entries will be made each day with the time, position used, and initials of person positioning the patient...broken or sensitive areas are to be identified..."


- Patient #1 admitted on 10/4/13 and discharged on 1/3/14 with diagnoses including intestinal fistula (an opening in the abdomen), chronic stomach ulcers, blood infection, and bacteremia (an infection). The medical record review between 3/31/14 to 4/3/14 evidenced an admission assessment indicating soft mushy heels and a Braden Scale of fifteen (at risk for skin issues). Patient #1's Braden Scale, completed daily (to identify patients with potential for alteration in skin integrity), and placed this patient in the "at risk" category. The admission assessment and subsequent shift assessments completed by RNs identified this patient at high risk for skin issues. Nursing notes on 12/5/13 noted "black right heel" and wound photo documentation on 12/5/13 indicated an area on the right heel length 2 centimeters (cm), width 3cm with no odor or drainage, surrounding skin pink, optifoam (a type of wound dressing) dressing. The documentation lacked a description of the wound bed, if the wound was open or if the skin remained intact. The photo showed a blackened round area on the right heel. Patient #1's nursing plan of care directed elevate heels off mattress, turn, and position every two hours. Patient #1's medical record lacked of evidence the patient had been turned every two hour on 19 different days, lacked evidence hospital staff used a pressure reduction device on the patient's bed, and lacked evidence hospital staff provided pressure relief to heels while the patient was in bed.


Wound Care Nurse staff E interviewed on 4/2/14 at 11:15am, acknowledged patient #1 developed a right heel pressure ulcer, their Braden Scale placed the patient at risk for development of a pressure ulcer, and the medical record lacked evidence patient #1 had been turned or pressure relieving devices had been provided. Staff E acknowledged hospital staff failed to follow hospital polices and the patient's care plan.

- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record contained a "Restraint Order Sheet", reviewed on 4/2/14. The medical record revealed patient #18 had mittens (a hand-covering restraint) applied on 3/22/14 and 3/23/14. Patient #18's medical record lacked evidence a registered nurse supervised, monitored and evaluated patient #18 while in restraints and the need for the uses of the mitten restraints.

Administrative staff B, interviewed on 4/2/14 at 9:05am, acknowledged the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for patient #18.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on medical record review, hospital policy review, and staff interview the hospital failed to ensure nursing staff developed and kept current a nursing care plan for one of one sampled patients who developed hospital acquired pressure sore (Patient #1) and one of two sampled patients with restraints (Patient #18). This deficient practice places all patients at risk for inadequate nursing care.


Findings include:

- The hospital's policy for nursing documentation, reviewed on 4/3/14 at 11:50am directed, "...The RN (Registered Nurse) must identify problems, measurable and objective goals and interventions for the patient. A nursing plan of care is to be established. An interdisciplinary plan of care is done weekly and nursing is to contribute to development and revision..."


- Patient #1 admitted on 10/4/13 and discharged on 1/3/14 with diagnoses including intestinal fistula (an opening in the abdomen), chronic stomach ulcers, blood infection, and bacteremia (an infection). The medical record review between 3/31/14 to 4/3/14 evidenced an admission assessment indicating soft mushy heels and a Braden Scale of fifteen (at risk for skin issues). Patient #1's Braden Scale, completed daily (to identify patients with potential for alteration in skin integrity), and placed this patient in the "at risk" category. The admission assessment and subsequent shift assessments completed by RNs identified this patient at high risk for skin issues. Nursing notes on 12/5/13 noted "black right heel" and wound photo documentation on 12/5/13 indicated an area on the right heel length 2 centimeters (cm), width 3cm with no odor or drainage, surrounding skin pink, optifoam (a type of wound dressing) dressing. The documentation lacked a description of the wound bed, if the wound was open or if the skin remained intact. The photo showed a blackened round area on the right heel. Patient #1's nursing plan of care directed elevate heels off mattress, turn, and position every two hours. Patient #1's medical record lacked of evidence the patient had been turned every two hour on 19 different days, lack evidence hospital staff used a pressure reduction device on the patient's bed, and lacked evidence hospital staff provided pressure relief to heels while the patient was in bed. Hospital nursing staff failed to follow interventions required in patient #1's plan of care and failed to revise the care plan when patient #1 developed a pressure ulcer.

Wound Care Nurse staff E interviewed on 4/2/14 at 11:15am, acknowledged patient #1 developed a right heel pressure ulcer, their Braden Scale placed the patient at risk for development of a pressure ulcer. Wound Care Nurse staff E interviewed on 4/2/14 at 11:15am, acknowledged patient #1 developed a right heel pressure ulcer, their Braden Scale placed the patient at risk for development of a pressure ulcer, and the medical record lacked evidence patient #1 had been turned on 19 different days or pressure relieving devices had been provided. Staff E acknowledged hospital staff failed to follow patient #1 ' s care plan or revise the plan of care when patient #1 developed a pressure ulcer.

- Patient #18's medical record, reviewed on 4/1/14, revealed an admission date of 2/26/14 with diagnoses including a wound. The medical record contained a "Restraint Order Sheet", reviewed on 4/2/14. The medical record revealed patient #18 had mittens (a hand-covering restraint) applied on 3/22/14 and 3/23/14. Patient #18's plan of care lacked evidence of the mitten restraints. The hospital failed to develop and keep current the nursing plan of care.

Administrative staff B, interviewed on 4/2/14 at 9:05am, acknowledged the hospital failed to keep the patient #18's plan of care current or revise the plan of care when patient #18 required restraints.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on observation, staff interview and document review, the hospital's infection control officer failed to develop an active infection control system ensuring hospital personnel followed basic infection control practices during two of two observations in an isolation area, one of two observed glucometer (blood sugar analyzer) tests, and one of five observed medication passes.

Findings include:

- The hospital's policy for isolation precautions reviewed on 4/1/14 at 10:30am directed, "...wear gloves whenever touching patient's skin or surfaces...wear a gown whenever anticipating that clothes will have direct contact with the patient or potentially contaminated environmental surfaces or equipment..."

- Observation on 3/31/14 at 1:00pm of room 511 revealed an isolation sign posted on the door that directed doctors and staff to follow precautions, wear a gown and gloves, when entering the room. Physician staff H, observed in room 511 without the required gown and gloves. When staff H left the room they performed hand hygiene then entered room 510. The door on room 510 revealed an isolation sign posted on the door that directed doctors and staff to follow precaution, wear a gown and gloves, when entering the room. Physician staff H failed to wear a protective gown and gloves to prevent the potential contamination and possible transfer of microorganisms.

Administrative staff B, interviewed on 3/31/14 at 4:15pm acknowledged isolation precautions were required when entering room 510 and 511. Staff B acknowledged the physician failed to wear the required gown and gloves when they entered isolation rooms.

- The hospital's policy for cleaning patient care equipment, reviewed on 4/3/14 at 12:25pm directed, "...Glucometers must be cleaned between each patient..."

- Nursing staff D, observed on 3/31/14 at 1:00pm, performed a glucometer test on patient #4 in room 501. Staff D performed hand hygiene, applied gloves, and completed the blood test, cleaned the glucometer, laid the glucometer on the counter, performed hand hygiene, and left the room. Staff D failed to clean the glucometer after they laid the glucometer on the counter in room 501.

- The hospital policy titled "III.R.18.02 Hand Hygiene", reviewed on 4/3/14 at 12:30pm, revealed "C. Alternatives to hand washing: 3. Decontaminate hands at the following times. b. before gloving, c. after glove removal".

- Patient #14's medical record, reviewed on 4/1/14, revealed an admission date of 3/26/14 with diagnoses including chronic kidney disease, dementia and anemia. Registered nurse I, observed on 4/1/14 at 9:00am, prepared to administer medications to patient #14, staff I washed their hands and turned the water off with their bare hands. Staff I applied protective gloves, applied a medicated skin patch, removed the gloves and failed to perform hand hygiene after removing gloves. Staff I applied another pair of protective gloves administered intravenous medications, removed the gloves and failed to perform hand hygiene. Staff I applied protective gloves, administered fluids and medications through patient #14's feeding tube, removed the gloves and failed to perform hand hygiene. Staff I applied protective gloves, provided care to patient #14's intravenous line, removed the gloves and failed to perform hand hygiene.

- Administrator/registered nurse A, administrative staff B and administrative registered nurse C, interviewed on 4/2/14 at 4:50pm, acknowledged hand hygiene must be performed after removal of protective gloves.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on medical record review, staff interview and document review, the hospital failed to timely evaluate patients discharge needs and coordinate services for four of twenty-one sampled patients (Patient #'s 1, 5, 9, and 10). This deficient practice places patient at risk for ineffective discharge planning.

Findings include:

- The hospital's policy for case management documentation, reviewed on 4/3/14 at 12:15pm directed, "...The case manager will complete the initial evaluation within 72 hours of admission...case management will provide written documentation of case progression, interaction, and communication throughout patient ' s stay in the interdisciplinary progress notes..."

- The hospital's policy for case management protocol reviewed on 4/1/14 at 4:45pm directed, "...Case management will assist patients in understanding their need for continued placement, assess their ongoing needs; collaborate with patients to set achievable goals related to discharge planning and post-discharge functioning..."

- Patient #1 admitted on 10/4/13 and discharged on 1/3/14 with diagnoses including intestinal fistula (an opening in the abdomen), chronic stomach ulcers, blood infection, and bacteremia (an infection). The medical record review between 3/31/14 to 4/3/14 revealed a discharge planning evaluation conducted on 10/9/13, five days after admission. The Case Manager failed to assess patient #1's discharge needs timely to assist patient #1 in understanding their need for continued placement, assess their ongoing needs and collaborate with the patient.

Case Manager staff G interviewed on 4/1/14 at 9:30am acknowledged the discharge planning evaluation on 10/9/13, five days after admission.

- Patient #5 admitted on 11/29/13 and discharged on 12/31/13 with diagnoses of left lower extremity cellulitis (an infection) and possible osteomyelitis infection in the bone). Medical record review on 4/1/14 revealed a discharge planning evaluation conducted on 12/3/13, four days after admission. The Case Manager failed to assess patient #5's discharge needs timely to assist patient #5 in understanding their need for continued placement, assess their ongoing needs and collaborate with the patient.

- Patient #9 admitted on 11/7/13 and discharged on 11/29/13 with diagnoses of right hand cellulitis and lower extremity lymphedema. Medical record review on 4/1/14 revealed a discharge planning evaluation on 11/12/13, five days after admission, indicating the patient's anticipated needs included in-home equipment and home health. The only Case Management note on 11/12/13 at 7:15am indicated discharge planning complete. The Case Manager failed to assess patient #9's discharge needs timely to assist patient #9 in understanding their need for continued placement, assess their ongoing needs and collaborate with the patient.

- Patient #10 admitted on 11/8/13 and discharged on 11/18/13 with a diagnosis of amputation of left second toe with osteomyelitis. Medical record review on 4/1/14 revealed a discharge planning evaluation on 11/12/13, four days after admission, indicating the patient's anticipated needs included in-home equipment and home health. The Case Manager failed to assess patient #10's discharge needs timely to assist patient #10 in understanding their need for continued placement, assess their ongoing needs and collaborate with the patient.

Administrative staff B interviewed on 4/2/14 at 4:30pm acknowledged the hospital failed to evaluate discharge needs and coordinate services within the required 72 hours for patient #'s 5, 9, and 10

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on medical record review, staff interview and document review, the hospital failed to provide ongoing evaluation of discharge planning for six of twenty-one sampled patients (Patient #'s 1, 5, 6, 7, 8, and 9). This deficient practice places patient at risk for ineffective discharge planning.

Findings include:

- The hospital ' s policy for care management protocol reviewed on 4/1/14 at 4:45pm directed, "...The patient and family will be notified of treatment plan including both long and short term goals for their agreement or concerns. Discharge planning will begin during the initial interview with the patient, and will be continued/revised throughout the patient's stay..."

-Patient #1 admitted on 10/4/13 and discharged on 1/3/14 with diagnoses including intestinal fistula ( an opening in the abdomen), chronic stomach ulcers, blood infection, and bacteremia. The medical record review between 3/31/14 to 4/3/14 revealed patient #1's medical record failed to include discharge instruction to the patient/family or the discussion of all discharge needs for patient #1.
Case Manager staff G, interviewed on 4/1/14 at 9:30am, acknowledged the medical record for patient #1lacked discharge instruction to the patient/family and lacked evidence the patient/family received education towards discharge.

- Patient #5 admitted on 11/29/13 and discharged on 12/31/13 with diagnoses of left lower extremity cellulitis (an infection) and possible osteomyelitis (infection in the bone). Medical record review on 4/1/14 revealed a discharge planning evaluation conducted on 12/3/13. The only case management note on 12/3/13 indicated discharge planning discussed with patient. The Case Manager failed to collaborate and evaluate ongoing needs with the patient #5 over their 32-day stay in the hospital.

- Patient #6 admitted on 9/23/13 and discharged on 10/18/13 with diagnoses of post-operative infection and sepsis. Medical record review on 4/1/14 revealed a discharge evaluation on 9/24/13 indicating the patient may require adaptive equipment upon discharge. The only Case Management note on 9/24/13 at 10:10am and 10:20am indicated the Case Manager spoke with the patient about equipment concerns and discharge planning discussed with patient. The Case Manager failed to collaborate and evaluate ongoing needs with the patient #6 over their 26-day stay in the hospital.


- Patient #7 admitted on 11/15/13 and discharged on 12/24/13 with a diagnosis of sepsis due to wound infection. Medical record review on 4/1/14 revealed a discharge planning evaluation on 11/18/13 indicating the patient's anticipated needs included home with family and home health. The only Case Management note on 11/18/13 at 12:15pm indicated discharge planning discussed with patient. The Case Manager failed to collaborate and evaluate ongoing needs with the patient #7 over their 37-day stay in the hospital.


- Patient #8 admitted on 10/7/13 and discharged on 10/31/13 with a diagnosis of status post colectomy (a type of bowel surgery) and sepsis (an infection). Medical record review on 4/1/14 revealed a discharge planning evaluation on 10/9/13 indicating the patient's anticipated needs included in-home equipment and home health. Case Management notes on 10/9/13 at 1:46pm indicated discharge planning discussed. Case Management notes on 10/14/13, 10/15/13, 10/18/13, 10/19/13, and 10/28/13 indicate communication for clinical update/approval with the patient's insurance company. Patient #8's medical record failed to include discharge instruction to the patient/family or the discussion of all discharge needs for patient #8. The medical record lacked evidence of communication with the patient for discharge planning. The Case Manager failed to collaborate and evaluate ongoing needs with the patient #8 over their 25-day stay in the hospital.

- Patient #9 admitted on 11/7/13 and discharged on 11/29/13 with diagnoses of right hand cellulitis and lower extremity lymphedema. Medical record review on 4/1/14 revealed a discharge planning evaluation on 11/12/13 indicating the patient's anticipated needs included in-home equipment and home health. The only Case Management note on 11/12/13 at 7:15am indicated discharge planning complete. The Case Manager failed to collaborate and evaluate ongoing needs with the patient #9 over their 23-day stay in the hospital.

Administrative staff B interviewed on 4/2/14 at 4:30pm acknowledged the medical record lacked evidence the Case Manager provided ongoing evaluation of discharge planning for patient #'s 5, 6, 7, 8, and 9.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on medical record review, staff interview and document review, the hospital failed to provide discharge instructions and discharge education for two of nine discharged sampled patients (Patient #1 and #8). This deficient practice places patient at risk for ineffective discharge.

Findings include:

- The hospital's policy for patient discharge reviewed on 4/1/14 at 4:45pm directed, "...Complete discharge summary sheet. Explain any procedure to be continued at home (dressing changes, diet, medications, and activity limitations, etc.). Have patient/significant other sign form and give one copy to them - retain original white copy for patient records to verify understanding of instructions..."

- Patient #1 admitted on 10/4/13 and discharged on 1/3/14 with diagnoses including intestinal fistula (an opening in the abdomen), chronic stomach ulcers, blood infection, and bacteremia (a type of infection). The medical record review between 3/31/14 to 4/3/14 revealed patient #1's medical record failed to include discharge instruction to the patient/family or the discussion of all discharge needs for patient #1. Hospital staff failed to educate patient #1 or their family about necessary post-hospital care.
Case Manager staff G, interviewed on 4/1/14 at 9:30am, acknowledged the medical record for patient #1lacked discharge instruction to the patient/family and lacked evidence the patient/family received education towards discharge.

- Patient #8 admitted on 10/7/13 and discharged on 10/31/13 with a diagnosis of status post colectomy (a type of bowel surgery) and sepsis. Medical record review on 4/1/14 revealed patient #8's medical record failed to include discharge instruction to the patient/family or the discussion of all discharge needs for patient #8. Hospital staff failed to educate patient #8 or their family about necessary post-hospital care.

Administrative staff B interviewed on 4/2/14 at 4:30pm acknowledged the medical record for patient #8 lacked discharge instruction to the patient/family and lacked evidence the patient/family received education towards discharge.

The hospital reported a current census of 15 patients with an average daily census of 17 patients. Based on medical record review, policy review, and staff interview the hospital failed to reassess and update discharge plans for six of nine discharged sampled patients (Patient #'s 1, 5, 6, 7, 8, and 9). This deficient practice places patients at risk for ineffective discharge planning.

Findings include:

- The hospital's policy for patient and family education, reviewed on 4/3/14 at 11:50am directed, "...When preparing for discharge the patient shall be provided, where applicable, additional resources in the community and any follow-up care that is appropriate by discharge planning..."

- The hospital's policy for case management scope of services, reviewed on 3/31/14 at 4:10pm directed, "...The case management department will employ one Masters in Social Work to meet regulatory requirements..."

- The hospital's policy for post-acute provider case management organization, reviewed on 3/31/14 at 4:10pm directed, "...If there is no Masters in Social Work on staff, the long term acute hospital will have a consulting contract for social work services..."

- The hospital's policy for discharge family conference, reviewed on 3/31/14 at 4:10pm directed, "...The social worker/case manager will arrange a meeting with the family, patient and other community resources prior to discharge...report of conference is written by social worker and signed by the family..."
- Patient #1 admitted on 10/4/13 and discharged on 1/3/14 with diagnoses including intestinal fistula (opening in the abdomen), chronic stomach ulcers, blood infection, and bacteremia. The medical record review between 3/31/14 to 4/3/14 revealed a discharge planning evaluation conducted on 10/9/13 which identified problems for discharge included in-home equipment and need for home health services. Documentation included discharge planning discussed with patient. Case management evidenced discussions with the patient's insurance company with the insurance company approving the patient for 120 days on 10/22/13. On 12/11/13 the insurance representative informed the hospital case manager that the patient's insurance only covered 60 days at the hospital and the patient was informed of the change in coverage. On 12/27/13 the case manager indicated they spoke with the patient and their spouse about arrangements to send the patient home on 1/3/14. The documentation indicated due to the cost of a hospital bed the family refused delivery.

Case Manager staff G, interviewed on 4/1/14 at 9:30am, indicated at the start of care the patient #1's insurance company approved 120 hospital days and on 12/11/13 the insurance representative notified her they had read the insurance plan wrong and the patient #1 only had 60 hospital days. Staff G indicated the patient #1 was already at 69 hospital days. Staff G indicated they spoke with the patient and spouse on 12/27/13 and they voiced concerns since they worked two jobs and they would try to get other family members to help with cares. Staff G acknowledged the medical record lacked reassessment and social service interventions to assist the patient/family when their financial needs changed. Staff G indicated the facility did not employ a social worker but was advertising for that position.

Administrative staff A, interviewed on 4/1/14 at 4:00pm, indicated they felt there was a lot of family dynamics between patient #1 and the spouse causing issues about the patient's goals. The spouse's expectations were the fistula was going to heal and we know this could take years to heal. Staff A did not feel the spouse understood even with education but thought spouse's expectation was the patient would go home and go back to work. There was a lot of frustration between them about when patient #1 could go back to work. Staff A acknowledged patient #1 ' s medical record lacked evidence of social service intervention.

Patient #1's medical record lack evidence of social service intervention to assist the patient/family with community resources and reassessment of their change in financial status.

- Patient #5 admitted on 11/29/13 and discharged on 12/31/13 with diagnoses of left lower extremity cellulitis (an infection) and possible osteomyelitis (infection in the bone). Medical record review on 4/1/14 revealed a discharge planning evaluation conducted on 12/3/13. The only case management note on 12/3/13 indicated discharge planning discussed with patient. The Case Manager failed to reassess patient #5's ongoing needs over their 32-day stay in the hospital.

- Patient #6 admitted on 9/23/13 and discharged on 10/18/13 with diagnoses of post-operative infection and sepsis. Medical record review on 4/1/14 revealed a discharge evaluation on 9/24/13 indicating the patient may require adaptive equipment upon discharge. The only Case Management note on 9/24/13 at 10:10am and 10:20am indicated the Case Manager spoke with the patient about equipment concerns and discharge planning discussed with patient. The Case Manager failed to reassess patient #6's ongoing needs over their 26-day stay in the hospital.

- Patient #7 admitted on 11/15/13 and discharged on 12/24/13 with a diagnosis of sepsis due to wound infection. Medical record review on 4/1/14 revealed a discharge planning evaluation on 11/18/13 indicating the patient's anticipated needs included home with family and home health. The only Case Management note on 11/18/13 at 12:15pm indicated discharge planning discussed with patient. The Case Manager failed to reassess patient #7 ' s ongoing needs over their 37-day stay in the hospital.

- Patient #8 admitted on 10/7/13 and discharged on 10/31/13 with a diagnosis of status post colectomy ( a type of bowel surgery) and sepsis. Medical record review on 4/1/14 revealed a discharge planning evaluation on 10/9/13 indicating the patient ' s anticipated needs included in-home equipment and home health. Case Management notes on 10/9/13 at 1:46pm indicated discharge planning discussed. Case Management notes on 10/14/13, 10/15/13, 10/18/13, 10/19/13, and 10/28/13 indicate communication for clinical update/approval with the patient's insurance company. Patient #8's medical record failed to include discharge instruction to the patient/family or the discussion of all discharge needs for patient #8. The medical record lacked evidence of communication with the patient for discharge planning. The Case Manager failed reassess patient #8's ongoing needs over their 25-day stay in the hospital.

- Patient #9 admitted on 11/7/13 and discharged on 11/29/13 with diagnoses of right hand cellulitis and lower extremity lymphedema. Medical record review on 4/1/14 revealed a discharge planning evaluation on 11/12/13 indicating the patient's anticipated needs included in-home equipment and home health. The only Case Management note on 11/12/13 at 7:15am indicated discharge planning complete. The Case Manager failed to reassess patient #9 ' s ongoing needs over their 23-day stay in the hospital.

Administrative staff B interviewed on 4/2/14 at 4:30pm acknowledged the medical record lacked evidence the Case Manager provided ongoing evaluation of discharge planning for patient #'s 5, 6, 7, 8, and 9.