HospitalInspections.org

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to ensure a patient's right to have hospital staff and practitioners comply with formulated advance directives for 2 of 2 patients admitted to the SBHU (Pts # 9 and 11).

Findings include:

Review of hospital policy/procedure titled Advanced Directives revealed: "...Admissions and Necessary Documentation: Medical record: a. If the patient has an advance directive in his/her prior...medical record, up-to-date information (including a copy of the document) is placed under the 'advance directive' tab on inpatient records. The directive is placed so it is readily visible to health care providers during the patient's treatment...Medical Record Documentation and Process/Inpatient Hospitalization; Upon arrival of the patient to the nursing unit, nursing personnel admitting the patient to the unit shall review the advance directive status documented on the patient's COA (Conditions of Admission) and the information entered in the EMR (electronic medical record)...a. If the COA indicates the patient has an advance directive, the nurse shall verify a copy of the directive has been placed on the patient's current medical record...."

Review of Pt # 9's medical record revealed:

Pt # 9 is an elderly female and was admitted to the SBHU on 1/19/15.

Pt # 9's medical record contained a form titled Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment with a section Advance Directive Acknowledgement. A check mark was placed in the box next to the statement: "I have executed an advance directive and have supplied a copy to the Facility."

On 1/27/15, Pt # 9's medical record did not contain a copy of her advance directive.

The CNO confirmed during interview conducted on 1/27/15, that Pt # 9's advance directive was not in the current medical record as required by policy/procedure. She obtained the advance directive from the Medical Records Department.

Review of Pt # 11's medical record revealed:

Pt # 11 is an elderly female, and was admitted to the SBHU on 1/12/15.

Pt # 11's medical record contained a form titled Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment with a section Advance Directive Acknowledgement. A check mark was placed in the box next to the statement: "I have executed an advance directive and have supplied a copy to the Facility."

On 1/22/15, Pt # 11's medical record did not contain a copy of her advance directive.

The Director of Behavioral Health confirmed, during interview conducted on 1/22/15, that Pt # 11's advance directive was not in the current medical record as required by policy/procedure. She stated that it was located in Medical Records.

Based on review of hospital policy/procedure, medical record and interview, it was determined that the hospital failed to require that the physician complete and document the one hour face-to-face evaluation of 1 of 1 patient who was restrained for the management of violent or self-destructive behavior (Pt # 1).

Findings include:

Review of hospital policy/procedure titled Restraint and Seclusion revealed: "...The LIP (Licensed Independent Practitioner) responsible for the patient in person (sic) within one (1) hour of the initiation of restraint or seclusion used for violent or self-destructive behavior...The in-person evaluation must include: a. An evaluation of the patient's immediate situation...b. the patient's reaction to the intervention...c. The patient's mental (sic) and behavioral condition...d. The need to continue or terminate the restraint or seclusion...Documentation: Each episode of restraint is documented in the patient's electronic medical record, consistent with policies and procedures...Any in-person medical and behavioral evaluation of the patient in restraint or seclusion for violent or self-destructive behavior...."

Review of Pt # 1's medical record revealed:

Pt # 1 was restrained with bilateral restraints to his upper and lower extremities, for the management of violent behavior, while he was in the ED. Restraints were initiated on 1/14/15, at 1250 and removed at 1640. A physician documented a physical examination at 1245 and documented that the patient was combative with severely slurred speech due to alcohol intoxication. At 1255, the MD documented "...face-to-face evaluation with this patient. He is currently requiring her strength (sic) (restraint) due to his altered mental status and belligerent behavior. Restrain orders have been written for the nursing staff...."

The CNO confirmed, during interview conducted on 1/23/15, that the medical record did not contain documentation of the elements of the one hour face-to-face evaluation required by hospital policy/procedure.