HospitalInspections.org

Based on observations, interviews, and document review in several outpatient settings from 1/6/16 through 1/8/16, it was determined that the documents provided to patients in all outpatient units when registered do not consistently contain the necessary addresses/contact information regarding how and with whom to files complaints or grievances with the hospital.


In the outpatient infusion center on 1/6/16, the registration representative was interviewed and asked to demonstrate the registration process for new patients. Forms were reviewed that a new patient would receive on registration. The only information provided that would identify who a patient would contact to file a complaint was on the " Notice of Privacy Practices " form, and contained the name and address of the Department of Health and Human Services, and specifically referenced privacy and HIPAA concerns. No contact information was provided for either the hospital complaint department or the State agency.

During observations in the outpatient perinatal center on 1/6/16 and the outpatient rehabilitation center on 1/8/16, it was determined that outpatients registering at these centers received the same (accurate and complete) information on rights and complaints/grievances as hospital inpatients.

Giving outpatients in some areas inconsistent and inaccurate information regarding rights and filing grievance fails to meet the requirement for fully informing all patients of their rights.

Based on a review of 11 closed records on 1/8/16, it was determined that, for one patient, the hospital was using a surrogate decision maker in the absence of either a healthcare power of attorney, or certificates indicating the patient lacked capacity to make informed decisions.

Patient #3 was an elderly patient admitted from home in November 2015. According to the history and physical examination, the patient suffered from dementia and the daughter was the primary historian. The daughter continued to act as the surrogate decision maker throughout the patient's hospitalization, including making discharge decisions. No healthcare power of attorney or advance directive naming the daughter as the healthcare decision-maker was found on the chart. In addition, the patient had not formally been certified as lacking capacity to make decision.

The hospital policy for informed consent (#PR 4) states that the attending physician may certify lack of capacity. However, State law specifies that the patient must be examined by two physicians before certification of incapacity.

Failure to follow the process for determining a patient's capacity for decision-making prior to allowing a surrogate decision maker circumvents the patient's rights to fully participate in his or her own care.

Based on a review of 37 open and 11 closed medical records, it was determined that one patient was not released from a seclusion room at the earliest possible time and was prevented from leaving the seclusion room when his symptoms no longer warranted seclusion.


On 11/19/2015, patient #2 requested to be allowed to use the quiet room (voluntary use of a seclusion room with the door open) due to increasing agitation with threats of harm to others. When the patient's behavior became more violent, staff closed the door and commenced seclusion at 0900.


Documentation revealed a 4-hour order for seclusion, however, patient #2 was noted on 15-minute documentation to be cooperative by 0945, and asleep by 1000. An RN narrative progress note of 1015 revealed in part, "At 1000, writer reassessed pt. (patient) who had been lying quietly on the mat. [Patient] was calm and able to engage in conversation. [Patient] told writer that he/she was no longer having violent intrusive thoughts, and AH (auditory hallucinations) were now manageable. Writer explained that the door would be opened for ODS (Open Door Seclusion) for a 1 hour period, at which time we would reassess if seclusion would be continued, or discontinued. [Patient] stated understanding and was agreeable to same..." Of note, the hospital policy "Restraints and Seclusion," has no provision for anything called "open door seclusion."


According to the Nurses aide's 15-minute documentation and the RN progress note, patient #2 met behavioral criteria for release at 1000 as he no longer represented an imminent danger to himself or others. However, patient #2 was prevented from leaving the seclusion room for another hour.

Based on a review of hospital Restraint & Seclusion policy on 1/7/16, it was determined that the policy fails to meet standards by allowing physicians to perform a face-to-face within 24 hours for patients who are released from restraint and seclusion before one hour has elapsed.

According to hospital policy, physicians are the only designated clinicians who conduct face-to-face evaluations. The hospital policy "Restraint and Seclusion" (revised 4-2015) reads in part D, "If the individual is no longer in restraint or seclusion within the first hour, the physician conducts an in-person evaluation of the individual within 24 hours of the initiation of restraint or seclusion."

Face-to-face evaluations must be done within one hour of the initiation of restraint or seclusion regardless of length of time a patient is actually in restraint or seclusion. While no examples that met this set of circumstances were found in the five restraint records reviewed, the policy leaves open the possibility that a patient exhibiting a behavioral crisis and placed in restraints or seclusion for less than one hour may not be assessed by a physician within the hour as required.

Based on a review of 37 open and 11 closed medical records, it was determined that one patient had observation flow sheets present on the record that were incomplete and inconsistent with the rest of the nursing documentation.


Patient #1 was admitted in early December 2015 from a group home with a new onset of violent behavior. Patient #1 remained in the hospital during the survey due to difficulty placing the patient in an appropriate facility. For the safety of the patient and others, patient #1 has had a sitter or a nurse's aide performing observations at the bedside 24/7 since admission. The form for recording this 24 hour observation of behavior is entitled "Constant & Suicide Observation 15 Minute Checks" and has directions to fill out the Type of Observation (Sitter Observation, Suicide Observation, or Restraint Observation) and then a box to choose the type of restraints (1-3 Wrist/ankle Restraints, Bilateral Freedom Splints, 4 Side Rails, etc.). A review of the form filled out for 57 shifts shows over 40 shifts in which the type of restraints is blank, and over 30 shifts when the type of observation is blank. A spot check of the nursing documentation (the restraint flow sheet) shows that the patient was often in two point wrist restraints for non-violent behavior during the shifts in which the restraint type was left blank.


Since these forms are kept at the bedside and are made a part of the permanent medical record after discharge, the failure to fill them out completely means that there is incomplete information available at the bedside, and then contradictory information in the permanent medical record.

Based on observations and staff interviews done in the outpatient Digestive Disease Center (DDC) on 1/7/16, it was noted that used endoscopes are transported through the unit on an open cart covered by a paper and plastic barrier (chux). According to an interview with staff on 1/7/16, the DDC uses hard closed cases to transport endoscopes to and from other units in the hospital, and they had recognized their mode of transport within the DDC was problematic and had ordered cases.

Later in the survey a second observation was made of the operation of the DDC on 1/8/16, it was noted that the staff were using the new covered cases to transport dirty endoscopes.