HospitalInspections.org

N2222

Citation Text for Tag 0043, Regulation FA24


Based on observations, interviews, and document review, the hospital's Governing Body failed to meet the requirements at 42 CFR 482.12 Condition of Participation for Governing Body due to the following:

Findings:

The Governing Body failed to effectively manage the functioning of the hospital to protect patients from harm as evidenced by the (2) two immediate jeopardy conditions identified on 6/16/2016 in the following areas:

1. Failure to be free from seclusion without clinical indications determined by comprehensive and ongoing assessments.

2. Failure to discontinue seclusion at the earliest possible time when documentation reflected no imminent risk of danger.

3. Failure to conduct effective daily environmental safety rounds for identification of hazards associated with ligature risk and patient safety.

Due to the scope and severity of deficiencies detailed under 42 CFR 482.13 Condition of Participation for Patient Rights and 42 CFR 482.41 Condition of Participation for Physical Environment, the Condition of Participation for Governing Body was NOT MET.

Cross Reference: Tags A0115; A0700
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N2222

Citation Text for Tag 0115, Regulation FA24

Kondrat, Paul
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Based on observations, interviews, and document review, the hospital failed to protect and promote patient's rights related to personal privacy and seclusion use.

Failure to protect and promote each patient's rights risks the patient's loss of personal freedom, privacy, dignity, and psychological harm. The cumulative effects of these systemic problems resulted in the hospital's inability to provide for patient safety and protection of personal freedoms.

Findings:

1. Failure to utilize the least restrictive alternatives to seculsion use without a clinical indication determined by comprehensive and ongoing assessments.

2. Failure to release the patient from seclusion at the earliest possible time when documentation reflected no imminent risk of danger.

The cumulative effect of these systemic problems resulted in the hospital's inability to provide for patient safety and protect patient rights.

Due to the scope and severity of deficiencies cited under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET.

Cross Reference: Tags A0143, A0154, A0164, A0167, A0174, A0187, A0196

N2222

Citation Text for Tag 0143, Regulation FA24

Kondrat, Paul
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Based on observation, document review, and review of hospital policies, the hospital failed to protect patients' right to personal privacy for 3 of 3 clinical units.
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Failure to provide for physical privacy risks patients' loss of personal dignity and freedom while sleeping or performing dressing activities.
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Findings:
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1. The hospital's patient rights form (ESH 13-22; Revised 9/23/2015) read in part: "YOU HAVE THE RIGHT: To be treated with dignity, courtesy, and respect . . .To privacy with regard to personal needs."
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2. On 6/14/2016 at 9:40 AM during a tour of clinical unit 1S1, Surveyor #2 observed that patient room doors had no window coverings, allowing any staff member or patient to observe inside the room. There was no place for patients to have privacy when changing their clothes.
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3. On 6/15/2016 at 8:30 AM during a tour of clinical unit 3S1, Surveyor #2 observed that patient room doors had no window coverings, allowing any staff member or patient to observe inside the room. There was no place for patients to have privacy when changing their clothes.
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4. On 6/15/2016 at 8:30 AM, Surveyor #2 reviewed the medical record of Patient #2 and noted the following in a progress note dated 6/3/2016: "Pt (sic) needs reminder to encourage appropriate attire when in bed due to visibility of bed at window in door."
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5. On 6/15/2016 at 8:40 AM during a tour of clinical unit 2S1, Surveyor #5 observed that patient room doors had window coverings located on the outside of the door. The window covering could easily be moved allowing any staff or patient the ability to observe any activity inside the room. The surveyor asked a registered nurse (Staff Member #6) about how the hospital maintains patient privacy. The staff member stated,"We try to give them privacy", but acknowledged that the location of the curtains outside the doors prevented patients from maintaining their own privacy.
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N2222

Citation Text for Tag 0154, Regulation FA24

Kondrat, Paul
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to protect a patient's right to be free from seclusion for 1 of 1 patients reviewed (Patient #1).
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Failure by hospital staff members to use seclusion only as a means to ensure the immediate physical safety of the patient and staff, risks psychological harm, loss of dignity, and personal freedom.
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Findings:
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1. The hospital's policy titled "Behavioral Health Administration Inter-Hospital Policy . . . Policy No. 1.7 . . . Subject: Seclusion and Restraint" (Revised 3/31/2016) read in part: "Seclusion or Restraint is used only in situations where it is required to protect the immediate physical safety of the patient, staff or others and alternative interventions are not effective. . . 3. Seclusion and/or restraint must never be used as a means of coercion, discipline, convenience of staff, retaliation. . ."
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The hospital's policy titled "Interdisciplinary Protocol: Seclusion and Restraint" (Revision 3/2016) under the section "DEFINITIONS" read in part: "Imminent danger/risk: attempted or actual assault or verbal or physical threat that indicates there is an immediate risk of harm, or clear and present danger of harm, to self or others."
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3. On 6/14/2016 at 9:40 AM, Surveyor #2 toured the clinical unit 1S1, reviewed the medical record of Patient #1 and noted the following:
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On 4/18/2016, hospital staff placed Patient #1 in seclusion immediately upon his/her admission to the ward. The hospital staff did not release the patient from seclusion until 6/14/2016, a period of 58 days.
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On 4/18/2016 AM at 12:00 PM, the admitting psychiatrist (Staff Member #1) annotated the following information on the patient's problem list: "pt (sic) well known to staff. Severe Assault Risk. Will observe in seclusion until sure pt is Behaving Himself." On 4/19/2016 at 1:00 PM, Staff Member #1 signed the patient's admission clinical profile psychiatric evaluation. The signed profile read, "The patient is a high risk violent offender. The first part of the treatment plan is to make sure that staff are not injured if at all possible. Initially we will keep the patient in a seclusion room until we can observe him and get an impression about his level of dangerousness at the moment".
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The surveyor reviewed the initial seclusion/restraint record completed at admission. Under the section "Patient Behavior", a staff member checked the box for "imminent harm to others with the description of that behavior annotated as "Newly admit to ESH 1S1. Hx (sic) of assaults here at ESH and report of disruptive behavior. Pt (sic) talking non-sense or non-verbal on assessment." There was no evidence in the patient record to indicate that staff members had first attempted a less restrictive alternative. The staff member left blank the section titled "Less Restrictive Alternatives attempted".
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4. On 6/15/2016 at 1:20 PM, Surveyor #2 interviewed a psychiatrist (Staff Member #2) about the use of seclusion. When the surveyor asked if hospital staff place any patients in seclusion immediately upon admission, Staff Member #2 stated, "They have done it in the past". The psychiatrist indicated that s/he trusts the nursing staff's judgment and "I have never overridden them" with recommendation for seclusion.
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N2222

Citation Text for Tag 0164, Regulation FA24

Kondrat, Paul
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Based on record review, interview, and review of hospital policies and procedures, the hospital staff failed to consider the effectiveness of less restrictive interventions before applying seclusion for 1 of 1 patients (Patient #5).
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Failure to utilize less restrictive alternatives to seclusion puts patients at risk for loss of personal freedom and dignity.
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Findings:
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1. The hospital policy titled "Behavioral Health Administration Inter-Hospital Policy . . . Policy 1.7 . . . Subject: Seclusion and Restraint" (Revised 3/31/2016) read in part: "19. Documentation of restraint of and seclusion in the medical record includes the following: a. Any in-person medical and behavioral evaluation. b. Any alternatives or less restrictive interventions attempted."
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2. On 6/15/2016 and 6/16/2016, Surveyor #6 reviewed the medical record of Patient #5. Patient #5 was admitted on 12/14/2015 and hospital staff placed him/her in seclusion for a total of 73 episodes between their admission date and 5/26/2016. The surveyor reviewed 21 days of seclusion episodes during the months of December 2015, January 2016, and February 2016. Surveyor #6 noted 45 separate periods where the hospital staff failed to complete the section titled "Less Restrictive Alternatives attempted". The surveyor was unable to locate any documentation to indicate that hospital staff considered less restrictive measures before continuing seclusion.
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3. On 6/16/2016 between 10:00 AM and 11:00 AM, Surveyor #5 interviewed the Director of the Adult Psychiatric Unit (Staff Member #5) who confirmed the results of the document review.
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N2222

Citation Text for Tag 0167, Regulation FA24

Kondrat, Paul
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Based on record review, interview, and review of hospital policy and procedures, the hospital failed to ensure staff members followed its policy for seclusion as demonstrated by 2 of 6 patients (Patient #5, #6).
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Failure to follow policies and procedures for patients in seclusion risks psychological harm, loss of dignity, and violation of patient rights.
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Findings:
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1. The hospital's policy titled "Interdisciplinary Protocol: Seclusion and Restraint" (Revision 3/2016) read in part: " Seclusion or restraint will be discontinued as soon as safely possible at the earliest possible time. . .Any doubts about the need for seclusion/restraint are resolved in favor of using a less restrictive alternative. . .h. Hourly Reassessment (RN). The patient is assessed hourly by a RN."
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2. On 6/15/2016 and 6/16/2016, Surveyor #6 reviewed the medical record of Patient #5. Patient #5 was admitted on 12/14/2015 and hospital staff placed him/her in seclusion a total of 73 episodes between the admission date and 5/26/2016. The surveyor reviewed 21 days of seclusion episodes during the months of December 2015, January 2016, and February 2016. Surveyor #6 noted 60 separate events in which the hospital staff failed to complete the section titled "Criteria for removal". The surveyor also noted that hospital staff failed to complete 15 registered nurse hourly assessments as required by hospital policy.
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3. On 6/16/2016 between 10:00 AM and 11:00 AM, Surveyor #5 interviewed the Director of the Adult Psychiatric Unit (Staff Member #5) who confirmed the results of the document review.
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4. On 6/17/2016 between 9:30 AM and 10:30 AM, Surveyor #7 reviewed the medical record of Patient #6 and identified 4 of 8 episodes of seclusion where hospital staff failed to document clinical criteria for discontinuing seclusion.
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N2222

Citation Text for Tag 0174, Regulation FA24

Kondrat, Paul
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Based on record review, interview, and review of hospital policies and procedures, the hospital failed to remove patients from seclusion at the earliest possible time for 5 of 5 patients reviewed (Patient #1, #2, #3, #4, #5).
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Failure to remove patients from seclusion at the earliest possible time puts patients at risk from psychological harm, loss of dignity, and personal freedom.
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Findings:
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1. The hospital's policy titled "Behavioral Health Administration Inter-Hospital Policy . . . Policy No. 1.7 . . . Subject: Seclusion and Restraint", (Revised 3/31/2016) read in part: "14. Seclusion and/or restraint will be discontinued as soon as safely possible at the earliest possible time, regardless of the scheduled expiration of the order. E.g. as soon as the imminent risk to self or others is no longer present or the patient's need can be addressed using less restrictive measures. . . When the clinical assessment indicates the patient will no longer pose an imminent threat, release shall be immediate."
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The hospital's policy titled "INTERDISCIPLINARY PROTOCOL: SECLUSION AND RESTRAINT" (Revision 3/2016) under the section "PROCEDURES" read in part: "K. Seclusion or restraint will be discontinued as soon as safely possible at the earliest possible time, regardless of the scheduled expiration of the order. . .K1. Any doubts about the need for seclusion/restraint are resolved in favor of using a less restrictive alternative. K2. No time limit can be used for how long patients must be calm prior to being released from seclusion/restraint."
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2. On 6/15/2016 at 8:30 AM, Surveyor #2 reviewed the medical record of Patient #2 on clinical unit 3S1 and noted the following:
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Documentation on the seclusion flow sheet indicated that the patient was "resting"," sleeping", or "awake" with no other documented behaviors during the following periods:
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a. From 5/14/2016 at 8:00 PM until 12:00 AM, a period of 4 hours.
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b. From 5/15/2016 at 9:45 AM until 12:45 PM, a period of 3 hours.
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c. From 5/15/2016 at 10:00 PM until 8:30 AM, a period of 10.5 hours.
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d. From 5/16/2016 at 8:00 PM until 5/17/2016 at 1:45 PM, a period of 17 hours and 45 minutes.
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e. From 5/17/2016 at 3:00 AM until 4:00 PM, a period of 13 hours.
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f. From 5/18/2016 at 12:00 AM until 7:15 AM, a period of 7 hours and 15 minutes.
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3. On 6/15/2016 at 11:25 AM, Surveyor #2 interviewed a registered nurse (Staff Member #3) on 3S1 about release criteria for patients who are placed in seclusion. S/he indicated the policy is that if they are sleeping, they do not pose a risk of imminent danger and the door should be unlocked.
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4. On 6/15/2016 at 1:30 PM in the clinical unit 1S1, Surveyor #2 reviewed the seclusion flowsheet records of Patients #1, #3, and #4 and noted the following:
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a. Hospital staff placed Patient #1 in seclusion on 4/18/2016 and did not release him/her from seclusion until 6/14/2016, a period of 58 days. Surveyor #2 noted that 32 of the 36 "seclusion days" records reviewed had documentation of the patient's observed behavior as either "asleep" or awake. The ranges of time when staff members documented the patient's behavior as continuous episodes of "sleeping" or "awake" were between 2 hours and 14 hours with the average at 7 hours. The surveyor was unable to locate any documentation to indicate that Patient #1's behavior reflected an imminent danger to self or to others during those time frames.
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b. Patient #3 was placed in seclusion on 6/6/2016 and was in seclusion at the time of review. Surveyor #2 noted the patient's observed documented behavior of sleeping for the following periods:
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· From 6/7/2016 at 12:00 AM until 6:00 AM, a period of 6 hours.
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· From 6/8/2016 at 9:17 PM until 11:45 PM, a period of 2 hours and 18 minutes.
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· From 6/9/2016 at 12:01 AM until 5:52 AM, a period of 5 hours and 52 minutes
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· From 6/10/2016 at 12:02 AM until 5:46 AM, a period of 5 hours and 44 minutes.
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· From 6/11/2016 at 12:01 AM until 7:46 AM, a period of 7 hours and 45 minutes
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· From 6/11/2016 at 12:01 AM until 7:46 AM, a period of 7 hours and 45 minutes
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· From 6/12/2016 at 12:01 AM until 7:34 AM, a period of 7 hours and 33 minutes.
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· From 6/16/2016 at 12:00 AM until 6:45 AM, a period of 6 hours and 45 minutes.
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· From 6/17/2016 at 12:00 AM until 5:45 AM, a period of 5 hours and 45 minutes.
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· No documentation could be found in the seclusion flowsheet for those periods that indicated Patient #3's behavior reflected an imminent danger to self or to others.
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c. Upon review of the seclusion flowsheet for Patient #4, Surveyor #2 noted similar entries for documented behaviors of sleeping while placed in seclusion.
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5. On 6/16/2016 at 10:20 AM, Surveyor #2 interviewed a clinical nurse specialist (Staff Member #4) about staff training on seclusion and restraints. When asked what clinical criteria warrant the use of seclusion, s/he indicated there must be an immediate danger or imminent threat by the patient to self or others. Staff Member #4 confirmed that if hospital staff recorded a patient's behavior as sleeping, then there is no imminent danger and the seclusion door needs to be unlocked.
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6. On 6/15/2016 and 6/16/2016, Surveyor #6 reviewed the medical record of Patient #5. Patient #5 was admitted on 12/14/2015 and was placed in seclusion a total of 73 episodes between their admission date and 5/26/2016. The surveyor reviewed 21 seclusion episodes during the months of December 2015, January 2016, and February 2016. Surveyor #6 noted 43 separate periods where the hospital staff members documented the patient's behavior as "sleeping" or "resting" with the range from 2 to 8 hours. The surveyor found no evidence in the seclusion documentation to indicate the hospital staff considered removing the patient from seclusion early.
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7. On 6/16/2016 between 10:00 AM and 11:00 AM, Surveyor #5 interviewed the Director of the Adult Psychiatric Unit (Staff Member #5) who confirmed the findings at the time of review.
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N2222

Citation Text for Tag 0187, Regulation FA24

Kondrat, Paul
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Based on record review and review of hospital policies and procedures, the hospital medical staff failed to perform comprehensive re-assessments to support the continued use of seclusion for 3 of 5 patients reviewed (Patient #1, #2, #5).
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Failure to describe clinical indications for seclusion put patients at risk for unnecessary restrictions on personal freedom and potential psychological harm.
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Findings:
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1. The hospital's policy and procedure titled "Behavioral Health Administration Inter-Hospital Policy . . . Policy No. 1.7 . . . Subject: Seclusion and Restraint" (Revised 3/31/2016) read in part: "Every 24 hours, a Physician must see and evaluate the patient before writing a new order for restraint or seclusion. . . Documentation of restraint and seclusion in the medical record includes the following: a. Any in-person medical and behavioral evaluation. . . c. The patient's condition or symptom(s) warranting the use of the restraint or seclusion. . .g. The patient's behavior and staff concerns regarding safety risks to the patient, staff, and others necessitating the use of restraint or seclusion."
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The hospital form 26-138 titled "SECLUSION/RESTRAINT TREATMENT ORDERS" on page 2 read in part: "Describe patient's behavior and physical condition at time of the face-to-face assessment, interventions utilized, and plan to help patient be released as soon as possible: The following elements for the face to face evaluation conducted within 1 hour of initiation of the seclusion/restraint must be conducted: 1. Patient's immediate physical condition. . . 2. Patient's reaction to the intervention. . . 3. Patient's medical and behavioral conditions (example: narrative/justification of Seclusion/Restraint and any physical contraindications)."
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2. On 6/15/2016 at 8:30 AM, Surveyor #2 reviewed the medical record of Patient #2 and noted the following information:
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Hospital staff placed Patient #2 in seclusion after s/he assaulted a staff member on 5/14/2016. The patient remained in seclusion until 5/18/2016, a period of 4 days. The surveyor reviewed the seclusion/restraint treatment orders (page 2) and observed that under item #3, "Patient's medical and behavioral condition", the staff had recorded "N/A" for the following dates and times:
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a. 5/15/2016 at 8:30 AM
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b. 5/15/2016 at 12:00 AM.
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3. On 6/15/2016 at 1:30 PM, Surveyor #2 reviewed the medical record of Patient #1 noted the physician wrote the following information on the seclusion/restraint treatment orders (page 2) under item #3, "Patient's medical and behavioral conditions (example: narrative/justification of Seclusion/Restraint and any physical contraindications)":
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a. 4/24/2016 at 12:00 AM as "N/A"
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b. 4/25/2016 at 8:00 AM as "N/A"
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c. 4/25/2016 at 4:00 PM as "Long Hx (sic) of Serious Assaults"
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d. 4/29/2016 at 8:00 AM as "Long Hx of Assaulting peoples"
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e. 4/29/2016 at 4:00 PM as "Hx of Serious Assault"
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f. 5/4/2016 at 8:00 AM, 4:00 PM, & 12:00 AM as "N/A"
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g. 5/5/2016 at 8:00 AM as "Hx of Assault"
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h. 5/9/2016 at 8:00 AM as "Long Hx of Assault"
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i. 5/10/2016 at 8:00 AM as "Hx of Assault"
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j. 5/10/2016 at 4:00 PM as "Assaultive"
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k. The surveyor noted similar findings on 5/12-13/2016, 5/16-18/2016, 5/22/2016, 5/24-27/2016, 6/8/2016 and 6/13/2016.


4. Surveyor #6 reviewed the record for Patient #5 on 6/15/2016 and 6/16/2016. Patient #5 was admitted on 12/14/2015 and was secluded from his/her admission date until 12/202015. Hospital staff placed the patient in seclusion again on 1/3/2016 through 2/3/2016, 2/6/2016 through 2/9/2016, 2/12/2016, 2/16/2016 through 2/24/2016, 3/5/2016 through 3/16/2016, and 3/26/2016. Record review indicated that hospital staff placed the patient in seclusion 7 additional times between 3/27/2016 and 5/25/2016, a total of 73 times between the patient's admission date and 5/26/2016. The surveyor reviewed a sample of record documentation for 21 episodes during the months of 12/2015, 1/2016, and 2/2016. On 24 occasions, there was no documentation in the physician's order to indicate the behavior that necessitated continued seclusion.

5. On 6/16/2016 between 10:00 AM and 11:00 AM, Surveyor #5 interviewed the Director of the Adult Psychiatric Unit (Staff Member #5) who confirmed the findings at the time of review.
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N2222

Citation Text for Tag 0196, Regulation FA24

Kondrat, Paul
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Based on staff interview, personnel file review and review of the hospital policies and procedures the hospital failed to ensure that staff received ongoing training to include demonstrating competencies involved with the management of patients in seclusion and restraints for 2 of 15 nursing personnel.

Failure to follow policies and procedures regarding care for secluded or restrained patients risks physical and psychological harm, loss of dignity and violation of patient rights.

Findings:

1. The hospital's policy and procedure titled "Eastern State Hospital Interdisciplinary Protocol: Seclusion and Restraint" (Revision 3/2016) read in part: "Staff will be provided education in the use of seclusion or restraint philosophy, application, assessment, and procedures during New Employee Orientation and at least every 3 years thereafter. This orientation/update is to include review of the current seclusion/restraint policy."

2. On 6/16/2016 at 2:00 PM, Surveyor #5 reviewed the human resource files of 15 staff members and noted the following:

a. In 2 of 15 records, the surveyor found no evidence that staff members had completed current restraint and seclusion training. One record indicated the staff member's last completed training occurred in 2012 and the other record indicated the staff member's last completed training occurred in 2010.

3. The Chief Operating Officer reported that the "Education and Training Department" had undergone change, and s/he was uncertain how the hospital monitored staff training.
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N2222

Citation Text for Tag 0283, Regulation FA24

Smith, Marieta
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Based on interview, review of the hospital's quality assessment and performance improvement (QAPI) plan, and review of QAPI program data, the hospital failed to develop and implement systematic action plans for improvement for key quality indicators.

Failure to develop action plans to improve hospital performance places patients at risk of harm related to poor treatment outcomes.

Findings:

1. The hospital's policy entitled "Quality Assessment and Performance Improvement Plan for 2015 - 2018", under "Feedback, Data Systems, and Monitoring" read in part: "The Quality Council has overall oversight of the performance measurement to ensure each committee is functioning according to its scope, and actions are identified and implemented to address opportunities for improvement. When the data indicates actions taken have not been effective, the Quality Council may make further recommendations for the committees to take or may take the issues to the Governing Body or refer to the Executive Leadership Team and/or Medical Executive Committee for further action, depending upon the issue."

2. Interview, policy review, and quality program data review for restraint and seclusion revealed the following:

a. The hospital's policy and procedure entitled "Interdisciplinary Protocol: Seclusion and Restraint" (No policy number; Revised March 2016), under "Daily Seclusion/Restraint Report" read in part: "Data relating to seclusion and restraint utilization and documentation is reported as part of the ESH Quality Assessment/Performance Improvement program. This data is reviewed, analyzed, and action plans developed via the Quality Council and associated subcommittees."

b. On 6/15/2016 from 8:30 AM to 11:30 AM, Surveyor #4 interviewed the Director of Quality Management (Staff Member #7) regarding the hospital's QAPI program. During this interview, Surveyor #4 reviewed data regarding medical record audits conducted from January through April 2016 of patients in restraint and/or seclusion. This review revealed that the hospital had not met its documentation goals, including ensuring that the record included orders written by a physician or licensed independent practitioner; and evidence that the patient was continuously monitored while in seclusion and/or restraints.

The review also revealed that hospital staff had not collected data regarding clinical justification for seclusion. Medical record review performed during the survey process revealed that patients were being secluded without clinical justification.

Cross Reference: A0172

There was no evidence that action plans had been developed to improve documentation for patients in restraints and/or seclusion. The Director of Quality Management confirmed this finding at the time of the review.

3. Interview and quality program data review for active treatment of patients revealed the following:

a. On 6/15/2016 from 8:30 AM to 11:30 AM, Surveyor #4 interviewed the Director of Quality Management (Staff Member #7) regarding the hospital's QAPI program. During this interview, Surveyor #4 reviewed data regarding active treatment of patients on the hospital's 10 inpatient units. Four of the hospital units had not met the active treatment goal of 15 hours per week per patient.

The surveyor found no evidence to support that the hospital had developed action plans to increase active treatment hours for patients on the units who did not meet goal. The Director of Quality Management confirmed this findings at the time of the review.

b. On 6/17/2016 at 8:45 AM during an interview with Surveyor #4, the Active Treatment Director (Staff Member #8) indicated that improvement activities had been ongoing, but a systematic action plan had not been developed and submitted to the Quality Council.

4. Interview and quality program data review for readmission of patients to the hospital within 30 days of discharge revealed the following:

a. On 6/15/2016 from 8:30 AM to 11:30 AM, Surveyor #4 interviewed the Director of Quality Management (Staff Member #7) regarding the hospital's QAPI program. During this interview, Surveyor #4 reviewed data regarding hospital readmissions. Review of performance goals and measures for hospital readmissions for the first quarter of 2016 revealed the hospital did not meet its readmission goals.

b. On 6/16/2016 from 10:05 AM to 11:10 AM, Surveyor #4 interviewed the Director of Social Services (Staff Member #18) regarding the hospital's discharge planning process. During the interview, the director indicated that the hospital tracked readmissions to the hospital within 30 days of discharge. The causes and contributing factors for readmission were analyzed for each individual patient. These causes and contributing factors were not aggregated and analyzed for patterns and trends that might be impacted by changes in the hospital's discharge planning process.

Cross Reference: A0843
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N2222

Citation Text for Tag 0286, Regulation FA24

Smith, Marieta
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ITEM #1 - ANALYSIS OF NEAR-MISS EVENTS

Based on interview, review of hospital policies and procedures, review of Pharmacy and Therapeutics committee meeting minutes, and review of hospital quality documents, the hospital failed to investigate a near-miss event involving medication labeling.

Failure to investigate near-miss events risks recurrence of medical errors that can result in patient harm and death.

Findings:

1. The Behavioral Health Service Integration Administration (BHSIA) policy titled "Adverse Patient Safety Events" (Policy No. 1.5; Effective March 2015), defined a "Close Call" as a "near miss" or "good catch"; a patient safety event that did not reach the patient, but could have resulted in harm. The policy stated that each hospital under BHSIA, including Eastern State Hospital, would have "a mechanism to track no-harm events, close calls, and hazardous conditions." The policy stated "The results of the tracking are used to identify opportunities to prevent harm."

2. On 6/15/2016 at 2:00 PM, Surveyor #4 interviewed the hospital's Risk Manager (Staff Member #9). During this interview, Surveyor #4 reviewed the analysis of a near miss event involving mislabeling medication that occurred in March 2016. Review of this analysis and Pharmacy and Therapeutics committee meeting minutes dated 4/26/2016 revealed the committee determined the error was an isolated event and was "closed". There was no evidence to indicate that the hospital had systematically investigated the error for possible contributing factors.


ITEM #2- ANALYSIS OF PATIENT SAFETY RISKS

Based on interview, review of hospital policies and procedures, and review of hospital quality documentation, the hospital staff failed to follow policies and procedures for investigation of unusual occurences that threatened patient safety.

Failure to investigate events that threaten patient safety risks patient harm and death.

Findings:

1. The hospital's policy and procedure titled "Unusual Occurrence Report (UOR)" (Policy #1.45; Reviewed March 2014), under "II. Scope and Definitions"; "B. Definitions 1. Unusual Occurrences", defined an "Unusual Occurrence" as "b. Events that affect staff's, patients', and visitor's safety/security."

2. On 6/15/2016 at 2:30 PM, Surveyor #4 interviewed the hospital's Risk Manager (Staff Member #9). During this interview, Surveyor #4 reviewed the Root Cause Analysis (RCA) of a patient suicide that occurred in May 2016 (Patient #7). The analysis indicated that on 5/5/2016 the patient accessed a locked room by forcing the lock open using a folded piece of paper. The analysis indicated that the patient entered the room and subsequently hung himself.

3. Review of the patient's medical record revealed an entry made by a hospital social worker that the patient had opened another locked door using a piece of folded paper on 4/18/2016.

4. On 6/21/2016 at 12:00 PM, during an interview with Surveyor #4, the hospital's risk manager (Staff Member #9) indicated that staff members had not submitted an "Unusual Occurrence Report" for the incident regarding Patient #7 entering the locked room on 4/18/2016.


ITEM #3 - ANALYSIS OF ADVERSE EVENTS

Based on interview, review of hospital policies and procedures, and review of hospital quality documentation, the hospital failed to develop action plans for improvement of patient health and safety that included implementation timeframes and associated responsible persons.

Failure to correct conditions and processes within the hospital that threaten patient safety risks patient harm and death.

Findings:

1. The Behavioral Health Service Integration Administration (BHSIA) policy titled "Adverse Patient Safety Events" (Policy No. 1.5; Effective March 2015), defined a "Sentinel Event" as a patient safety event not primarily related to the natural course of the patient's illness or underlying condition that reaches a patient and results in death, permanent harm, or severe temporary harm. According to the policy's definition, suicide of a patient was considered a "Sentinel Event".

The policy stated that all Sentinel Events would be investigated using a Root Cause Analysis (RCA). The policy stated that the RCA team leader would complete and provide a "thorough and timely report following the TCP [The Joint Commission] standards". The policy stated that hospital leadership would "review the report and propose action plans and provide direction as needed, ensuring the action plan specifies the person responsible for each action and the timeframes for achievement."

2. On 6/15/2016 at 2:30 PM, Surveyor #4 interviewed the hospital's Director of Quality Management (Staff Member #7) and Risk Manager (Staff Member #9). During this interview, Surveyor #4 reviewed the root cause analysis (RCA) of a patient suicide that occurred on 5/5/2016 (Patient #7). The RCA did not include that the patient had been previously observed unlocking a door using folded paper. (See Item #2).

Several RCA findings impacted the health and safety of all patients, indicating that immediate action was necessary. Under a section of the RCA entitled "Risk Reduction Plan of Action", the action items did not have identifiable timelines or persons responsible for implementation of the actions.

During the interview, the Director of Quality Management was able to provide evidence that various committees and staff members were working on improvement projects related to the RCA findings. However, the hospital was not systematically tracking these projects through the hospital's quality program.


ITEM #4 - CULTURE OF SAFETY

Based on interview and review of hospital policies and procedures, the hospital failed to develop and implement policies and procedures that supported a "Culture of Safety" within the hospital.

Failure to have policies that support a non-punitive approach to staff reporting adverse patient events, medical errors or "near misses" (close calls), and unsafe situations risks staff fearing to report and failure to correct such events, which can result in patient harm and death.

Findings:

On 6/15/2016 from 8:30 AM to 11:30 AM, Surveyor #4 interviewed the Director of Quality Management (Staff Member #7) regarding the hospital's QAPI program. During this interview, Surveyor #4 reviewed a hospital policy titled "Behavior by Staff that Undermines a Culture of Safety" (Policy #2.20; Reviewed August 2015). The policy identified staff behavior that undermines a Culture of Safety. The policy did not define "Culture of Safety".

During the interview the Director of Quality Management confirmed that the hospital did not have a policy that defined and supported the elements of a "Culture of Safety".
.

N2222

Citation Text for Tag 0503, Regulation FA24

Kondrat, Paul
.
Based on observation, interview, and review of hospital policy and procedures, the hospital failed to assure proper security and control of controlled substances.

Failure to secure controlled substances and other medications risks diversion, theft, and/or tampering which endangers staff and patients.

Findings:

1. Hospital policy titled "Administration of Medications/Treatments" (Policy #806; Revised 6/2012) read in part "4. Do not leave medications unattended unless in a locked medication cart or in the locked medication room. The medication room door is never to be left open or unlocked when the medication nurse is not present."

2. On 6/14/2016 at 3:20 PM, Surveyor #5 observed an open medication room door on the Geriatric Psychiatric Unit Ward D. The room was unoccupied and the door was propped open. The surveyor observed a 2 milliliter injectable vial of lorazepam (a controlled substance, Schedule IV) left on the counter, unattended.

3. The Charge Nurse (Staff Member #12) confirmed these findings at the time of the observation and indicated "we don't do that on days" acknowledging the practice was not consistent with hospital policy.
.

N2222

Citation Text for Tag 0620, Regulation FA24

Giel, Alex
.
Based on observation, interview and document review the hospital failed to ensure that dietary staff members implemented procedures for safe food handling consistent with the Washington State Retail Food Code, Washington Administrative Code (WAC) 246-215.

Failure to implement safe food handling practices for dietary staff members puts patients, staff, and visitors at risk for development of a food-borne illness.

Findings:

1. On 6/15/2016 between the hours of 10:00 AM and 11:00 AM, at the Westlake Campus Cafe, Surveyor #1 observed small plastic cups without handles stored in direct contact with food items. In order to prevent contamination of food, food utensils must be stored with handles above the top of the food and container.

Reference: Washington State Retail Food Code 246-215-03333 (2009 FDA Food Code 3-304.12).

2. On 6/15/2016 between 11:00 AM and 2:00 PM, at the East Lake Campus, Surveyor #1 observed a large container of pasta greater than 4 inches in depth with the lid on. The temperature of the pasta measured at 67.2 degrees Fahrenheit. During an interview with a dietary cook (Staff Member #10) regarding the cooling process, the dietary cook was unable to provide documentation to ensure that the pasta was cooled within the time frame as required per Washington State Retail Food Code.

Reference: Washington State Retail Food Code 246-215-03515 (2009 FDA Food Code 3-501.14)

3. In the Taylor Model 337 Operations Manual, on page 26, it indicated daily cleaning and sanitizing, based on requirements of state or local regulatory agencies.

On 6/15/2016 between 11:00 AM and 2:00 PM, at the East Lake Cafeteria, Surveyor #1 observed a soft serve ice cream machine (Taylor Model 337) on the counter in the service area. The surveyor interviewed the dietary manager (Staff Member #11) about how the dietary staff clean and sanitize the machine. Staff Member #11 provided documentation that indicated staff cleaned and sanitized the machine on the following dates in 2016:

January 4th
January 22nd
February 9th
February 19th
March 25th
April 8th
May 17th
June 3rd

On 6/8/2016, the staff documented the machine as "broken". The frequency of the machine cleaning and sanitizing was not consistent with the manufacturer's instructions for use.

Reference: Reference: Washington State Retail Food Code 246-215-04605 (2009 FDA Food Code 4-602.11)(i)

N2222

Citation Text for Tag 0700, Regulation FA24

Kondrat, Paul
.
Based on observations, document review, and staff interviews, the hospital failed to ensure the condition of the physical plan and the overall hospital environment was maintained in such a manner that the safety and well-being of patients was protected.

Failure to maintain a safe and secure patient environment risks patient safety and protection from harm.

Findings:

Failure to conduct effective daily environmental safety rounds for identification of hazards associated with ligature risk and patient safety.

Due to the scope and severity of deficiencies cited under 42 CFR 482.41, the Condition of Participation for Physical Environment was NOT MET.

Cross Reference: Tags A0701
.

N2222

Citation Text for Tag 0701, Regulation FA24

Giel, Alex
.
Based on observation, review of hospital policy, and document review, the hospital failed to provide an environment that was conducive to the safety of its psychiatric patient population.

Failure to provide a safe environment placed patients at risk of harm to self and or others in the facility.

Reference: National Association of Psychiatric Health Systems "Design Guide for the Built Environment of Behavioral Health Facilities" (edition 7.1, April 2016) Subtitled, "Construction and Materials Considerations", (page 27): "J. Window-covering hardware 1. Mini-blinds mounted between layers of safety glass200 are preferred because they are not accessible to patients. Care should be taken to assure that any exposed devices to control the tilt of the blinds not create a potential ligature attachment point." On page 28, (4) Cabinet pulls should be either recessed, with no protruding openings or of a closed ligature resistant type.460

Findings:

1. In review of the hospital's policy and procedure titled, "WARD CHECKS" (Last Revised 4/16) on page 3 subtitled "GPU ADDENDUM" part c. stated, "Routine checks of the ward environment are conducted hourly on the ward/shift specific patients check sheets (appendix c), according to unit specific standards. The specific unit standards are stated in Appendix F. Appendix F subtitled, "Routine Environment Check Standards for GPU" stated the following environmental checks: All entrances/exits are secure; All patient rooms, hallways, and common areas are visually inspected, free of safety hazards, and egresses unobstructed; All locked doors with AA key are opened, visually inspected and secured; Patient phone and phone cords are intact; Non-permeable linen bags are secured behind locked doors and no garbage liners are unattended.

2. In the policy and procedure referenced above "Ward Check" was identified as an interim measure/plan of action in the "Annual Risk Assessment". The hospital failed to include the identified environmental risks in the "Ward Check" document.


3. On 6/16/2016 between 4:20 PM and 5:35 PM, Surveyor #1 and Surveyor #5 toured the West Lake Geriatric Psychiatric Wards B, D, E, D, and the Habilitative Mental Health Unit (HMH). During the tour, Surveyor #1 and Surveyor #5 observed, weight-bearing hooks attached to window frames and loop-able handles on closet doors in 52 out of 52 patient rooms. Surveyor #1 observed two patients (Patient #8 and Patient #9) on suicide obsevation, one each in Ward E room 216 and Ward B room 108. Both rooms contained ligature risk items including weight-bearing window frame hooks and closet handles. The hospital failed to identify and include these items in the hospital annual risk assessment.

4. On 6/16/2016 between 4:20 PM and 5:35 PM, Surveyor #1 and Surveyor #5 toured the West Lake Geriatric Psychiatric Wards B, D, E, and the Habilitative Mental Health Unit (HMH). During a tour of ward E, Surveyor #1 observed plastic hangers hanging in the closet of patient rooms 211, and 209. After review of the hospital annual risk assessment, the hospital identified coat hangers as a level 3 intermediate risk item for Ward E. The corrective plan of action for these items stated in part, "hospital wide hourly environmental checks. . . staff are required to visually verify the location and condition of each patient and document findings." This information was not included in the "Ward Check" policy and procedures.

N2222

Citation Text for Tag 0710, Regulation FA24

Kondrat, Paul
.
Based on observation, interview, and document review, the hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association
(NFPA), 2000 edition.

Findings:

Refer to the deficiencies written on the ACUTE CARE HOSPITAL MEDICARE LIFE SAFETY inspection reports.
.

N2222

Citation Text for Tag 0724, Regulation FA24

Mahoney, Lisa
.
Based on observation, interview and review of hospital policies and procedures, the hospital failed to maintain patient care supplies in a manner that prevented storage and use beyond the manufacturer's designated expiration date.
.
Failure to ensure patient care supplies do not exceed their expiration dates risks deteriorated and contaminated supplies being available for patient use.

Findings:

1. In the hospital policy titled "Monthly Tracking, (Revised 2/2016) it stated in Appendix A, "Monthly Tracking, Description of Expected Conditions", under Exam Room," Supplies not outdated". In the same document, under Appendix F, "Dental Monthly Tracking, Description of Expected Conditions", under Operatory and Storage Areas, "There are no expired supplies".

The hospital policy and procedure titled "Blood Glucose Monitoring (Point of Care)" (Policy # 111.118, Revised 12/13) stated in part, "Safety Factors: . . . 7. Glucose control solutions are dated when opened and must be stored at room temperature. Glucose control solutions are stable for 90 days after opening or until the expiration date, whichever comes first."

2. On 6/14/2016 at 9:15 AM during a tour of ward D, Surveyor #5 with a registered nurse (Staff Member #12) inspected exam room D227. The surveyor observed blood draw equipment which included 2 orange topped vacutainers with an expiration date of 3/2016, 3 blue topped blood vacutainer with an expiration date of 4/2016, and 5 yellow topped vacutainers with an expiration date of 4/2016. Staff Member #12 reported that s/he was unaware of who was responsible to monitor the outdated supplies.

3. On 6/14/2016 at 1:00 PM, Surveyor #7 inspected the medication room of ward B and examined an Accu-Check (a blood glucose monitoring device) machine which included a glucose control solution which an expiration date of 4/2016. The Charge Nurse (Staff Member #13) discarded the solution at the time of the observation, and acknowledged that the solution should not be available for use.
.
4. On 6/14/2016 at 1:05 PM, Surveyor #7 found a vial of Hemo-cult (a test used to detect blood in feces) developer with an expiration date of 1/2016 in the medication room of ward B. The Charge Nurse (Staff Member #13) discarded the item at the time of the observation, and acknowledged that the bottle should not be available for use.

5. On 6/14/2016 at 3:45 PM in the 2N1 Medication room, Surveyor #3 observed empty syringes with an expiration date of 4/2016.

6. On 6/15/2016 at 8:30 AM in the 3S1 medication room, Surveyor #2 found six 5- micron particulate ampule filter straws with an expiration date of 9/2008.
.
7. On 6/16/2016 at 11:15 AM in the nursing overstock room, Surveyor #3 observed a box of vacutainers with an expiration date of 10/2015 and a box of miscellaneous sterile supplies with expiration dates as early as 2006. Surveyor #3 interviewed a Central Supply Technician (Staff Member #14) who indicated that no one had responsibility for checking for outdated supplies in the room.
.

N2222

Citation Text for Tag 0726, Regulation FA24

Mahoney, Lisa
.
Item #1- Air Balances

Based on observation, the hospital failed to maintain ventilation according to industry standards.

Failure to maintain ventilation in soiled work areas puts patients, staff and visitors at risk from airborne contaminants.

Reference: Table 7-1 Design Parameters from ANSI/ASHRE/ASHE, Standard 170-2008.
(American National Standards Institute/ American Society of Heating, Refrigerating and Air-Conditioning Engineers/American Society for Healthcare Engineering)

Findings:

1. On 6/15/2016 between 10:00 AM and 11:00 AM, Surveyor #1 used a lightweight string to determine the airflow between the soiled/decontamination room and the adjacent corridor. The airflow was positive to the corridor rather than negative as required by industry standard.

2. On 6/16/2016 at 11:30 AM, Surveyor #3 toured the soiled laundry holding areas on the basement level and the Adult Psychiatric Unit. The surveyor used a lightweight string to determine the airflow between the rooms and the adjacent corridor. The airflow was positive to the corridor rather than negative as required by industry standard.

Item #2- Lighting

Based on observation, the hospital failed to maintain adequate lighting in patient care areas.

Failure to maintain adequate lighting in patient care areas puts patients and staff at risk of harm due to lack of security in a high-risk location.

Finding:

On 6/14/2016 at 3:30 PM, Surveyor #3 observed burned out light fixtures in shower rooms on 2 North (215 and 231).
.

N2222

Citation Text for Tag 0747, Regulation FA24

Williams, Joyce
.

Based on observation and interview, the hospital failed to clean patient care areas in a manner that maintained compliance with national guidelines for cleaning and disinfection of health care facilities.

Failure to employ cleaning processes consistent with national guidelines puts patients, visitors and staff at risk of communicable diseases.

Reference: Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashford D, Besser R,
Fields B, McNeil MM, Whitney C, Wong S, Juranek D, Cleveland J. Guidelines for environmental infection control in health-care facilities. Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Chicago IL; American Society for Healthcare Engineering/American Hospital Association; 2004.

On Page 74 under "Cleaning Housekeeping Services" it stated, "Application of contaminated cleaning solutions, particularly from small-quantity aerosol spray bottles or with equipment that might generate aerosols during operation, should be avoided, especially in high-risk patient areas. Making sufficient fresh cleaning solution for daily cleaning, discarding any remaining solution, and drying out the container will help to minimize the degree of bacterial contamination.Containers that dispense liquid as opposed to spray-nozzle dispensers (e.g., quart-sized dishwashing liquid bottles) can be used to apply detergent/disinfectants to surfaces and then to cleaning cloths with minimal aerosol generation. A pre-mixed, "ready-to-use " detergent/disinfectant solution may be used if available."


Findings:

1. On 6/14/2016 at 9:55 AM, Surveyor #3 interviewed a member of the housekeeping staff (Staff Member #15) about the hospital's cleaning process for patient bathrooms. While s/he described the process, the surveyor observed Staff Member #15 using a spray bottle to apply the peroxide-based disinfectant to the environmental surfaces. The staff member explained that s/he sprays down all the environmental surfaces in the bath/shower room.

2. On 6/14/2016 at 1:15 PM, Surveyor #7 inspected the medication room on ward B. The surveyor noted the sink was dirty, with a ring of white material near the top of the sink. Additionally, there was a brush that appeared to be a nail brush, sitting near the faucet in standing water.

3. On 6/14/2016 at 1:45 PM, Surveyor #4 observed and interviewed a licensed practical nurse (Staff Member #16) while the nurse prepared medication for administration to patients. The nurse removed the medications from their unit dose packaging while sitting at a computer at the unit's nurse's station. The nurse did not prepare the medications for administration in a clean area.

4. On 6/15/2016 at 9:30 AM, Surveyor #7 observed a registered nurse (Staff Member #17) complete a medication pass. S/he did not disinfect the medication cart or the keyboard prior to returning it to the medication room.
.

N2222

Citation Text for Tag 0749, Regulation FA24

Giel, Alex

.
Based on observation and document review, the hospital failed to ensure that staff members followed manufacturer's instructions for use when reprocessing dental instruments.

Failure to follow manufacturer's instructions for sterilizing instruments puts patients and staff at risk for infection.

Reference: Sterilising (sic) with PeelVue+ (Trademark) Sterilisation Pouches Guidelines and Validation Instructions; Dental Office QMS Support Copyright 2014, Page 6; Subtitled, "Defining the right pouch size" Stated, "Select the right pouch size for the product(s) to be sterilised and make sure the sterilisation pouch is loaded to only three-quarters of its volume. If in doubt, select the next largest PeelVue+ sterilisation pouch

Findings:

On 6/15/2016 at 9:20 AM Surveyor #1 observed 10 instruments in a ready for use peel pouch in the dental department. After review of manufacturer's instruction for use, it was determined that the number of instruments in the pouch exceeded the maximum "three-quarters volume" size of the pouch.
.

N2222

Citation Text for Tag 0810, Regulation FA24

Smith, Marieta
.
Based on interview and medical record review, the hospital staff failed to verify post-discharge living arrangements to ensure that patients have access to a safe and appropriate living environment for 1 of 6 patients reviewed (Patient #10).

Failure to verify that patients are discharged to a safe and appropriate living environment risks adverse patient outcomes and hospital readmissions.

Findings:

On 6/16/2016 at 10:50 AM, Surveyor #4 interviewed the hospital's Director of Social Services (Staff Member #18) regarding the hospitalization and subsequent discharge of Patient #10. The interview and review of the patient's medical records revealed the patient's discharge plans included transfer of the patient to a transitional housing facility. On the day of discharge, the staff failed to verify the housing facility's acceptance of the patient. After discharge, the housing facility did not accept the patient as a resident. The patient was subsequently taken to to his/her mother's residence without arrangement prior to discharge.
.

N2222

Citation Text for Tag 0811, Regulation FA24

Smith, Marieta
.
Based on interview and medical record review, the hospital failed to ensure that the patient's family was involved with discharge arrangements to allow patients access to a safe and appropriate living environment, as demonstrated by 1 of 6 patients reviewed (Patient #10).

Failure to discuss discharge arrangements with persons acting on the patient's behalf risks adverse patient outcomes and hospital readmissions.

Findings:

On 6/16/2016 at 10:50 AM, Surveyor #4 interviewed the hospital's Director of Social Services (Staff Member #18) regarding the hospitalization and subsequent discharge of Patient #10. The interview and review of the patient's medical records revealed the patient's discharge plans included transfer of the patient to a transitional housing facility. On the day of discharge, the living arrangements were not verified. After discharge, the housing facility did not accept the patient as a resident. The patient was subsequently taken by hospital transportation staff to his/her mother's residence without arrangement prior to discharge. The patient's mother was not involved in the discharge planning process.
.

N2222

Citation Text for Tag 0820, Regulation FA24

Smith, Marieta
.
Based on interview and medical record review, the hospital staff failed to provide all patients with discharge instructions, including clear indications of changes from the patient's pre-admission medications for 6 of 6 patients reviewed (Patients #10, #11, #12, #13, #14, #15).

Failure to identify clearly any changes in the patient's medication regimen risks adverse outcomes related to incorrect dosages and/or medication types.

Findings:

1. On 6/17/2016 from 9:15 AM to 11:10 AM, Surveyor #4 reviewed the medical records of six patients who had been discharged from the hospital within the past five weeks. The record review revealed the following:

a. The medical records of Patient #11 did not include evidence that the patient had received written discharge instructions.

b. The medical records of Patients #10, #12, #13, #14, and #15 indicated that the patients' medication regimen had changed during their hospitalization. Copies of written discharge instructions in the patients' medical records did not clearly inform the patient which medications and/or which medication dosages had changed.

2. During an interview at the time of the record review, the Director of Social Services (Staff Member #18) and the Director of Medical Records (Staff Member #19) confirmed the findings above.
.

N2222

Citation Text for Tag 0837, Regulation FA24

Smith, Marieta
.
Based on interview and medical record review, the hospital failed to provide evidence that necessary medical information was sent to healthcare providers caring for patients in the community prior to their first post-discharge appointment, as demonstrated by 5 of 6 patients reviewed (Patients #11, #12, #13, #14, #15).

Failure to provide medical information to community healthcare providers impairs continuity of care, and risks adverse patient outcomes and hospital readmissions.

Findings:

1. On 6/17/2016 from 9:15 AM to 11:10 AM, Surveyor #4 reviewed the medical records of six patients who had been discharged from the hospital within the past five weeks. The medical records of Patient #11, #12, #13, #14, #15 did not include evidence the hospital sent medical information regarding the patients' admissions to the healthcare providers caring for patients in the community prior to their first post-discharge appointment.

2. During an interview at the time of the record review, the Director of Social Services (Staff Member #18) indicated that information regarding transmission of this information was kept by the patient's social worker in a separate file and was not documented in the patient's medical record.
.

N2222

Citation Text for Tag 0843, Regulation FA24

Smith, Marieta
.
Based on interview and review of data regarding hospital readmissions, the hospital failed to aggregate and analyze hospital readmission data to determine if readmissions were related to ineffective discharge planning.

Failure to perform analyses on the hospital readmissions impairs the hospital's ability to improve its discharge planning process and reduce the risk of patient readmissions.

Findings:

1. On 6/15/2016 from 8:30 AM to 11:30 AM, Surveyor #4 interviewed the Director of Quality Management (Staff Member #7) regarding the hospital's QAPI program. During this interview, Surveyor #4 reviewed data regarding hospital readmissions. Review of performance goals and measures for hospital readmissions for the first quarter of 2016 revealed the hospital did not meet its readmission goals.

2. On 6/16/2016 from 10:05 AM to 11:10 AM, Surveyor #4 interviewed the Director of Social Services (Staff Member #18) regarding the hospital's discharge planning process. During the interview, the director indicated that the hospital tracked readmissions to the hospital within 30 days. The hospital analyzed the causes and contributing factors for readmission for each individual patient. The hospital failed to analyze the data in aggregate to identify patterns and trends that might be impacted by changes in the hospital's discharge planning process.

Cross Reference: A0283
.