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Based on hospital document review, medical record review and staff interview it was determined the hospital failed to ensure the patient or patient's representative has the right to make informed decisions regarding his or her care. This occurred in 1 of 10 medical records reviewed (#5).
Findings:
1. Patient #5 was admitted to the facility on 12/24/2013 from a group home. The patient was accompanied by a care giver from the group home. The patient was incapacitated and could not make self-care decisions.
2. The medical record for patient #5 contained a copy of the informed consent form that was signed by the care giver.
3. The medical record for patient #5 documented that the patient's mother was not happy about the patient being admitted to the hospital and having a surgical procedure without her knowledge. The medical record further documented that the patient ' s mother and the patient's sister have medical power of attorney over the patient's care. This was documented by the Social worker in charge of this case.
4. Staff D was asked if she was aware of the concerns expressed by the patient's mother. Staff D states yes she had talked with the patient's mother. Staff D stated that the Emergency Department admitting RN did not ask the care giver for the patient's advance directive or medical power of attorney, and did not ask the care giver who was the individual designated to make the medical decisions on behalf of the patient. Staff D stated that the admitting RN only asked the care giver who was responsible for making decisions on behalf of the patient.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure family and or legal representatives were notified of the patient's admission when the patient was unable to represent himself/herself. This occurred for Patient #5.

Findings:

Patient #5 was admitted to the emergency room on the night of 12/23/2013, went for emergency surgery and was then admitted to the hospital's intensive care unit on 12/24/2013 at 0345. The record did not demonstrate that the patient's family/legal representatives were notified of the the patient's admission or involved with patient care decisions until 12/26/2013, after the social worker became involved with the patient's case and asked the patient's caregiver it they had legal authority/Power of Attorney to make decisions on behalf of the patient.

This finding was reviewed and verified with Staff A and D on 01/09/2014.

Based on review of hospital documents, policies and procedures and medical records and interviews with hospital staff, the hospital failed to ensure restraints were used only to ensure the immediate safety of patients and staff and were discontinued at the earliest possible time. The hospital does not review and analyze restraint through the quality assessment and performance improvement (QAPI) program to ensure restraints are:
a. Used appropriately and according to hospital policy and physician order;
b. Discontinued as soon as possible.

This was noted in three of four patients' records (Records #2, 5 and 9 of Records #2, 5, 9, and 10), who were restrained and whose medical records were reviewed.

Findings:

The hospital's policy, MHC-PC-IN-0030, required restraints to be used only after least restrictive measures were tried, be used according to orders, renewed every day, and terminated as soon as possible.

1. The surveyors requested to review meeting minutes where restraint use was reviewed. The minutes did not contain evidence of a review and analysis of restraint use to ensure:
a. the least restrictive restraint was utilized,
b. restraints followed physician orders,
c. renewed according to hospital policy, and
d. discontinued as soon as possible.

This finding was reviewed and verified with Staff A on the afternoon of 1/08/2014.

2. Record #2, the patient was admitted on 12/14/2013. The restraints utilized did not follow the physician's orders on 12/23, 26, 29, and 30/2013 and on 01/03, and 06/2014. There were no physician orders for restraints used on 12/16, 18, 20, 24, 25, and 28/2013 and on 01/02/2014. These findings were reviewed and verified with Staff W at the time of record review on the afternoon of 01/08/2014.

3. Record #5, the patient was admitted on 12/24/2013. There were no orders for restraints used on 12/26, 27, and 29/2013 and on 01/01 and 03/2014. These findings were reviewed and verified with Staff W at the time of record review on the morning of 01/09/2014.

4. Record #9, the patient was admitted on 12/24/2013 to intensive care unit and was placed on a ventilator. Restraints were used from 12/24/2013 through 01/08/2014. The record did not contain orders for restraints on 01/06/2014. Nursing documentation did not support the need for restraints. Nursing documentation only documented one occurrence, 12/29/2013, of the patient being agitated. The rest of the time nursing documentation recorded the patient was obtunded, sedated, lethargic,semiconscious,alert and/or confused. None of the documentation described behavior that necessitated the continued use of restraints.

Based on review of medical records and hospital policies and procedures and interviews with hospital staff, the hospital failed to ensure restraints were only used in accordance with physician orders. This occurred in two (Records #2 and 5) of four records reviewed of patients who were restrained.

Findings:

The hospital's policy, MHC-PC-IN-0030, required restraints to be used only after least restrictive measures were tried, be used according to orders, and renewed every day.

1. Record #2, the patient was admitted on 12/14/2013. The restraints utilized did not follow the physician's orders on 12/23, 26, 29, and 30/2013 and on 01/03, and 06/2014. There were no physician orders for restraints used on 12/16, 18, 20, 24, 25, and 28/2013 and on 01/02/2014. These findings were reviewed and verified with Staff W at the time of record review on the afternoon of 01/08/2014.

2. Record #5, the patient was admitted on 12/24/2013. There were no orders for restraints used on 12/26, 27, and 29/2013 and on 01/01 and 03/2014. These findings were reviewed and verified with Staff W at the time of record review on the morning of 01/09/2014.

3. On the afternoon of 01/08/2014, Staff A stated hospital staff had also reviewed the medical records the surveyors chose for review and stated restraint deficiencies were noted.

Based on review of hospital documents, quality improvement meeting minutes, medical records, incident reports and grievances, and interviews with hospital staff, the hospital's quality assessment and performance improvement (QAPI) program failed to identify and analyze process of care issues identified by the surveyors, staff and voiced by patients/patient representatives.

Findings:

1. The QAPI program does not ensure restraints are reviewed and analyzed to ensure patients are restrained only on the order of a physician; restraint use complies with physicians' orders; and patients are released as soon as possible.

2. Incident reports are not analyzed and processed through the QAPI program for identification or opportunities for improvement of patient care/practices. The data provided to the surveyors only showed statistical review.

3. These findings were reviewed and verified with Staff A on the afternoon of 01/08/2014 and reviewed with administrative staff during the exit conference on the afternoon of 01/09/2014.