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Based on medical record review and interview, the facility failed to ensure one (#4) of 3 sampled patients admitted in observation status of a total sample of 10 patients received the Medicare Outpatient Observation Notice.

Findings included:

The review of the Face Sheet revealed Patient #4 was admitted to the facility on 11/02/2017 under observation status. The review of the record failed to reveal any evidence Patient #4 was provided with the Medicare Outpatient Observation Notice.

An interview was conducted with the Case Manager for the Clinical Decision Unit on 1/17/18 at 10:10 a.m. The Case Manager indicated the process for delivering the Medicare Outpatient Observation Notice was the responsibility of the Case Management Department. The Case Manager delivers the notice to the patient, obtains the patient's signature and submits a copy of the document to be scanned into the chart prior to the patient's discharge. The Case Manager indicated nursing staff is responsible for notifying Case Management of an observation status patient's impending discharge.

An interview conducted on 01/17/18 at 11:05 AM with the Quality Resources Manager confirmed the above findings.

Based on review of the medical record, policy and procedures review, and staff interview, it was determined the facility failed to ensure nursing staff assessed the physical safety of a patient in restraints on an ongoing basis for one (#8) of ten medical records sampled.

Findings included:

The face sheet revealed Patient #8 was admitted to the facility on 01/10/2018 via the Emergency Department

The physician orders dated 01/15/2018 at 6:54 PM showed non-violent bilateral soft wrist restraints were ordered to prevent Patient #8 from pulling out tubes and lines. The physician orders included the patient was to be assessed every 2 hours while in restraints.

The review of the facility policy entitled, Restraint Management, #AHS CW OCE 0007, revised 11/07/17, indicated the restrained patient shall be monitored at regular intervals consistent with physician orders, will have documented assessments to assure the patient is free from adverse events, and assessments to determine if restraints are still needed.

The facility policy entitled, Restraint Management Addendum, #GN95150, revised 04/19/17, indicated patients in non-violent (medical) restraints must be assessed every 2 hours, and the assessment should include monitoring, release, range of motion, type of restraint, location of the restraint, hygiene & elimination, nutrition & hydration, positioning, privacy and patient dignity.

The review of nursing documentation from 01/15/18 at 6:00 PM through 01/17/18 at 6:00 AM, revealed 22 out of 22 nursing assessments indicated the patient had ankle restraints and not wrist restraints. The nursing documentation dated 01/16/18 failed to reveal the presence of an assessment at 2:00 PM and 4:00 PM, resulting in a total of 5 hours between assessments.

A tour of the nursing unit where Patient #8 was currently located was conducted on 01/17/18 at 11:12 AM. Observations of Patient #8 conducted at the time of the tour revealed the patient to have wrist restraints in place and not ankle restraints.

An interview with Patient #8's registered nurse (RN) on 01/17/18 at 11:15 AM, revealed the patient had never had ankle restraints on, only wrist restraints, as ordered by the physician on 01/15/2018 at 6:54 PM.

An interview with the Quality Resources Manager on 01/17/18 at approximately 10:20 AM, confirmed the above findings in the medical record of Patient #8