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Based on a review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to provide Medicare beneficiaries with "An Important Message from Medicare (IMM)" prior to discharge for five of five medical records reviewed for IMM (MR2, MR3, MR4, MR5, MR6).

Findings include:

Review on February 9, 2016, of MR2 revealed the patient was admitted to the facility on December 15, 2015, and discharged on December 23, 2015. Further review of MR2 revealed no documented evidence that a second IMM was provided to the patient prior to discharge from the facility.

Review on February 9, 2016, of MR3 revealed the patient was admitted to the facility on December 17, 2015, and discharged on December 22, 2015. Further review of MR3 revealed no documented evidence that a second IMM was provided to the patient prior to discharge from the facility.

Review on February 9, 2016, of MR4 revealed the patient was admitted to the facility on January 5, 2016, and discharged on January 13, 2016. Further review of MR4 revealed no documented evidence that a second IMM was provided to the patient prior to discharge from the facility.

Review on February 9, 2016, of MR5 revealed the patient was admitted to the facility on December 14, 2015, and discharged on December 21, 2015. Further review of MR5 revealed no documented evidence that a second IMM was provided to the patient prior to discharge from the facility.

Review on February 10, 2016, of MR6 revealed the patient was admitted to the facility on January 20, 2016, and discharged on January 28, 2016. Further review of MR6 revealed no documented evidence that a second IMM was provided to the patient prior to discharge from the facility.

On February 10, 2016, surveyor requested facility policy for IMM; none was provided.

Interview on February 10, at 2:00 PM, with EMP2 confirmed there was no documented evidence that a a second IMM was given prior to discharge for each patient in MR2, MR3, MR4, MR5, MR6. EMP2 confirmed the facility did not have a policy for IMM.

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that restraint orders contained the type of mechanical restraints for four of five medical records reviewed for mechanical restraints (MR13, MR14, MR15, MR16).

Findings include:

Review on February 10, 2016, of facility policy "Restraint, Seclusion and Holds," revised October 2015, revealed " ... Physician Orders, Consultation, and Evaluation ... Restraint or seclusion shall be used in emergency situations only and requires an order from a physician ... The physician's order for use of restraint or seclusion will be recorded in the medical record and include ... 3. The type of restraint or seclusion to be used ... Application of Mechanical Restraints ... 2. A staff member will securely hold each of the patient's extremities, as another staff member applies cuffs to each extremity ... ."

Review of facility document "Restraint/Seclusion Physician Order and Assessment," dated September 2014, revealed "Type [with a check box next to] Hold ... Seclusion ... Restraint ... ."

Review on February 9, 2016, of MR13 revealed a "Restraint/Seclusion Physician Order and Assessment" form, dated September 18, 2015, with a check mark at "Type ... 'Restraint.' " There was no documentation in the physician order to indicate if the restraint was for a mechanical two point or four point restraint. Further review of MR15 revealed the patient was placed in restraints. There was no documentation to clarify if the patient was placed in two or four point mechanical restraints.

Review on February 9, 2016, of MR14 revealed a "Restraint/Seclusion Physician Order and Assessment" form, dated November 14, 2015, with a check mark at "Type ... 'Restraint.' " There was no documentation in the physician order to indicate if the restraint was for a mechanical two point or four point restraint. Further review of MR14 revealed the patient was placed in restraints. There was no documentation to clarify if the patient was placed in two or four point mechanical restraints.

Review on February 9, 2016, of MR15 revealed a "Restraint/Seclusion Physician Order and Assessment" form, dated November 17, 2015, with an "X" at "Type ... 'Restraint.' " There was no documentation in the physician order to indicate if the mechanical restraint was for two point or four point restraints. Further review of MR15 revealed nursing documentation that the patient was placed in four point restraints.

Review of February 10, 2106, of MR16 revealed a "Restraint/Seclusion Physician Order and Assessment" form dated September 17, 2015, with a circle around "Type ... 'Restraint.' " There was no documentation in the physician order to indicated if the restraint was for a mechanical two point or four point restraints. Further review of MR16 revealed the patient was placed in restraints. There was no documentation clarifying if the patient was placed in two or four point mechanical restraints.

Interview on February 9, and 10, 2015, with EMP2 confirmed that all patients requiring restraints are placed in four point restraints with the exception of amputees or patient's with fractures. EMP2 confirmed the physicians order for "restraint" does not contain whether the order is for a two or four point mechanical restraints.

Based on review of facility documents and interviews with staff (EMP), it was determined that the facility failed to provide evidence to show that the facility had an effective, data-driven, hospital-wide QAPI (Quality Assessment Performance Improvement) program that involved all hospital departments and services and that focused on indicators related to improved health outcomes.

Findings include:

Review on February 8, 2016 of facility document, "2015 Plan for Performance Improvement and Patient Safety," revealed "... The Patient Safety Council is led by the Patient Safety Officer and CEO. The Medical Director and Director of Nursing are also standing members of the hospital's Patient Safety Council. ... The Patient Safety Council shall: a. Receive and analyze patient safety data that has been assembled from both internal and external sources which relates to near misses, adverse events, adverse drug events hazardous conditions and sentinel events. ... The Safety Committee is co-chaired by the Patient Safety Officer and Facility Safety Officer. Multi-discipline membership includes medical, pharmacy, infection control, and other hospital staff. Community members, who may provide consultation/resources, are invited to participate and assist Safety Committee, when indicated. The Safety Committee includes dedicated review of Infection Control, Environment of Care, and Patient/Staff/Visitor Safety. The Safety Committee shall: a. Coordinate and integrate patient safety related activities to identify and mediate risks, reduce duplications, omissions, inconsistencies and failure to effect change; b. Evaluate and include feedback from patients and staff into plans. ..."

Requests were made to EMP2, on February 10, 2016, for "Patient Safety Council" meeting minutes in order to determine if all incidents and serious events were being reported and investigated; and to evaluate whether data regarding reports of such events and incidents were being tracked and analyzed by the facility, and were being used to improve health outcomes. EMP2 was only willing to provide the serious event identification numbers and the date that it was reviewed by the facility. EMP2 would not provide any additional information or the "Patient Safety Council" meeting minutes in their entirety.
EMP2 was asked to provide alternate evidence to show that the facility measured, analyzed, and tracked all adverse patient events and incidents. None was provided.
The facility failed to provide adequate evidence to show that the facility had an effective, data-driven, hospital-wide QAPI program that involved all hospital departments and services and that focused on indicators related to improved health outcomes.

Based on a review of facility documents and staff interviews (EMP), it was determined that the facility failed to measure, analyze, and track all adverse patient events and incidents.

Findings include:

Review on February 8, 2016 of facility document, "2015 Plan for Performance Improvement and Patient Safety," revealed "... The Patient Safety Council is led by the Patient Safety Officer and CEO. The Medical Director and Director of Nursing are also standing members of the hospital's Patient Safety Council. ... The Patient Safety Council shall: a. Receive and analyze patient safety data that has been assembled from both internal and external sources which relates to near misses, adverse events, adverse drug events hazardous conditions and sentinel events. ... The Safety Committee is co-chaired by the Patient Safety Officer and Facility Safety Officer. Multi-discipline membership includes medical, pharmacy, infection control, and other hospital staff. Community members, who may provide consultation/resources, are invited to participate and assist Safety Committee, when indicated. The Safety Committee includes dedicated review of Infection Control, Environment of Care, and Patient/Staff/Visitor Safety. The Safety Committee shall: a. Coordinate and integrate patient safety related activities to identify and mediate risks, reduce duplications, omissions, inconsistencies and failure to effect change; b. Evaluate and include feedback from patients and staff into plans. ..."

Requests were made to EMP2, on February 10, 2016, for "Patient Safety Council" meeting minutes in order to determine if all incidents and serious events were being reported and investigated; and to evaluate whether data regarding reports of such events and incidents were being tracked and analyzed by the facility, and being used to improve health outcomes. EMP2 was only willing to provide the serious event identification numbers and the date that it was reviewed by the facility. EMP2 would not provide any additional information or the "Patient Safety Council" meeting minutes in their entirety.
EMP2 was asked to provide alternate evidence to show that the facility measured, analyzed, and tracked all adverse patient events and incidents. None was provided.
Interview on February 10, 2016, at 11:20 AM, with EMP2 indicated that they wouldn't provide the "Patient Safety Council" meeting minutes, the committee that is responsible for analyzing patient safety data, in their entirety citing that the information is privileged and confidential.

The facility failed to provide documented evidence to show that the facility measured, analyzed and tracked all adverse patient events and incidents.