HospitalInspections.org

Based on records reviewed and interview the Hospital failed to follow their policy for invoking a Health Care Proxy for one (Patient #6) of one patient requiring activation of their Health Care Proxy.

The Hospital Policy titled "Advance Directives", dated 9/28/18, indicated that when the Attending Physician determines that a patient lacks capacity to make health care decisions the physician enters the written determination into the medical record with the opinion of the cause and nature of the patient's incapacity, as well as the extent and probable duration.

The Surveyor reviewed Patient #6's medical record at 9:30 A.M. on 5/30/19. Patient #6 was unresponsive and on a breathing machine. Patient #6's Health Care Proxy had signed an informed consent for a procedure; however, there was no written evidence to reflect that the physician had activated Patient #6's Health Care Proxy.

The Surveyor interviewed the Director of Quality at 2:00 P.M. on 5/30/19. The Director of Quality said that physicians should be documenting in the medical record when the Health Care Proxy has been invoked.

Based on observations and interview the Hospital failed to provide privacy for two (Patient #5 and Non-Sampled Patient #1) of eight patients on telemetry (a continuous visual monitor of the heart rhythm).

The Surveyor toured the Intensive Care Unit and interviewed the Nurse Director of the Unit at 8:45 A.M. on 5/30/19. The Surveyor observed the telemetry screen where eight patients were being monitored. The telemetry screen was located in a public walkway that was visible to anyone walking by the screen. Two of the eight patients had their full first and last name posted.
The Nurse Director said the policy of the Unit was to use the Patient's first initial and the first three letters of their last name so as not to disclose a Patient's identity.

Based on observations, records reviewed and interviews, the Hospital failed to identify environmental risk factors to eliminate the potential of ligature related injury to patients on the inpatient psychiatric unit.

On 5/30/19, during a tour of the inpatient psychiatric unit, the Surveyor identified toilet paper holders that were not flush to the wall and posed increased risk for ligature related injury to all patients admitted to the 22- bed unit. The Surveyor also observed a box labeled, Health and Human Services, Department of Mental Health, Complaint Form Mailbox on the wall of the common hallway on the inpatient psychiatric unit that posed increased risk for ligature related injury to all patients admitted to the 22 - bed unit.

The Surveyor interviewed the Director of Psychiatric Services on 5/30/19 at 9:30 A.M. The Director of Psychiatric Services said that he had identified the risks, but he wasn't sure if they were included in the Environmental Safety and Ligature Risk Assessment.

Review of the Hospital's Environmental Safety and Ligature Risk Assessment, dated 4/30/18, did not identify the ligature risks observed on the inpatient psychiatric units.

The Surveyor interviewed Risk Manager #1 on 5/30/19 at 1:15 P.M. Risk Manager #1 said that the current complaint mail box was replaced by a plastic one that kept falling off of the wall when patients shut their doors. She said that the other one had a slanted top to prevent ligature risk.

Based on records reviewed and interview, the Hospital failed to ensure that all security staff whose job requires assistance in the application of restraints, were certified in first aid technique and cardiopulmonary resuscitation.

The Surveyor interviewed the Director of Psychiatric Services and the Clinical Manager on the inpatient psychiatric unit on 5/30/19 at 9:30 A.M. The Director and the Clinical Manager said that the contracted security guards employed by the Hospital for patient safety assist in the application of restraints on the inpatient psychiatric unit.

Review of the personnel records of the Director of Security and Security Officer #1 indicated that neither employee had certification in first aid or cardiopulmonary technique.

The Surveyor interviewed the Director of Quality on 5/30/19 at 1:00 P.M. The Director of Quality said that the security personnel are hired through a contracted service. The Director of Quality said that the contracted company is going to train all of the security personnel in first aid and cardiopulmonary resuscitation in June of 2019.