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Based on a review of facility documentation, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to follow their adopted process related to the Important Message from Medicare (IMM) by ensuring that the patient or patient's representative signed the (IMM) for seven of seven medical records (MR30, MR31, MR32, MR33, MR34, MR35, MR36) and by failing to ensure that the second IMM was provided to all applicable discharged patients.
Findings Include:
Review of facility document Medicare Important Message Process, 7/9/07, " ... The process is mandated by CMS for all patients upon admission as well as at discharge to provide any MC (primary or secondary) patient a Notification of Rights. Responsibilities: Admissions Clerk will deliver the Important Message from Medicare (IM) for the patient to sign by answering the question ... Two copies will print (both need signed) First copy-after signing, belongs to the patient. Second copy-after signing is to be scanned for retention and verification purposes, then sent via TUBE system to the appropriate Unit. If no tube is available, phone the Unit and ask for a tube to be sent down to you. We are not to keep this copy with our records as CMS will audit the Medical Record, not our scanning. Nursing Unit Clerk (Nursing) will receive the IM and place the signed copy on the patient chart (MR Chart). Case Management (CM) will review the daily IM Report, identifying any 'N' ... responses and follow up as necessary (there should be very few of these cases) The 'Y' ... will indicate: The patient signed, received their copy, scanning occurred, IM was tubed to floor, and nursing is placing the IM on the MR. CM will be following requirements of CMS to follow up with patients (within 48 hours of discharge) to have the patient re-sign the original IM (that was placed on the MR Chart). CM will then enter appropriate date for follow up case ... Insurance Verification will be monitoring the ADM chart folders. Any IM's enclosed in the folder will have the assumption the IM's did NOT get sent to the floor for the MR. If one is enclosed, Insurance Verification will ensure it is placed in scanning and then notify ... via Email (copy Patient Access Supervisor as well) that there is an IM needing to be placed on the MR ... Case Management and Patient Access will continue to monitor any deviations as well as negative trends identified and address accordingly."

1) An interview was conducted with EMP2 on June 3, 2014. "There is no formal policy on the IMs. They follow this [above mentioned] process. EMP6 is not forwarding anything to Case Management and Patient Access is now responsible for the IMs.

2) An interview was conducted with EMP6 on June 3, 2014, at 1:30 PM. "There is no folder. The IMs do not get sent to the floor, they are scanned in. We don't really follow that process anymore."

A review of MRs revealed that verbal consent was being obtained even when the patient or their representative was available to sign the IM.

MR30 revealed, "Admit Date 05/10/14 ... Discharge Date 5/23/14, Discharge Time 19:15, ... Neurologically: Patient is awake, alert, and oriented. [Patient] follows verbal commands and has a normal affect. Plan: ... My thoughts as well as the diagnosis were discussed with the patient again ... The Admission Nursing Assessment dated May 10, 2014, at 7:50 PM, ... Able to Write: Yes, ... Communication Barriers: No areas of concern, ... Able To Understand Screening Material: Yes, ... History provided by Patient ... ." The Important Message from Medicare documentation revealed, " ... pt gave verbal for IM rights/[staff initials] 5-10-14 ... Patient gave verbal for IM rights/[staff initials] 5/23/14." In addition there was no time entered following the date on the admission or discharge IMM.

MR31 revealed, " ... Admit Date 05/20/14 ... Discharge Date 5/24/14, Discharge Time 18:41, ... Physical Examination: General: patient is awake, alert, and oriented X 3.. ... Plan: The situation and treatment options were discussed with patient. ... After reviewing the risks, benefits, and alternatives, informed consent was obtained. ... The Admission Nursing Assessment dated May 20, 2014, at 3:03 PM, ... Able To Understand Screening Material: Yes, ... Self Care Barriers: Impaired Mobility, ... ." The Important Message from Medicare documentation revealed, " ... Patient signature ... 5/20/14, ... Patient's niece gave verbal for IM rights/[staff initials] 5/23/14." In addition there was no time entered following the date on the admission or discharge IMM.

MR32 revealed, " ... Admit Date 05/18/14 ... Discharge Date 5/22/14, Discharge Time 18:40, ... Physical Examination: Patient is alert and oriented, not in distress. ... 8. Plan of care discussed at length with patient and patient's family at bedside who agree to the plan of care. ... The Admission Nursing Assessment dated May 18, 2014, at 1:33 PM, ... Able to Write: Yes ... Able To Understand Screening Material: Yes ... History provided by Patient Family Member ... ." The Important Message from Medicare documentation revealed, " ... pt gave verbal/[staff initials] ... 5/18/14, ... Patient gave verbal for MC rights/[staff initials] 5/21/14." In addition there was no time entered following the date on the admission or discharge IMM.

MR33 revealed, "Admit Date 05/29/14 ... Discharge Date 5/2/14, Discharge Time [left blank], ... Physical Examination: Patient is pleasant, alert, oriented, ... 9. ... Findings discussed with patient and patient's daughter at bedside who agrees to the plan of care. ... The Admission Nursing Assessment dated May 29, 2014, at 8:44 PM, ... Able to Write: Yes, ... Able to Understand Screening Material: No ... Reason For Not Completing Literacy Screening: Confusion ... Accompanied by Caregiver ... History provided by Family Member ... ." The Important Message from Medicare documentation revealed, " ... verbal rights to pts daughter [staff initials] 5/29/14, ... pt gave verbal on IM MC Rights [staff initials] 6/3/14." In addition there was no time entered following the date on the admission or discharge IMM.

MR34 revealed, "Admit Date 04/28/14 ... Discharge Date 5/2/14, Discharge Time 14:31 ... The Admission Nursing Assessment dated April 28, 2014, at 4:49 PM, " ... Able to Write: Yes, ... Communication Barriers: Cognitive, ... Able to Understand Screening Material: Yes, ... Accompanied by family member ... History provided by family member ... ." The Important Message from Medicare documentation revealed, " ... pts family gave verbal [no staff initials] 4/28/14, ... Pt gave verbal for IM Rights [staff initials] 5-2-14." In addition there was no time entered following the date on the admission or discharge IMM.

MR35 revealed, "Admit Date 04/27/14 ... Discharge Date 5/2/14, Discharge Time 13:20 ... Neuro: Negative ... ." The Important Message from Medicare documentation revealed, " ... Patient's daughter gave verbal for IM Rights [staff initials] 4/28/14, ... Pt gave verbal for IM Rights [staff initials] 5-2-14." In addition there was no time entered following the date on the admission or discharge IMM.

MR36 revealed, "Admit Date 04/21/14 ... Discharge Date 5/2/14, Discharge Time 1700, ... Neurologic: Patient is alert when awakened. Patient is oriented to the hospital and knows me. ... The Admission Nursing Asessment dated April 21, 2014, at 9:53 PM, ... Able to Write:Yes ... Able To Understand Screening Material: No ... Accompanied By Family Member ... History provided by Family Member ... ." The Important Message from Medicare documentation revealed, " ... Verbal per family on IMMC Rights [staff initials] 4/22/14, ... Patient's wife gave verbal on IM Rights [staff initials] 5-1-14." In addition there was no time entered following the date on the admission or discharge IMM.

An interview was conducted with EMP6 and EMP7 on June 3, 2014, at 1:30 PM. "Sometimes the patients aren't able to sign for themselves. It depends on their condition. They may be in isolation or confused. They may have altered mental status or they may be off the floor for a test or not in their room."

Following review of MR30-MR36 an interview with EMP5 was conducted on June 4, 2014, at 11:30 AM. EMP5 confirmed that, "None of these patients were in isolation."

2) An interview was conducted with EMP7 on June 3, 2014, at 1:30 PM. "If the patients are discharged and we missed giving them an IM, they are not getting the second IM in the mail."

Based on a review of facility policy, medical record (MR), and staff interview (EMP), it was determined that facility staff failed to use the least restrictive measure to protect the patient from harm in one of five medical record reviewed.(MR10)

Findings include:

Review of facility policy, "Restraint and Seclusion" dated November 2013, "Philosophy: ACMH Hospital continues to explore ways to prevent, reduce, and eliminate the use of restraint and seclusion through performance improvement activities. We recognize the use of restraint and seclusion poses an inherent risk to the physical and psychological well-being of both patients and staff and may result in violation of the patient's rights, loss of dignity and even death. Physical/chemical restraint or seclusion will only be used after non-physical alternatives have proven ineffective, unless safety issues demand immediate response. Furthermore, restraint or seclusion will never be used as a means of coercion, discipline, for staff convenience, or to cause a patient pain, discomfort, or harm. ... ."

1. Review of MR10 dated January 21, 2014 at 6:15 PM, revealed that the patient was ordered a chemical restraint, leather restraints to all four extremities, and seclusion, all in the same order.
MR10 revealed a preprinted Restraint/Seclusion Order sheet with the following options indicated: " ... B. Reason for Restraint: ... aggressive/violent behavior ... other elopement risk ... C. Type of Restraint (check all that apply) NOTE: Less restrictive methods should be attempted prior to restraint use. Chemical/Physical Hold. Drug: Ativan. Dose 2 mg. Route IM. Frequency: x1. Drug: Zyprexa. Dose: 10mg. Route: IM. Frequency: x1. ... Point Restraint/Physical Hold ... Leathers x 4 ... Seclusion/Physical Hold ... ."
Physician Notes revealed, "Plan ... Patient began to progressively get more agitated ... began to attempt to rip out their IV and required physical restraints ... applied four-point restraints to the patient's upper and lower extremities and patient was given 2 mg Ativan and 10 mg of Zyprexa IM after patient dislodged the IV. Patient was sedated at that point ... ."

Continued review of MR10 dated January 21, 2014, revealed no documented nursing assessments that the seclusion intervention was still required after the simulanteous intervention of a chemical restraint and the application of the leather restraints to all four extremities.

Based on a review of facility policy, medical record review (MR), and staff interview (EMP), it was determined the facility failed to ensure that the use of restraint or seclusion was in accordance with the order of the physician or other licensed independent practitioner for two of five restraint records reviewed (MR10 and MR12).

Findings include:

Review of facility policy Restraint and Seclusion, revised November 2013, "Purpose: To provide guidelines for the safe use of physical/chemical restraint ... Physician Orders: Appendix B: ... Non-Violent/Non Self-Destructive Behavior: ... Must be renewed each calendar day by attending physician. If restraint or seclusion is discontinued prior to the expiration of the original order, a new order must be obtained prior to reinitiating the use of restraint or seclusion ... Violent/Self-Destructive Behavior: ... Order Renewal by attending physician; Every 4 Hr for age 18 and above; Every 2 hours for ages 9-17 years; Every 1 hour for children under 9 years of age. If restraint or seclusion is discontinued prior to the expiration of the original order, a new order must be obtained prior to reinitiating the use of restraint or seclusion ... ."

1. MR10 revealed a Physician Order dated January 21, 2014, at 6:15 PM, for Seclusion/Physical Hold, and Leathers x 4. There was no Nursing documentation indicating that the physician order was implemented as written related to Seclusion.
Nursing documentation dated January 21, 2014, at 9:04 PM, "Patient transferred to (acute facility) ... with soft restraints x 4 limbs". There was no documented Order for soft restraints on transfer.

2. MR12 revealed a Physician Order dated January 10, 2014, at 7:45 PM, for soft limb restraints - two limbs. Nursing restraint documentation dated January 10, 2014, at 9:00 PM, through January 11, 2014, at 3:25 PM, revealed, "Restraint Type: Mitts with straps."


An interview was conducted with EMP4 on June 3, 2014, at approximately 11:30 AM. EMP4 confirmed that MR10 did not contain documentation for the use of seclusion and no documented evidence of a Physician Order for soft restraints.
EMP4 also confirmed that MR12 contained a Physician Order was for soft limb restraints on two limbs, not mitts with straps as documented.

Based on a review of facility policy, medical records (MR), and staff interviews (EMP), it was determined the facility failed to document that a face to face evaluation was performed within one hour after the initial application of restraints for two of two medical records. (MR10 and MR14)

Findings include:

Review of policy Restraint and Seclusion, revised November 2013, "Philosophy: ACMH Hospital continues to explore ways to prevent, reduce, and eliminate the use of restraint and seclusion through performance improvement activities. We recognize the use of restraint and seclusion poses an inherent risk to the physical and psychological well-being of both patients and staff and may result in violation of the patient's rights, loss of dignity, and even death ... Persons who may perform a one hour face to face evaluation: A physician or Physician Assistant of a Psychiatrist ;Psychiatic Registered Nurses who have received special education according to CMS requirements ... Guidelines For The Use Of Restraint and Seclusion: ... Time Frame for a Face to Face Evaluation ... Violent/Self-Destructive Behavior: ... A face-to-face evaluation must be done within one hour by a physician/LIP or specially educated Registered Nurse from the Psychiatic Registered Nurse from the Psychiatric Unit. If the evaluation was done by a PA or RN, the attending physician must be notified ASAP. After 24 hours, before writing a new order the PA or physician must see and assess the patient ... Documentation of the one-hour face-to-face evaluation when restraint or seclusion is used for violent or self-destructive behavior will include: a) the patient's immediate situation. b) the patient's reaction to the intervention. c) the patient's medical and behavioral condition. d) the need to continue or terminate the restraint or seclusion ... ."


1. MR10 dated January 21, 2014, revealed a Physician Order for restraints at 6:15 PM, for violent/self destructive behavior. MR10 revealed no documented evidence that a face to face evaluation was performed within one hour by physician/LIP or specially educated Registered Nurse.


2. MR14 dated May 5, 2014, revealed a Physican Order for restraints at 10:00 AM, for violent/self destructive behavior. MR14 revealed no documented evidence that a face to face evaluation was performed within one hour by physician/LIP or specially educated Registered Nurse.


3. An interview was conducted with EMP4 on June 3, 2014, at 11:05 A.M. EMP4 confirmed the above findings,"There is no documentation that the face to face was completed."

Based on a review of facility documentation and staff interview (EMP), it was determined that the facility failed to monitor the effectiveness and safety of their use of restraints and seclusion, by failing to identify problem prone areas and to identify opportunities for improvement, as required by their adopted Policy.

Findings include:

Review of Performance Improvement Plan, revised May 2013. "The purpose of this plan is to provide a conceptual framework for promoting and sustaining integrated performance improvement at ACMH Hospital. With the objective of exceeding our customers expectations, this Plan will ensure the improvement of the quality of care and treatment provided by this facility and all contracted Clinical Services ... The Quality and Risk Management Department will combine the functions of Quality and Risk and Management and will report directly to the Chief Medical Officer. The primary function of the Department will be to spur the application of objective data analysis with a patient safety focus, which will allow medical, clinical and support staff to improve the delivery of patient care and service.


Review of Restraint and Seclusion policy revised November 2013. "ACMH Hospital continues to explore ways to prevent, reduce, and eliminate the use of restraint and seclusion through Performance Improvement activities ... ."


1. The Restraint Log for the period of January - May 2014, was requested and reviewed. The Log was noted to monitor restraint usage on the following Nursing Units: 2A, 2D, ED, 3B, 3C, ICU, ARU & PACU. The Quality Indicators that were being monitored are: Trends of Type; Shift; Day of Week; Staff Person Initiating the Restraint. It was noted that all of the Quality Indicators for January - May 2014, were marked as None. Indicating that no trends were identified.


2. A telephone interview was conducted with EMP8 on June 10, 2014, at 11:00AM. "The Restraint Log review does not go to Quality, it stays in the Nursing Department."