HospitalInspections.org

Based on review of hospital policies/procedures, hospital documents, medical records, and interviews, it was determined the hospital failed to protect and promote each patient's rights as evidenced by:

(A131) failing to ensure that the patient or his/her representative make informed decisions regarding the patient's care, including being able to request or refuse treatment;

(A145) failing to assure that a patient has the right to be free from all forms of abuse or harm;

(A166) failing to require that the use of restraint be in accordance with a written modification to the patient's plan of care;

(A168) failing to require that restraint be in accordance with the order of a physician;

(A179) failing to require a face-to-face assessment of the patient within one hour of a restraint, used for the management of violent or self-destructive behavior, include an evaluation of the patient's medical and behavioral condition;

(A182) failing to require that if the face-to-face evaluation of a patient is conducted by a trained RN, the RN must consult the attending physician or other LIP who is responsible for the care of the patient as soon as possible after the completion of the 1 hour face-to-face evaluation; and

(A194) failing to require the safe implementation of restraints by trained staff.

The cumulative effect of these systemic problems resulted in the hospital's failure to protect and promote each patient's rights.

Based on review of hospital policy/procedure, medical records, and interview, it was determined that the hospital failed to ensure that the patient (pt) or his/her representative make informed decisions regarding the patient's care, including being able to request or refuse treatment as evidenced by:

1. failure to require informed consent by the patient or his/her legal representative for hospital admission per hospital policy for 6 of 10 patients (Pts #1, 8, 11, 18, 24, and 25); and

2. failure to require written informed consent (or verbal consent with two witnesses and documented reason) for psychotropic medication per hospital policy for 8 of 10 patients (Pts #1, 5, 6, 7, 8, 18, 24, and 25).

Findings include:

1. Review of the hospital policy/procedure titled Informed Consent Guidelines revealed: "...In order to facilitate sound decision making, patients or there (sic) legal representatives have a right to be informed of the presence of any material risk as well as the probability of success related to proposed treatments and procedures. Informed consent is a process which entails disclosure of information by health care professionals to the patient (and/or parent and/or legal guardian), who is presumed to have the capacity to understand the information being imparted to him/her, in order to make an informed decision based upon the information received. It is the policy of (name of hospital) to obtain informed consent for the following: Voluntary admission to the facility and treatment...Generally the following persons may give consent: Any person 18 years or older-for him or herself...The legal representative of any person who has been declared incompetent as provided by law. Again, a copy of the legal document indicating the legal representative (guardianship documents) should be obtained...In some situation, a Durable Power of Attorney with Mental Health Power may provide sufficient consent. Obtain a copy of this document and then contact the Corporate Legal or Risk Management Department if you have questions...."

Review of the facility's form titled Intent to Seek Mental Health Guardianship revealed: "...According to Arizona Law, by signing below I understand and agree that I will begin emergency mental health guardianship proceedings for...(patient name). I understand that I must file for Guardianship within 2 working days of patient admission and agree that I will keep (name of hospital) fully informed of the status of this proceeding. I also agree that copies of all temporary and permanent court documents will be provided to (name of hospital) to be included in the patient chart. A list of several local attorneys specializing in Elder Law has been provided to me...."

Review of medical records:

Pt #1 was admitted on 2/11/11 with Dementia, increased agitation and aggression. On 2/11/11, a family member signed the Consent for Treatment Application for Voluntary Admission. On 2/11/11, at 1700, the same family member signed the form titled Intent to Seek Mental Health Guardianship. Pt #1 was discharged on 3/1/11. The medical record did not contain documentation that the family member had begun emergency mental health guardianship proceedings, or that the patient had voluntarily consented to admission.

Pt #8 was admitted on 6/9/11 with Bipolar Disorder and increased agitation, irritability, and confusion. On 6/9/11, a family member gave verbal Consent for Treatment Application for Voluntary Admission. A staff member documented the verbal consent and documented: "...POA (Power of Attorney) gave verbal consent for admission-emailing paperwork...."

Pt #8's medical record contained a "Statutory Durable Power of Attorney." Review of this document revealed: "...THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL OR OTHER HEALTH-CARE DECISIONS FOR YOU...."

Pt #8 was discharged on 6/19/11. His/her medical record did not contain a form signed by the family member for Intent To Seek Mental Health Guardianship. The medical record did not contain any documentation that the family member who signed for the patient's admission was a Legal Representative for the patient. The medical record did not contain documentation that the patient had voluntarily consented to admission.

Pt #11 was admitted on 2/24/11 for management of behavioral problems. A staff member documented verbal consent for admission by a family member. On 2/25/11, a family member signed the Consent for Treatment Application for Voluntary Admission. Pt #11's medical record contained a copy of a Health Care Power of Attorney (HCPOA) signed by the patient on 9/29/06, giving the family member HCPOA. The HCPOA did not contain Mental Health Powers and the medical record did not contain documentation that the family member had begun emergency mental health guardianship proceedings, or that the patient had voluntarily consented to admission. The patient remained in the hospital through 3/3/11, when she was physically restrained and given emergency medication.

Pt #18 was admitted on 5/8/11 with Dementia. His/her medical contained documentation that the patient was combative and agitated. On 5/9/11, a family member signed the Consent for Treatment Application for Voluntary Admission. On 5/9/11, at 0830, the same family member signed the form titled Intent to Seek Mental Health Guardianship. Pt #18 was discharged on 5/19/11. The medical record did not contain documentation that the family member had begun emergency mental health guardianship proceedings, or that the patient had voluntarily consented to admission.

Pt #24 was admitted on 7/9/11 with a diagnosis of Psychotic Disorder NOS (Not Otherwise Specified)/ Bipolar Disorder. On 7/9/11, a family member signed the Consent for Treatment Application for Voluntary Admission. On 7/9/11 at 1230, the same family member signed the form titled Intent to Seek Mental Health Guardianship. The patient was transferred to another hospital for medical treatment on or about 7/12/11. She was readmitted to this facility on 7/15/11 and remained an inpatient on 7/27/11. Review of Pt #24's medical record on 7/27/11, revealed that it did not contain documentation that the family member had begun emergency mental health guardianship proceedings, or that the patient had voluntarily consented to admission.

A Social Worker documented in the progress notes on 7/27/11, at 1210: "...Reviewed importance of obtaining any documentation regarding obtaining guardianship...Reviewed that psychiatrist possible considering ECT (Electro-Convulsive Treatment)...to discuss ECT w/ family. SS (Social Service) to follow-up w/...regarding guardianship...."

Pt #25 was admitted on 7/14/11 with a diagnosis of Dementia with Behavioral Disturbance. On 7/15/11, a family member signed the Consent for Treatment Application for Voluntary Admission. On 7/15/11, at 1346, the same family member signed the form titled Intent to Seek Mental Health Guardianship. Review of Pt #25's medical record on 7/27/11, revealed that it did not contain documentation that the family member had begun emergency mental health guardianship proceedings, or that the patient had voluntarily consented to admission.

Director of Quality and Social Work confirmed on 7/27/11, that Social Work staff are to call family members and document each step that the family is taking to obtain guardianship. She confirmed on 7/27/11, that the medical records of Pts #24 and #25 did not contain documentation that family members were seeking Mental Health Guardianship within 2 working days of patient admission as required by facility.

On 7/28/11 at 0830, a Social Worker documented in Pt #25's medical record: "...This writer contacted pt's son to ask him to send us any documentation or proof that he is pursuing guardianship...."

On 7/28/11 at 1101, a Social Worker documented in Pt #25's medical record: "...Pt son went on to say 'I expect a call today regarding what specifically is required and if needed I will file an application.' This writer to follow-up as needed...."

The Director of Quality and Social Work confirmed on 8/2/11, that the medical records of Pts #1, 8, 11, and 18 did not contain the required documentation. She stated on 8/2/11, that she was unaware of the facility's practice/policy when an individual fails to provide documentation of pursuit of guardianship within 2 working days of patient admission. She acknowledged that the facility does not have a written policy.

2. Review of hospital policy/procedure titled Informed Consent- Psychotropic Medications revealed: "...In order to facilitate sound decision making, patients or there (sic) legal representatives have a right to be informed of the presence of any material risk as well as the probability of success related to psychotropic medications...generally, the following persons may give consent: Any person 18 years or older-for him or herself...The legal representative of any person who has been declared incompetent as provided by law. A copy of the legal document indicating the legal representative (guardianship documents) should be obtained...In some situations, a Durable Power of Attorney with Mental Health Power may provide sufficient consent. Obtain a copy of this document...The patient's attending physician or the covering physician will be responsible for providing education concerning treatment and/or procedures requiring informed consent to patients or legal representative and ensuring that informed consent is obtained prior to the treatment or procedure...Consent granted by the patient may be revoked at any time when the patient is legally responsible for the consent decision or by the legal representative if applicable...If only verbal consent can be obtained, a note stating that fact should be entered into the patient's record and witnessed by at least two (2) staff members. This note should include the reason that only verbal consent could be obtained. The same procedure can apply for revocation of consent...."

Review of medical records:

Pt #1 was admitted on 2/11/11. Her medical record contained a form titled Informed Consent for Psychotropic Medication. The form contained the names of 4 psychotropic medications. The physician marked boxes, indicating that s/he discussed the medications "In-Person." The physician initialed and dated the form "15 Feb," next to the medication categories. The physician documented that s/he discussed the medications with the patient. The form did not contain a signature of the patient or legal representative or signatures of 2 witnesses. The medical record did not contain documentation that the patient/legal representative gave verbal consent or the reason that only verbal consent could be obtained per policy. The patient received psychotropic medications on 2/11/11.

Pt #5 was admitted on 6/24/11. Her medical record contained a form titled Informed Consent for Psychotropic Medication. The form contained the names of 3 categories of psychotropic medications. The physician marked a box, indicating that s/he discussed the medications via telephone, and documented that consent was obtained from the patient's "POA" (Power of Attorney) on 6/29/11. The form did not contain a signature of the patient or legal representative or signatures of 2 witnesses. The medical record did not contain documentation regarding the reason that only verbal consent could be obtained per policy. The patient received psychotropic medications on 6/25/11.

Pt #6 was admitted on 5/27/11. His medical record contained a form titled Informed Consent for Psychotropic Medication. The form contained the names of 3 psychotropic medications. The physician marked boxes, indicating that s/he discussed the medications "In-Person." The form did not contain a signature of the patient or legal representative or signatures of 2 witnesses. The medical record did not contain documentation regarding the reason that only verbal consent could be obtained per policy. The patient received psychotropic medications on 5/27/11.

Pt #7 was admitted on 6/8/11. Her medical record contained a form titled Informed Consent for Psychotropic Medication. The form contained the names of 5 categories of psychotropic medications. The physician marked boxes, indicating that s/he discussed the medications "In-Person." The physician initialed and dated the form 6/9/11 next to the medication categories. The spaces for Patient/Guardian Printed Name and Signature were blank. The medical record did not contain documentation that the patient/legal representative gave verbal consent or the reason that only verbal consent could be obtained per policy. The patient received psychotropic medications on 6/8/11.

Pt #8 was admitted on 6/9/11. Her medical record contained a form titled Informed Consent for Psychotropic Medication. The form contained the names of 4 psychotropic medications and 1 category of psychotropic medication. The physician marked boxes, indicating that s/he discussed the medications "In-Person." The physician documented that s/he discussed the medications with a family member of the patient on 6/10/11. The form did not contain a signature of the patient or legal representative or signatures of 2 witnesses. The medical record did not contain documentation regarding the reason that only verbal consent could be obtained per policy. The patient received psychotropic medications on 6/9/11.

Pt #18 was admitted on 5/8/11. His medical record contained a form titled Informed Consent for Psychotropic Medication. The form contained the names of 2 psychotropic medications.
The physician marked boxes, indicating that s/he discussed the medications via telephone. The physician initialed and dated the form 5/12/11 next to the medications. The spaces for Patient/Guardian Printed Name and Signature were blank. The medical record did not contain documentation that the patient/legal representative gave verbal consent or the reason that only verbal consent could be obtained per policy. The patient received the medications on 5/9/11.

Pt #24 was admitted on 7/9/11. Her medical record contained a form titled Informed Consent for Psychotropic Medication. The form contained the names of 4 medications and the physician's signature. The physician marked a box, indicating that s/he discussed the medications "In-Person." The form did not contain a signature of the patient or legal representative or signatures of 2 witnesses. The medical record did not contain documentation regarding the reason that only verbal consent could be obtained per policy. The patient received psychotropic medications on 7/9/11.

Pt #25 was admitted on 7/14/11. His medical record contained a form titled Informed Consent for Psychotropic Medication. The form contained the names of 4 categories of psychotropic medications. The physician marked a box, indicating that s/he discussed the medications via telephone. The physician initialed and dated the form 7/15/11, next to the medication categories. The physician also documented: "...Spoke (with) son 7/18/11...." The form did not contain a signature of the patient or legal representative or signatures of 2 witnesses. The medical record did not contain documentation regarding the reason that only verbal consent could be obtained per policy. The patient received psychotropic medications on 7/14/11.

The Director of Quality and Social Work confirmed during interview conducted on 7/28/11, that the documentation of Informed Consent for Psychotropic Medication in the patient records did not meet the requirements of the hospital policy/procedure .

Based on review of facility documents, facility policy/procedures, medical records, and interviews, it was determined that the hospital failed to assure that a patient has the right to be free from all forms of abuse or harm for 1 of 1 patient (Pt #20).

Findings:

Facility Policy and Procedure titled "Elder Abuse Reporting" dated 10/1/08, revealed: "...The hospital to the best of its ability protects from real or perceived abuse from anyone including...other patients...."

RN #16's documentation on the facility form revealed: "...Date of incident: 06/18/11 at 2115 Patient (# 32) was upset that peer was standing outside of his door and pushed his walker into other patient( # 20). Other patient (#32) became angry and shoved his walker into patient and hit patient (#20) with open hand across left side of face...Small amount of blood on left side of patient's (#20) mouth, no redness or bruising to left side of face, patient denies pain. No blood on inside of patient's mouth, no swelling on left side of face noted...Patient (#32) was yelling at peer (#20). Patient (#32) was redirected away and was able to calm down...."

RN #16's nurse's notes written on 06/18/11 at 2200, revealed: "...Patient (pt #20) was standing outside of another patient's room. The other pt (pt #32) asked him to move and he did not. The other pt (pt #32) pushed his walker into pt (pt #20) and hit pt (pt #20) on lt (left) side of face with an open hand. Pt (pt #32) was redirected away from other pt (pt #32) by staff. Pt (pt#20) denied pain. Pt (pt#20) had small cut on Lt side of lip area, small amount of blood noted. Area cleaned, no redness/bruising on Lt side of face noted. Evening nurse will be back in AM and stated will let wife know tomorrow and will re-assess pt (pt#20) in am...."

RN #16's nurse's notes written on 06/18/11 at 2245, revealed: "...Dr (Dr # 13) and AOC (Administrator on Call) notified of incident...."

RN # 17's nurse's notes written on 06/19/11, revealed no mention of re-assessment of patient's (pt #20) face and lips. DON confirmed on July 28, 2011 at 1655, the absence of the re-assessment of patient's face and lips in the charting.

Medical Progress Notes in medical chart were reviewed for dates of 6/18/11 and 6/19/11. Physician #5 confirmed on July 28, 2011, that there was no mention of assessment of patient's #20 face and lips in the medical progress notes for the dates of 06/18/11 and 06/19/11.

Physician # 5's discharge summary written on June 20, 2011, revealed no mention of incident occurring on June 18, 2011. There was no mention of examination of patient #20's face and lips for bruising, swelling, pain or bleeding. Physician #5 confirmed on July 28, 2011 that there was no mention of assessment of patient's #20 face and lips in the discharge summary.

Based on review of hospital policy/procedure, medical records, and interview, it was determined that the facility failed to require that the use of restraint be in accordance with a written modification to the patient's plan of care for 5 of 5 patients (Pts #9, 10, 11, 12, and 13).

Findings include:

Review of the hospital policy/procedure titled Restraint revealed: "...The treatment plan of patients requiring physical restraint shall be reviewed and amended following the first episode of restraint to include measures to prevent recurrence...."

Review of the hospital policy/procedure titled Chemical Restraint revealed that it did not contain the CMS requirement for restraint to be in accordance with a written modification to the patient's plan of care.

Cross reference Tag (A 0179) for information regarding restraint of Pts #9, 10, 11, 12, and 13.

The Director of Quality and Social Work confirmed during interview conducted on 8/3/11, that the medical records of Pts #9, 10, 11, and 13 did not contain modification of the patient's plan of care related to restraint.

The Director of Nursing (DON) confirmed during interview conducted on 8/4/11, that Pt #12's medical record did not contain modification of the patient's plan of care related to restraint.

Based on review of facility policy/procedure medical record, and interviews, it was determined that the hospital failed to require that restraint be in accordance with the order of a physician.

Findings include:

Review of hospital policy/procedure titled Restraint revealed: "...Restraint is a special treatment procedure ordered by a physician in an emergency situation which utilizes physical or mechanical measures to limit or restrict body movement in a highly agitated or self-destructive patient...Physical restraint shall require the order of a physician who will specify the criteria for release from restraint...A qualified RN may initiate physical restraint in an emergency situation, prior to obtaining a physician order. The physician will be contacted immediately following initiation of physical restraint...."

Review of hospital policy/procedure titled Chemical Restraint revealed: "...Chemical Restraint is defined as administering a medication to control the patient's behavior which poses an immediate, serious danger to his/her safety or that of others and is not a standard treatment for the patient's medical or psychiatric condition. These medications are used in addition to or in replacement of the patient's regular drug regimen to control extreme behavior during an emergency...."

Review of Pt #25's medical record revealed:

The patient was admitted on 7/14/11 due to Dementia with Behavioral Disturbance.

On 7/16/11 at 0835, an RN recorded a physician's telephone order: "...Zyprexa 5 mg IM (intramuscular) prn (as needed) aggression, acute agitation...."

On 7/17/11 at 0105, an RN recorded a physician's telephone order: "...Geodon 5 mg IM now for severe agitation. May repeat in 1 hour if necessary...."

An RN documented on 7/17/11 at 0600: "...Pt rec'd Zyprexa 5 mg IM @ 2330 (without) effect. Con't to pace the hallway, going back & forth toward the...door 'to get out'. Pt. became more aggressive physically towards staff members-kicking and punching staff but accidentally hit his face against the door...Pt sustained a linear lac (laceration)...around...temporal area and a small abrasion on the bridge of his nose...Pt rec'd Geodon 5 mg IM @ 0110 and repeated @ 0235 for continued aggression and severe agitation...."

RN #27 confirmed during interview conducted on 8/3/11, that it was necessary to physically hold the patient to administer the injections.

On 7/21/11 at 1237, an RN recorded a physician's telephone order: "...Zyprexa 2.5 mg IM bid (twice a day) prn severe agitation/aggression...."

On 7/25/11 at 0205, an RN recorded a physician's telephone order: "...Haldol 2 mg IM now for severe agitation...."

On 7/25/11 at 0300, an RN documented: "...Pt rec'd Zyprexa 2.5 mg IM @ 0105, (with) no effect. Pt continues to pace, physically striking at staff then started to run around the unit. Pt was swinging and striking at staff. Hit this writer in Rt thigh when pt starting (sic) kicking his legs. Dr...called @ 0205-rec'd order to give Haldol 2 mg IM now. Pt rec'd med @ 0220 hour...."

On 7/25/11, at 0615, an RN documented: "...Pt continues to pace, hostile combative...physically striking at staff. pt tried to pick up the beige armed chair to throw at staff but was intercepted...."

RN #15 confirmed during interview conducted on 8/2/11, that it was necessary to utilize two staff to physically escort the patient and then lower him to the floor and hold him to administer the Haldol injection. S/he stated that all staff working that shift were necessary to assist. S/he stated that s/he has heard that staff can't hold anyone longer than 5'. S/he stated that after 5', the hold is considered a restraint.

RN #27 confirmed during interview conducted 8/3/11, that the patient was very aggressive and it was necessary to hold him on the floor to administer the Haldol IM. When he was less aggressive, the staff escorted him back to bed. S/he stated that a physical hold is considered a restraint if it lasts longer than 5'. S/he stated that a chemical restraint is IM antipsychotic medication that the patient hasn't received before. Since staff held the patient less than 5', s/he didn't believe that they used a physical restraint.

Pt #25's medical record did not contain physicians' orders for physical restraint (or physical hold).

RN #24 stated during interview conducted on 7/27/11, that it is frequently necessary to physically escort patients and hold them for injections due to out of control, aggressive, and/or combative behavior. S/he does not consider an escort a restraint, even when the patient is not voluntarily walking with staff. S/he doesn't consider a physical hold less than 5' to be a restraint. S/he believes that an IM medication is a chemical restraint if it is given for behavior and the patient has not had that medication before.

RN #10 stated during interview conducted on 7/28/11, that a physical hold is considered to be a restraint only if staff hold the patient longer than 5'. In that case, the RN calls the physician and s/he instructs the RN to monitor the patient. The physician doesn't come into the hospital to assess the patient unless the patient is injured.

Physician #5 stated during interview conducted 7/27/11, that if a patient is acting out and it is necessary for staff to hold the patient down to give an IM medication, staff should get a restraint order. S/he stated that if there is physical resistance, s/he would consider a hold a restraint. She stated that if staff have to hold a patient down to administer medication, s/he would consider the administration of the medication a chemical restraint as well. S/he assumes that if s/he gives an order for an IM medication that the RN was able to give it successfully, without holding the patient or the RN would call the physician back or s/he would see the restraint forms in the chart the next day since the RN can do the one hour face to face evaluation.

Physician #6 stated during interview conducted 7/28/11, that almost no patients are medicated forcefully. S/he stated that a court order would be required. S/he acknowledged that s/he gives orders for the RN to administer an IM medication if the patient refuses oral medication. S/he stated that s/he doesn't know how staff administer IM medications. S/he believes that there is usually no coercion. S/he assumes that the patient is cooperating. It has never been brought to his/her attention one way or the other.

Based on review of hospital policy/procedure, medical records, and interview, it was determined that the hospital failed to require a face-to-face assessment of the patient within one hour of a restraint, used for the management of violent or self-destructive behavior, included an evaluation of the patient's medical and behavioral condition for 5 of 5 patients (Pts #9, 10, 11, 12, and 13).

Findings include:

Review of the hospital policy/procedure titled Restraint revealed: "...A LIP (Licensed Independent Practitioner) or specialty (sic) trained Registered Nurse shall conduct a face-to-face assessment of the patient within one hour of initiation of restraint to assess physical and psychological status and recommend any further interventions to prevent recurrence of the psychiatric emergency...."

Review of the hospital policy/procedure titled Chemical Restraint revealed: "...The LIP will conduct a face-to-face assessment of the patient within one hour of administration of the emergency medication to assess physical and psychological status, including the effectiveness of the medication...."

Review of medical records:

Pt #9 was admitted on 1/14/11 with Dementia (with) psychosis and behavioral disturbance. His medical history included: atrial fibrillation, arrythmia, pacemaker, "IBS" (Irritable Bowel Syndrome) and "cancer on elbow." An RN recorded physician telephone orders on 1/14/11 at 1635: "...Geodon 10 mg IM Now for severe agitation...."

On 1/14/11 at 1650, a nurse charted administration of Geodon 10 mg IM.

The medical record contained a form titled R.N. Chemical Restraint Assessment Flowsheet. Review of the form revealed: Pt #9's name, the date 1/14/11, and time 1900. "...Pt became agitated, yelling out for daughter, swiping at BHT's (Behavioral Health Technicians), unredirectable, verbally threatened 'I'm going to kick you in the balls,' refuse (sic) to get up from chair, attempted to kick RN, exit seeking...." An RN's name was recorded in the space designated: Staff Assigned for Face-to-Face assessment. Neither the form nor the medical record contained documentation of a face to face assessment of the patient's physical and psychological status completed by an RN or LIP within one hour of the restraint.

Pt #10 was referred from an Extended Care Facility on 2/23/11, due to escalating behavior problems. She had been diagnosed with Alzheimer's Disease, and had a history of depression and anxiety.

On 2/24/11 at 1715, an RN recorded a physician's telephone order: "...Geodon 5 mg IM, may repeat in 2 hours if necessary...."

An RN documented a progress note on 2/24/11 at 2355: "...Pt given Geodon 5 mg IM @ 1725 and 1925 due to pt unable to be redirected. pt continues to hit staff upon redirection and escort out of other pt's rooms. pt combative and uncooperative...Hit staff...."

An RN completed the R.N. Chemical Restraint Assessment Flowsheet form on 2/24/11 at 1845; "...shot given at 1725...." The space on the form for Staff Assigned for Face-to-Face assessment was blank. Neither the form nor the medical record contained documentation of a face to face assessment of the patient's physical and psychological status completed by an RN or LIP within one hour of the restraint.

Pt #11, was transferred from an Emergency Department and admitted to the facility on 2/24/11, for management of behavioral problems.

On 3/3/11 at 1315, an RN documented: "...Pt Became combative with staff...She pinched, scratched staff. she punched wall causing bruising to R (Right) Hand. She kicked staff...Pt was Held for 15' IM Injection, Zyprexa given...

The Seclusion/Restraint Flowsheet contained documentation from 1315 through 1330.

On 3/3/11 at 1400, an RN recorded a physician's verbal/phone order for a Physical Restraint on a form titled Seclusion/Restraint Physician Order. Review of the form revealed: "...PRN Medication Given...Yes...Zyprexa 5 mg...Emergency Medication given...Zyprexa 5 mg...Patient's present condition, including medical and behavioral status...Pt Hitting staff. Hitting self...."

The medical record did not contain assessment of the patient's physical and psychological status completed by an RN or LIP within one hour of the restraint.

On 3/3/11 at 1430, an RN documented: "...Pt found on floor in day room, no witness to apparent fall, sustained injuries to left forehead (sic), left area below eye...Physician notified order received to send to (name of hospital)...Neuro-check done pupils 2 mm, sluggish, Pt responds slowly to painful stimuli...."

Pt #12 was admitted on 5/12/11 via referral from a rehabilitation facility, where he had been receiving physical therapy following a leg fracture. He had "...been increasingly agitated, uncooperative with care, sexually inappropriate, and increasingly acting in an erratic manner...." He had a history of depression and "...escalating cognitive difficulties with significant behavior problems...."

On 5/17/11 at 0110, an RN recorded a physician's telephone order: "...Haldol 2 mg IM now...Ativan 1 mg IM now...Indication...Agitation...yelling...."

The medical record contained a form titled R.N. Chemical Restraint Assessment Flowsheet. Review of the form revealed: Pt #12's name, the date 5/17/11, and time 0115: "...pt yelling, screaming, asking staff to come help. restless, unable to indicate where exactly pain coming from-disruptive to roommate...." An RN's name was recorded in the space designated: Staff Assigned for Face-to-Face assessment. Neither the form nor the medical record contained documentation of a face to face assessment of the patient's physical and psychological status completed by an RN or LIP within one hour of the restraint.

Pt #13 was admitted on 5/4/11. He had a history of Dementia and was transferred to the facility from an assisted living facility due to an increase in paranoia, agitation and physical aggression.

On 5/21/11 at 2015, an RN documented: "...pt was standing (with) FWW (Front Wheel Walker) in his room doorway & grabbed female peer on her wrist as she walked by. pt refused to let go and when approached by staff, he lunged toward staff...Pt began grabbing other pts as they walked by his room. pt began hitting pts (with) his FWW. Pt lunged at staff & attempted to hit nurse...Dr...notified ordered Ativan 0.5 mg po (by mouth) (with) Ativan 0.5 mg IM for refusal of PO. Pt refused PO Ativan Pt remained aggressive & extremely agitated. Ativan 0.5 IM given to Pt...."

On 5/21/11 at 1840, an RN recorded a physician's telephone order: "...Ativan .5 mg po X 1 now, severe agitation if pt refuses Ativan .5 mg IM X 1 now.

The medical record contained a form titled R.N. Chemical Restraint Assessment Flowsheet. Review of the form revealed Pt #13's name, the date 5/21/11, and time 1910: "...pt grabbed female peer on hand/wrist and would not let go. Pt was hitting peers (with) walker. Pt lunged at staff & was swinging aggressively at staff/peers...." An RN's name was recorded in the space designated: Staff Assigned for Face-to-Face assessment. Neither the form nor the medical record contained documentation of a face-to-face assessment of the patient's physical and psychological status completed by an RN or LIP within one hour of the restraint.

The Director of Nursing (DON) confirmed during interview conducted on 7/28/11, that the medical records did not contain documentation of a face-to-face assessment of the patients' physical and psychological status completed by an RN or LIP within one hour of the restraints.

Based on review of hospital policy/procedure and interview, it was determined that the hospital's policy/procedure failed to reflect the CMS requirement that if the face-to-face evaluation is conducted by a trained RN, the RN must consult the attending physician or other LIP who is responsible for the care of the patient as soon as possible after the completion of the 1 hour face-to-face evaluation.

Findings include:

Review of the hospital policy/procedure titled Restraint revealed that it did not contain the requirement for a trained RN to contact the patient's attending physician or other LIP who is responsible for the care of the patient as soon as possible after completing the 1 hour face-to-face evaluation.

Review of the hospital policy/procedure titled Chemical Restraint revealed that it required an LIP to conduct the 1 hour face-to-face assessment of the patient. This policy/procedure did not contain a provision for a trained RN to conduct a 1 hour face-to-face evaluation.

The DON acknowledged during interview conducted on 8/4/11, that the hospital policies/procedures did no reflect the CMS requirement.

Based on review of medical records, hospital documents, and interview, it was determined that the hospital failed to require the safe implementation of restraint by trained staff.

Findings include:

Cross reference Tag (A-0179) for information regarding restraint of Pts #9, 12, and 13.

Review of medical records of Pts #9, 12, and 13 revealed that RN #28 was assigned to complete the 1 hour Face-to-Face assessment for Pt #9; RN #8 was assigned to complete the 1 hour Face-to-Face assessment for Pt #12; RN #16 was assigned to complete the 1 hour Face-to-Face assessment for Pt #13.

Review of the attendance roster for training of RN's to conduct the 1 hour Face-to-Face assessment revealed that the roster did not contain the names of RN's #28, 8, and 16.

On 8/4/11, the DON provided documentation of the contents of the training provided to RN's to enable them to conduct the 1 hour Face-to-Face assessments for patients requiring restraint to manage violent or self-destructive behavior. The date of the training was 4/2/09.

The DON confirmed during interview conducted on 8/4/11, that the training did not include training in assessment of a patient's physical status/ medical condition and/or documentation of RN's competency in assessment of a patient's physical status/medical condition.

Based on review of hospital documents, medical records, and interview, it was determined that the hospital failed to measure and analyze quality indicators that assess processes of care, hospital service and operations as evidenced by:

1. failure to measure, analyze, and track high risk, high-volume, problem-prone area related to Informed Consent for Admission;

2. failure to measure and analyze data related to quality key indicator Medication Safety: Medication Consent; and

3. failure to measure and analyze data related to quality key indicator Provision of Care: Restraint/Therapeutic Hold.

Findings include:

1. Cross reference Tag (A0131), #1, for information related to Informed Consent for Admission.

The Director of Quality and Social Work confirmed during interview conducted on 8/3/11, that the Quality Assessment and Performance Improvement Program had not identified the issues of noncompliance by surrogate decision makers in beginning emergency guardianship proceedings when required by the hospital.

2. Cross reference Tag (A0131), #2, for information related to Informed Consent for Psychotropic Medication.

Review of hospital document titled Performance Improvement Scorecard Quarter 1ST-2011 revealed a Key Indicator of Medication Management: "...Medication Safety: Medication Consent...." The column of the document titled Key Findings (Analysis and Recommendations) contained the following: "...95% Threshold/GOAL: Overall 1st Quarter: 94% compliance...."

The Director of Quality and Social Work stated during interview conducted on 8/3/11, that the data collected to support these findings is "...Medication Consent is obtained and documented...." S/he confirmed that the data is not analyzed regarding whether physicians follow the hospital policy/procedure titled Informed Consent for Psychotropic Medication.

3. Cross reference Tags (A0166, A0168, A0179, A0182, A0194), for information related to patient restraint.

Review of hospital document titled Performance Improvement Scorecard Quarter 1ST-2011 revealed a Key Indicator of Provision of Care: Restraint/Therapeutic Hold: "...Restraint and Seclusion (Therapeutic Holds): Event Documentation...." The column of the document titled Key Findings (Analysis and Recommendations) contained the following: "...Threshold/GOAL is <3 per 1000 Patient Days: Overall compliance at 100%. Documentation, policy and procedures followed at 100% 3 restraints for the 1st Quarter: Jan-1 Chemical...Feb-1 Chemical...Mar-1 Physical Restraint (Hold) that remained less than 5 minutes...."

The Director of Quality and Social Work confirmed during interview conducted 8/3/11, that the findings and analysis are not accurate regarding 100% compliance with policy/procedure and documentation requirements for patient restraint.

Based on review of hospital policy/procedure, hospital documents, and interview, it was determined that the hospital failed to require that a registered nurse make individual patient assignments based on assessment of patient care needs.

Findings include:

Review of the hospital policy/procedure titled Acuity System revealed: "...The Licensed staff will proactively assess the acuity of each patient identifying potential and actual risks and care needs for each patient. These assessments will assist in identifying the appropriate number and skill mix of assigned staff...The acuity patient category system will be completed on each shift. Each unit's charge nurse will assign a category to each patient using information gained during the shift...Completed acuity sheets are routed to the DON daily for review...The assessment criteria for each classification category are as follows...Level 1...Level 2...Level 3...Level 4...When assigning staff for day and evening shift the following will be considered a guideline. Each MHT (Mental Health Technician) will have a patient assignment not to exceed 70 points and/or a maximum of 8 patients based on the previous shifts (sic) patient acuity tool calculations and each RN not to exceed 45 points and/or a maximum of 10 patients...When assigning staff for night shift the following is considered a guideline. The staff to patient ratio will be 1:8...."

The Acuity System included a form which contained the following statement along the top of the form: "...SHADED CATEGORIES ARE PRIMARY RN/LICENSED NURSING CARE ACTIVITIES. UNSHADED CATEGORIES ARE PRIMARY MHT/NON-LICENSED NURSING ACTIVITIES...." A column on the left side of the form contained the heading "NURSING CARE ACTIVITIES." This column contained several sections: "...I. THERAPEUTIC INTERACTION...II. MEDICATIONS...III. PHYSICAL PROBLEMS/TX (Treatment)...IV. DIET/NUTRITION...V. HYGIENE/ADL's (Activities of Daily Living)...VI. ACTIVITIES/GROUPS...VII. RISK...VIII. TEACHING/PLANNING...IX. RESTRAINT/SECLUSION...X. NEW ADMISSION...XI. TRANSPORT...XII. OTHER...."

The form contained space along the top for patients' initials and vertical columns and spaces with numbers corresponding to classification categories 1, 2, 3, 4 for the nurse to circle, indicating the level of care requirements for each patient. The form contained spaces along the bottom for "TOTAL POINTS" for each patient and "ACUITY LEVEL" for each patient. The form also contained the following: "...Acuity Level I: 3-14 pts...Acuity level II: 15-24 pts...Acuity Level III: >24 pts...This form is scored daily on day or evening shift by the RN and individual acuity may be changed to reflect change in patient status. Scores will be tabulated by the RN and reports forwarded to the Director of Nursing...."

The DON explained, during interview conducted on 8/2/11 at 1130, that each RN is to score each of his/her patients each shift. The charge nurse takes the scores and completes the Patient Acuity/24-Hour Program Report. The information is submitted to the DON 3 hours before the next shift to be used for staffing.

On 8/2/11, review of the "Acuity Book" which contained completed Patient Acuity/24-Hour Program Reports and completed patient point sheets revealed that it contained completed sheets for July, 2011: 7/24, 7/6, 7/4, 7/3, 7/2, and 7/1. The Patient Acuity/24-Hour Program Reports contained information for one shift (either Shift II (0700-1530) or Shift III (1500-2330). Point sheets were stapled to the Program Reports: 2 sheets for 7/24; 2 sheets for 7/6; 2 sheets for 7/4; 2 sheets for 7/3; 3 sheets for 7/2; and 3 sheets for 7/1.

The DON confirmed during interview conducted on 8/2/11, that the point sheets (patient category system) are to be completed by each nurse on each shift. S/he confirmed that this is not being accomplished. S/he was unable to explain how the points are utilized. S/he also confirmed that s/he was unable to explain how the current acuity system establishes the types and numbers of nursing personnel that are required for the hospital unit. S/he confirmed that the Staffing Grid, based on patient census, is used to determine the required staff for the hospital unit with the addition of staff for patient's requiring 1:1 observation.

Review of the Assignment Sheets for the Day Shift 7/27/11, revealed one assignment sheet for the "Purple" side which includes 10 semi-private patient rooms and one assignment sheet for the "Green" side, which includes 20 semi-private patient rooms. The assignment sheet for the Purple side contained the room numbers "200-208" written under the RN's name. Consecutive room numbers with patients' names were written under the BHT's names. The assignment sheet for the Green side contained room numbers written under each RN's name: "220-228; 210-218." Consecutive room numbers with patients' names were written under each BHT's name.

RN #6 stated during interview conducted on 7/27/11, that the acuity system is based on the number of patients on the unit. S/he described a "grid" that is used to determine how many BHT's and RN's are needed based on the number of patients on the unit. S/he stated that s/he rates his/her patients during the shift. There is no specific time of day to complete the rating. S/he gives his/her ratings to the Charge Nurse who files the sheets. S/he stated that the patient acuity ratings are used primarily to justify the number of staff scheduled. S/he was uncertain whether acuity ratings are used in making assignments. S/he confirmed that assignments of staff to patients are made by room numbers. If the patients in those room numbers are high acuity, the staff member will be assigned fewer patients.

Review of the Assignment Sheets for the Day Shift, 7/28/11 revealed:

The assignment sheet for the Purple side contained the room numbers "200-208" written under the RN's name. Consecutive room numbers with patients' names were written under the BHT's names. The assignment sheet for the Green side contained room numbers written under each RN's name: "210-218; 220-228." Consecutive room numbers with patients' names were written under each BHT's name.

RN #10 stated during interview conducted on 7/28/11, that patients with similar problems are put in the same room. The Charge Nurse completes the Acuity ratings for the patients and makes the assignments.