HospitalInspections.org

Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to patient's rights as follows:

(482.13 Tag A-0123) The information reviewed during the survey provided evidence that two of two patients (MR17 and MR18) did not receive a written resolution letter for grievances filed.

(482.13 Tag A-0166) The information reviewed during the survey provided evidence written modification to the patient ' s plan of care was not completed for one (MR1) of six medical records sampled for a review of restraint use.

(482.13 Tag A-0168) The information reviewed during the survey provided evidence one (MR1) of six medical records sampled for a review of restraint use was placed in restraint without provider orders.

(482.13 Tag A-0172) The information reviewed during the survey provided evidence two (MR1 and MR12) of six medical records sampled for a review of restraint use were not assessed daily for the need to continue the use of restraint.

(482.13 Tag A-0175) The information reviewed during the survey provided evidence two of six medical records sampled for a review of restraint use were not monitored according to the time frame specified by the facility for non-violent restraint (MR1) and violent/self-destructive restraint (MR14).

(482.13 Tag A-0176) The information reviewed during the survey provided evidence the facility did not have documentation of restraint/seclusion training for three (CF2, CF3 and CF4) of six physicians who wrote restraint orders.

(482.13 Tag A-0178) The information reviewed during the survey provided evidence a face-to-face evaluation was not performed within one hour after initiation of restraints for one (MR14) of two medical records sampled for a review of violent/self-destructive restraint use.

Based on review of facility policy and facility documentation and staff (EMP) interview, it was determined the facility failed to ensure its grievance policy was followed by failing to send a written resolution letter once the grievance investigation was completed for two of two grievances reviewed (MR17 and MR18).

Findings include:

Review on July 22, 2022, of facility policy "Complaint/Grievance Process for Patients," last approved June 29, 2021, revealed "...F. Grievance Procedure...5. The Patient Safety Program Manager or a member of the Patient Safety Department will acknowledge and attempt to resolve all grievances to the patient/surrogate within seven (7) days. The patient/surrogate will be sent a written acknowledgement or resolution letter within 7 days of receipt of the grievance. If the grievance cannot be resolved within seven (7) days, an appropriate time frame for resolution will be communicated to the patient or their representative. A final resolution will be communicated to the patient or their representative via written response within 30 days from the date of the receipt of the grievance. ... 6. At the conclusion of the formal grievance, the patient/surrogate will be given written notice of the Hospital's investigation and decision. The notice will contain the name of the Hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date the process was completed. The written notice will be prepared in a language that the patient/surrogate understands. If the original grievance was submitted via email or if the patient/representative requests, the written notice can be sent via email form. ..."

Review on July 22, 2022, of MR17 revealed a grievance was filed by MR17 on June 1, 2022. Documentation revealed phone calls were made to MR17 on June 8 and 9, 2022. There was no documentation of a written resolution letter to MR17.

Review on July 22, 2022, of MR18 revealed a grievance was filed by MR18 via email on June 17, 2022. An email from the facility was sent on June 21, 2022, stating the complainant's concerns had been forwarded to the appropriate staff for investigation and follow-up. The email did not address the results of the grievance process or the date the process was completed.

Interview with EMP2 on July 22, 2022, at 1040 confirmed there was no documentation of a written resolution letter in MR17. EMP2 confirmed the email to MR18 did not address the results of the grievance process or the date the process was completed and there was no resolution letter on file.

Based on review of facility policy and medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure that the use of restraint/seclusion were utilized in accordance with a written modification to the patient's plan of care for one of six MRs reviewed. (MR1)

Findings include:

Review on July 21, 2022, of facility policy "Restraints," last approved July 18, 2022, revealed "...C. General Provisions...5. Care Plan I. The patient's written plan of care shall be modified to address restraint. ..."

Review of MR1 on July 21, 2022, revealed there was no documentation in the nursing plan of care to address the use of the Posey bed restraint from June 8 through June 15, 2022, and from June 19 through July 4, 2022.

Interview with EMP9 on July 21, 2022, at 1215 confirmed MR1's nursing plan of care did not address the use of the Posey bed restraint from June 8 through June 15, 2022, and from June 19 through July 4, 2022.

Based on review of facility policy and medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the use of non-violent restraint was in accordance with a complete order of a physician or licensed practitioner for one of six medical records reviewed. (MR1)

Findings include:

Review on July 21, 2022, of facility policy "Restraints," last approved July 18, 2022, revealed "...D. Restraints for Non-Violent/ Non-Self Destructive (NV/NSD) Behavior (Also known as Physical Healing or Medical)... 2. Restraint Order I. A provider's order is required to initiate restraint...4. Documentation...V. Order every calendar day (daily)..."

Review of MR1 on July 21, 2022, revealed MR1 was ordered a [name of] bed restraint on July 8, 2022, at 1825. MR1 remained in the [name of] bed until it was discontinued on June 15, 2022, at 0530. There was no provider order for the use of the [name of] bed on June 12, 2022. MR1 was placed back in the [name of] bed at 2000 on June 15, 2022. There was no provider order for the use of the [name of] bed on June 15, 2022. Nursing documentation revealed MR1 was removed from the [name of] bed at 0600 on June 16, 2022, and returned to the [name of] bed at 1315 on June 19, 2022. There was no provider order on June 19, 2022, for the use of the [name of] bed.

Interview with EMP9 on July 21, 2022, at 1130 confirmed there were no provider orders for the use of the [name of] bed restraint on June 12, 15 and 19, 2022.

Based on review of facility policy and medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a provider documented a daily assessment of the need for continued use of restraint per facility policy in two of six MRs (MR1 and MR12).

Findings include:

Review on July 21, 2022, of facility policy "Restraints," last approved July 18, 2022, revealed "...D. Restraints for Non-Violent/ Non-Self Destructive (NV/NSD) Behavior (Also known as Physical Healing or Medical)...2. Restraint Order... IV. The provider shall perform an in-person assessment of the restrained patient at least once every calendar day to assess medical and behavioral condition to determine if restraint shall be either re-ordered or discontinued. The assessment is documented in the progress note. ..."

Review of MR1 on July 21, 2022, revealed physician progress notes for June 8, 9, 20, 21, 22, 23, 24, 25, 26, 27, 29, and 30, 2022, did not document an assessment related to MR1's behavioral condition and the need to continue the [name of] bed restraint. Further review of MR1 revealed there was no physician progress note recorded on June 28, 2022.

Interview with EMP9 on July 21, 2022, at 1225 confirmed physician progress notes for June 8, 9, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30, 2022, did not document an assessment related to MR1's behavioral condition and the need to continue the [name of] bed restraint. EMP9 further confirmed there was no physician progress note recorded on June 28, 2022.

Review of MR12 on July 21, 2022, revealed the use of bilateral wrist restraints during a period of intubation in the ICU setting. MR12 did not contain documentation of a daily assessment related to the need for continued use of restraint on July 15, 16, 17, 18, 19, and 20, 2022.

Interview with EMP9 on July 21, 2022, at 1345 confirmed MR12 did not contain documentation of a daily assessment related to the need for continued use of restraint on July 15, 16, 17, 18, 19, and 20, 2022.

Based upon a review of facility policy and medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure documentation of a reassessment every two hours for a patient in non-violent restraints in one of four applicable MRs reviewed (MR1) and failed to ensure documentation of 15-minute reassessments for a patient in violent/self-destructive restraints in one of two applicable MRs reviewed (MR14).

Findings include:

Review on July 21, 2022, of facility policy "Restraints," last approved July 18, 2022, revealed "...D. Restraints for Non-Violent/ Non-Self Destructive (NV/NSD) Behavior (Also known as Physical Healing or Medical)...3. Patient Monitoring... III. Other monitoring activities shall be performed at least every two (2) hours, or more frequently if indicated by the condition or behavior of the patient. ... E. Restraint for Violent/ Self Destructive (V /SD) Behavior (that jeopardizes the immediate safety of a patient, a staff member, or others)... III. Monitoring a. A staff member who has demonstrated competency shall assess the patient at the initiation of restraint and every 15 minutes thereafter and a one-one constant observation. ...IV. Documentation ... d. Patient monitoring listed above in section iv- shall be documented as indicated with time frames listed for assessment..."

Review of MR1 on July 21, 2022, revealed documentation of two-hour restraint checks by nursing staff were missing on June 9, 2022, at 1800, June 10, 2022, at 1800, June 11, 2022, at 0400, June 12, 2022, at 1500 and 1700, June 20, 2022, from 0515 until 2300, June 23, 2022, from 0530 until June 24, 2022, 0800, June 26, 2022, from 0300 until 0700 and July 2, 2022, at 1800.

Interview with EMP9 on July 21, 2022, at 1135 confirmed restraint checks for non-violent restraints are to be documented every two hours. EMP9 further confirmed the missing restraint checks on June 9, 2022, at 1800, June 10, 2022, at 1800, June 11, 2022, at 0400, June 12, 2022, at 1500 and 1700, June 20, 2022, from 0515 until 2300, June 23, 2022, from 0530 until June 24, 2022, 0800, June 26, 2022, from 0300 until 0700 and July 2, 2022, at 1800.

Review of MR14 on July 21, 2022, revealed four-point restraints were initiated on June 9, 2022, at 2000 by the RN for violent behavior. A provider order for violent restraints was obtained at 2004 and renewed at 2258. During the time MR14 was restrained for violent behavior from June 9, 2022, at 2000 until June 10, 2022, at 0100, there was no documentation of every 15-minute restraint checks.

Interview with EMP9 on July 21, 2022, at 1445 confirmed MR14 was restrained for violent behavior from June 9, 2022, at 2000 until June 10, 2022, at 0100. EMP9 also confirmed there was no documentation of the required 15-minute restraint checks.

Based on a review of facility policy and credential files (CF) and staff interview (EMP), it was determined the facility failed to ensure medical staff were trained on the facility seclusion and restraint policy for three of six CFs reviewed (CF3, CF4 and CF5).

Findings include:

Review on July 22, 2022, of facility policy "Restraints," last approved July 18, 2022, revealed "...F. Staff Training... 2. Hospital staff and providers shall receive training in the following subjects as it relates to duties performed under this policy. 3. Such training shall take place during orientation (prior to performing these duties) and shall be repeated periodically as indicated based on results of performance monitoring/departmental competency determination. I. Providers who order restraint shall have a working knowledge of this policy. ..."

Review of credential files (CF) was conducted on July 22, 2022, with EMP11. No evidence was found in CF3, CF4 and CF5 of training regarding restraints during initial appointment to the medical staff.

Interview with EMP1 on July 22, 2022, at 1100 revealed restraint education and policy review is provided during new provider orientation by OTH1.

Interview with EMP2 on July 22, 2022, at 1130 confirmed the facility had no documentation of restraint education for CF3, CF4 and CF5.

Review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that a face-to-face evaluation was completed within one hour after the initiation of violent/self-destructive restraints for one of two applicable medical records reviewed. (MR14)

Findings include:

Review on July 21, 2022, of facility policy "Restraints," last approved July 18, 2022, revealed "...E. Restraint for Violent/ Self Destructive (V /SD) Behavior (that jeopardizes the immediate safety of a patient, a staff member, or others) 1. Requirement for All Settings I. Restraint Order a. A provider's order is required. b. If the provider is not available, and in an emergency, a registered nurse, mental health therapist security guard or other authorized staff may initiate restraint in advance of a provider's order and the RN will contact the provider immediately (within a few minutes) for an order and document it within one hour. c. The provider shall perform a face-to-face assessment of the patient within 1 hour of the initiation of the restraint to evaluate the patient's immediate situation and reaction the patient's medical and behavioral condition and need for restraint. ..."

Review of MR14 on July 21, 2022, revealed four-point restraints were initiated on June 9, 2022, at 2000 by the RN for violent behavior. A provider order for violent restraints was obtained at 2004 and renewed at 2258. MR14 was restrained for violent behavior from June 9, 2022, at 2000 until June 10, 2022, at 0100. There was no documentation of a face-to-face assessment by a provider performed within an hour of restraint initiation.

Interview with EMP9 on July 21, 2022, at 1445 confirmed MR14 was restrained for violent behavior from June 9, 2022, at 2000 until June 10, 2022, at 0100. EMP9 further confirmed a provider did not document a face-to-face assessment within an hour of restraint initiation.