HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient was informed of his/her patient rights prior to furnishing or discontinuing care whenever possible for 1 of 10 patient charts reviewed (Patient #1).

Findings were:

Facility policy #MCH-2087 entitled Patient Rights and Responsibilities, last revised 01/14, included the following:
"The patient has a right to: ...Prompt resolution of grievances ...Patients are to be informed of their rights and responsibilities upon admission to an inpatient setting ...This will be accomplished by providing the patient with a written and/or posted statement of the rights and responsibilities ..."

A review of the medical record of Patient #1 revealed he was seen at the Medical Center Hospital (MCH) emergency department on 4/1/16 at 6:40 a.m. A handwritten note at the top of the emergency physician record included, "Poison control wants 24 hr obs (observation). VSS (vital signs stable). A&O (alert and oriented) en route per EMS ..."

A consent for care and treatment form for admission to MCH included the following phrase at the top: "Patient and/or guardian must review and complete the following information." The form for Patient #1 was dated 4/1/16, but was not signed by the patient. On the signature line was handwritten the word, "Verbal." Two witnesses had signed the form. Included on the form was the following: "XI. I acknowledge receipt of patient Bill of Rights." No reason was included as to why the patient had not signed the form, though he had been alert and oriented upon admission.

In an interview with Staff #5, Admitting Supervisor, on the afternoon of 8/23/16 in the facility conference room, she stated, "If a patient doesn't sign a consent when they come in and we write "verbal," we usually go by again--so we make two attempts to get them to sign. That doesn' t seem to have happened in this case--I'm not sure why...As far as the patient rights document, we'll usually go up and leave a copy in their room...I' m still not sure what happened in this case..."

Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient was informed of whom to contact to file a grievance in 10 of 10 patient charts reviewed (Patient #1).

Findings were:

Facility policy #MCH-2087 entitled Patient Rights and Responsibilities, last revised 01/14, included the following:
"The patient has a right to: ...Prompt resolution of grievances ...Patients are to be informed of their rights and responsibilities upon admission to an inpatient setting ...This will be accomplished by providing the patient with a written and/or posted statement of the rights and responsibilities..."

A review of the facility's form entitled "The Patient Care Partnership (The Patient Bill of Rights) - Understanding Expectations, Rights and Responsibilities," revealed no information regarding making a patient care complaint or whom to contact regarding such a complaint or grievance.

In an interview with Staff #1, Director of Quality, on the morning of 8/23/16 in the facility conference room, she stated, "I think patient rights information is posted in the lobby, and it has contact information for complaints." She agreed that a patient entering via the emergency department would not have access to the information. She agreed the written patient rights information provided to the patients did not include information regarding how or to whom to make a patient care complaint or grievance.

Based on a review of facility documentation and staff interviews, the facility failed to discontinue a patient restraint at the earliest possible time for 1 of 5 patients undergoing restraint (Patient #1).

Findings were:

Facility policy #MCH-2053 entitled Restraints, last revised 01/2015, included the following:
"DISCONTINUATION OF RESTRAINT OR SECLUSION
Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. Restraint or seclusion may only be employed while the unsafe situation (clinical justification) continues. Once the unsafe situation ends, the use of restraint or seclusion must be discontinued..."

A review of the medical record of Patient #1 revealed a nursing note on 4/1/16 at 12:15 which included the following:
"...spoke with the patient with the police about if he did not stop trying to harm himself or the staff then we would have to restrain him. Pt yelled at the police and the director saying he will "whatever he wants and there is nothing we can do about it it [sic] is my right to decide when to die" Patient was restrained ..."

A physician's order for initial restraint on 4/1/16 at 12:15 p.m. read as follows: "Started initial restraint ...Rationale: pulling lines, harm to self and others, actual date/time of restraint...1158...Type of restraint: both wrists..." An additional order at 12:15 p.m. included the following: "Type of restraint: both ankles..."

A nursing note at 1:54 p.m. on 4/1/16 included the following: "Patient has calmed down immensely and one arm has been unrestrained."

A nursing note at 2:00 p.m. on 4/1/16 included the following: "Pt stated he was angry with the way the nurse on 9C and the cops handled the previous situation and was upset bc (because) they had taken his phone away and he was expecting a phone call from his adopted granddaughter at 12:30, the time at which the nurse took it aw ...he came to his right mindset and called for help and he feels like he is being treated like a criminal here in MCH; teaching was done about MCH policy for suicide attempts and pt had help if needed and he verbalized understanding."

The next patient restraint assessment was at 2:00 p.m. on 4/1/16 and included, "Effect on behavior: inadequate..."

There was no documentation in the medical record of Patient #1 of when physical restraints were removed, or if they were removed during the approximate 24-hour inpatient stay of Patient #1.

In an interview with Staff #1, Director of Quality, on the morning of 8/23/16 in the facility conference room, she assisted with the review of the medical record of Patient #1. She stated, "I'm not sure when the restraints came off. It doesn't seem to be documented and the record doesn't contain a discontinue restraints order from the physician." She agreed that the restraint had been applied in order to manage the violent and self-destructive behavior of Patient #1.

Based on a review of facility documentation and staff interviews, the facility failed to renew orders for restraint used for the management of violent or self-destructive behavior of an adult patient at least every four hours according to regulatory requirements and faciity policy for 1 of 5 patients undergoing restraint (Patient #1).

Findings were:

Facility policy #MCH-2053 entitled Restraints, last revised 01/2015, included the following:
"ORDERING OF RESTRAINT OR SECLUSION FOR VIOLENT OR SELF DESTRUCTIVE BEHAVIOR
Each order for restraint or seclusion used for the management of violent or self-destructive behavior (behavioral restraint or seclusion) that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be obtained and renewed in accordance with the following limits for up to a total of 24 hours: ...
o Up to four (4) hours for adults age 18 and older ...
At the end of time frame, if the continued use of restraint or seclusion to manage violent or self-destructive behavior is deemed necessary based on individualized patient assessment, another order is required ...Whether or not an onsite assessment is necessary prior to renewing the order is left to the discretion of the physician or other LIP (licensed independent practitioner) in conjunction with a discussion with the RN who is over-seeing the care of the patient ..."

A review of the medical record of Patient #1 revealed a nursing note on 4/1/16 at 12:15 which included the following:
"...spoke with the patient with the police about if he did not stop trying to harm himself or the staff then we would have to restrain him. Pt yelled at the police and the director saying he will "whatever he wants and there is nothing we can do about it it [sic] is my right to decide when to die" Patient was restrained ..."

A physician's order for initial restraint on 4/1/16 at 12:15 p.m. read as follows: "Started initial restraint ...Rationale: pulling lines, harm to self and others, actual date/time of restraint...1158...Type of restraint: both wrists..." An additional order at 12:15 p.m. included the following: "Type of restraint: both ankles..."

The next patient restraint assessment for Patient #1 was at 2:00 p.m. on 4/1/16 and included, "Effect on behavior: inadequate..."

There was no documentation in the medical record of Patient #1 of when physical restraints were removed, or if they were removed during the approximate 24-hour inpatient stay of Patient #1. The facility could provide no documented evidence of additional physician's orders to continue the restraints beyond the initial order above.

In an interview with Staff #1, Director of Quality, on the morning of 8/23/16 in the facility conference room, she assisted with the review of the medical record of Patient #1. She stated, "I'm not sure when the restraints came off. It doesn't seem to be documented and the record doesn't contain a discontinue restraints order from the physician." She agreed that the restraint had been applied in order to manage the violent and self-destructive behavior of Patient #1.

Based on a review of facility documentation and staff interviews, the facility failed to discontinue a patient restraint at the earliest possible time for 1 of 5 patients undergoing restraint (Patient #1).

Findings were:

Facility policy #MCH-2053 entitled Restraints, last revised 01/2015, included the following:
"DISCONTINUATION OF RESTRAINT OR SECLUSION
Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. Restraint or seclusion may only be employed while the unsafe situation (clinical justification) continues. Once the unsafe situation ends, the use of restraint or seclusion must be discontinued ..."

A review of the medical record of Patient #1 revealed a nursing note on 4/1/16 at 12:15 which included the following:
"...spoke with the patient with the police about if he did not stop trying to harm himself or the staff then we would have to restrain him. Pt yelled at the police and the director saying he will "whatever he wants and there is nothing we can do about it it [sic] is my right to decide when to die" Patient was restrained ..."

A physician's order for initial restraint on 4/1/16 at 12:15 p.m. read as follows: "Started initial restraint ...Rationale: pulling lines, harm to self and others, actual date/time of restraint...1158...Type of restraint: both wrists..." An additional order at 12:15 p.m. included the following: "Type of restraint: both ankles..."

A nursing note at 1:54 p.m. on 4/1/16 included the following: "Patient has calmed down immensely and one arm has been unrestrained."

A nursing note at 2:00 p.m. on 4/1/16 included the following: "Pt stated he was angry with the way the nurse on 9C and the cops handled the previous situation and was upset bc (because) they had taken his phone away and he was expecting a phone call from his adopted granddaughter at 12:30, the time at which the nurse took it aw ...he came to his right mindset and called for help and he feels like he is being treated like a criminal here in MCH; teaching was done about MCH policy for suicide attempts and pt had help if needed and he verbalized understanding."

The next patient restraint assessment was at 2:00 p.m. on 4/1/16 and included, "Effect on behavior: inadequate..."

There was no documentation in the medical record of Patient #1 of when physical restraints were removed, or if they were removed during the approximate 24-hour inpatient stay of Patient #1.

In an interview with Staff #1, Director of Quality, on the morning of 8/23/16 in the facility conference room, she assisted with the review of the medical record of Patient #1. She stated, "I'm not sure when the restraints came off. It doesn't seem to be documented and the record doesn't contain a discontinue restraints order from the physician." She agreed that the restraint had been applied in order to manage the violent and self-destructive behavior of Patient #1.

Based on a review of facility documentation and staff interviews, the facility failed to monitor the restraint used for the management of violent or self-destructive behavior according to facility policy for 1 of 5 patients undergoing restraint (Patient #1).

Findings were:

Facility policy #MCH-2053 entitled Restraints, last revised 01/2015, included the following:
"ONGOING MONITORING & ASSESSMENT OF A PATIENT IN RESTRAINT OR SECLUSION...
Ongoing assessment means that the patient will be evaluated to determine the patient's response to the restraint or seclusion, and if the patient has any care needs. This assessment shall include checking the patient's vital signs, hydration and circulation; the patient's level of distress and agitation; or skin integrity, and may also provide for general care needs (e.g., eating, hydration, toileting, and range of motion exercises). This assessment shall also determine if the patient continues to require restraint or seclusion ...
Minimum Frequency of Monitoring and Assessment of a Patient in Restraint or Seclusion
Patients placed in restraint or seclusion for violent or self-destructive behavior should be monitored at least every 15-30 minutes ...
DOCUMENTATION OF THE USE OF RESTRAINT OR SECLUSION
Each episode of restraint or seclusion should contain at least the following documentation in the patient's medical record:
Individual patient assessments and reassessments ...
The intervals for monitoring ..."

A review of the medical record of Patient #1 revealed a nursing note on 4/1/16 at 12:15 which included the following:
"...spoke with the patient with the police about if he did not stop trying to harm himself or the staff then we would have to restrain him. Pt yelled at the police and the director saying he will "whatever he wants and there is nothing we can do about it it [sic] is my right to decide when to die" Patient was restrained ..."

A physician's order for initial restraint on 4/1/16 at 12:15 p.m. read as follows: "Started initial restraint...Rationale: pulling lines, harm to self and others, actual date/time of restraint...1158...Type of restraint: both wrists..." An additional order at 12:15 p.m. included the following: "Type of restraint: both ankles..."

The next patient restraint assessment for Patient #1 was at 2:00 p.m. on 4/1/16 and included, "Effect on behavior: inadequate..."

There was no documented evidence in the medical record of Ronald Cox of an Inpatient Behavior/Close Observation Multidiscipline Flow sheet that the facility required for individuals at risk for suicide. The type of monitoring to be checked on the flow sheet included: "Low Risk: Every 1 hour ...High Risk: Every 15 minutes ..."

In an interview with Staff #1, Director of Quality, on the morning of 8/23/16 in the facility conference room, she assisted with the review of the medical record of Patient #1. She stated the patient was on suicide precautions while he was at the facility. She added, "I know they [nursing staff] were seeing the patient, but it wasn't documented as an assessment...There should have been an increased level of monitoring for this patient too. By our policy, he should have been monitored every 15 minutes for a behavioral restraint... We saw retrospectively that this chart didn't have the required documentation ..."

Based on a review of facility documentation and staff interviews, the facility failed to have a physician or other licensed independent practitioner see the patient face-to-face within 1-hour after initiation of a restraint used for the management of violent or self-destructive behavior according to facility policy for 1 of 5 patients undergoing restraint (Patient #1).

Findings were:

Facility policy #MCH-2053 entitled Restraints, last revised 01/2015, included the following:
"SPECIAL ASSESSMENT REQUIREMENT FOR PATIENTS PLACED IN RESTRAINT OR SECLUSION FOR VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR
When restraint or seclusion is used to manage violent or self-destructive behavior, a physician or other LIP, or a registered nurse (RN) or physician assistant (PA) trained in accordance with this policy must see the patient face-to-face within one (1) hour after the initiation of the intervention ...The one (1) hour face-to-face patient evaluation must be conducted in person ...The one (1) hour face-to-face evaluation should include both a physical and behavioral assessment of the patient ...
DOCUMENTATION OF THE USE OF RESTRAINT OR SECLUSION
Each episode of restraint or seclusion should contain at least the following documentation in the patient's medical record:
Any in-person medical and behavioral evaluation for restraint or seclusion used to manage violent or self-destructive behavior - including the one (1) hour face-to-face assessment for patients placed in restraint or seclusion for violent or self-destructive behavior ..."

A review of the medical record of Patient #1 revealed a nursing note on 4/1/16 at 12:15 which included the following:
"...spoke with the patient with the police about if he did not stop trying to harm himself or the staff then we would have to restrain him. Pt yelled at the police and the director saying he will "whatever he wants and there is nothing we can do about it it [sic] is my right to decide when to die" Patient was restrained ..."

A physician's order for initial restraint on 4/1/16 at 12:15 p.m. read as follows: "Started initial restraint...Rationale: pulling lines, harm to self and others, actual date/time of restraint...1158...Type of restraint: both wrists..." An additional order at 12:15 p.m. included the following: "Type of restraint: both ankles..."

The next patient restraint assessment for Patient #1 was at 2:00 p.m. on 4/1/16 and included, "Effect on behavior: inadequate..."

There was no documented evidence in the medical record of Ronald Cox of a face-to-face assessment being of Mr. Cox being performed by a physician within one hour.

In an interview with Staff #1, Director of Quality, on the morning of 8/23/16 in the facility conference room, she assisted with the review of the medical record of Patient #1. She stated, "I'm not sure when the restraints came off. It doesn't seem to be documented and the record doesn't contain a discontinue restraints order from the physician." She agreed that the restraint had been initiated to manage the violent behavior of Patient #1. She stated, "The one-hour face-to-face assessment wasn't done, and it should have been for this restraint. I know they were seeing the patient, but it wasn't documented as an assessment... Our nurses aren't trained to do the assessments here, so at this point in time, they have to be completed by a physician..."