HospitalInspections.org

Based on review of medical records, staff interviews and policies and procedures it was determined that the facility failed to insure:

A-0117- that hospital personnel followed the approved policies and procedures for notification to patient representatives of plans of care, changes in treatment, and discharge planning.

A-0130-that the hospital failed to ensure that seven of seven patients (# 11,22,23,24,29,30,31) were able to participate in the development and implementation of their care plans.

A-0154-that hospital personnel and medical staff followed the approved policies and procedures for restraints by documenting the alternative interventions that were initiated and the results of the use of those alternatives prior to the use of restraint. (Patient #1, 2, 3, 4, 5)

Based on a review of current medical records, policy and procedure and interview, it was determined the administrator failed to require that hospital personnel followed the approved policies and procedures for notification to patient representatives of plans of care, changes in treatment, and discharge planning. Facility failed to document in 5 of 5 current records (Patient #1, 2, 3, 4, 5, 6, 16, 17).

This deficient practice poses a potential risk to the patient is their representative is unaware of changes that may affect the patient's care and make decisions on the patient's behalf.

Findings include:

Policy titled "Restraints", no policy number, last revised 11/2019, required "...Patients have the right to be free from restraints...alternatives...Ask a family member to sit with the patient when possible..."

Policy titled "Assessment/Re-assessment, Interdisciplinary", no policy number, last revised 9/2019, requires "...The assessment process will be a continuous inter-disciplinary function and a collaborative effort with all departments function as a care team. Information generated...by all clinical disciplines will be integrated to identify and prioritize the patient's needs...will be collaborative...and discussed as an interdisciplinary group...care planning will be guided by the data...the expectations of the family and / or guardian will also be considered...patients and family members may request further evaluation for specific needs...Case management (complete) within 72 hours of admission...Interview with patient or family member...discharge planning needs...Case management...planning will continue until the time of discharge...make appropriate arrangements to meet the needs of the patient/family...."

Document titled "A Guide to Patient Services", no document number, last revised 9/09/2020, and described as the "Welcoming Packet", revealed "...As a patient in our hospital, you or your representative have the right to...assurance that restraints...of any form will not be used as a means of...convenience...(You or your representative have a right to) a patient representative or advocate...be informed of your rights and responsibilities in advance of receiving or discontinuing patient care...participate in the development and implementation of a plan of care...discharge plan...(the patient may have a) Durable Power of Attorney for Healthcare, to express choices about your care or name someone to act on your behalf...."

Facility document titled "KPC Promise Hospital Case Management Progress Notes", did not reveal documentation that the patient or patients representative were consulted or participated in plan of care by Case Management on:
Patient #1 on: 7/13, 7/15, 7/22, 7/29, 8/04, 8/11, 8/12, 8/17, 8/24, 8/31, 9/02, and 9/08/2020.
Patient #2 on: 8/10/2020 - there was no further case management notes available for review in medical record,
Patient #3 on: 9/03/2020 and 9/09/2020 - there was no further case management notes available for review in medical record,
Patient #4 on: 8/19/2020 - there was no further case management notes available for review in medical record,
Patient #5 on: 8/25/2020 and 9/02/2020,
Patient #6 on: 9/08/2020,
Patient #16 on: 8/23/2020 and 8/30/2020.


Facility document titled "Weekly Interdisciplinary Team Conference / Plan of Care Report" revealed sections of the plan separated with labels of "...Medical...Safety...Bladder/Bowel...Skin Integrity/Circulation...Nutrition...Mobility...Self Care...Communication / Cognition /Swallowing...Education...Other (times two)...Discharge Planning / Recommendations...Signatures...." Patient medical records for Patient #1 through Patient #5 revealed:

Patient #1 - An area marked with "...Discharge Planning/Recommendation", did not contain documentation that family was notified or participated in planning. Area marked with signature lines does not contain a signature for patient or family members. Omission was noted for records dated:
7/12/2020, 7/19/2020, 7/26/2020, 8/02/2020, 8/09/2020, 8/17/2020, 8/30/2020 - no further plan of care reports were available for review. Patient was admitted on 7/10/2020. In addition, throughout the documentation there is multiple areas of no responses by a "discipline", they are blank.

Patient #2 - An area marked with "...Discharge Planning/Recommendation", did not contain documentation that family was notified or participated in planning. Area marked with signature lines does not contain a signature for patient or family members. Omission was noted for records dated:
8/23/2020 and 8/30/2020 - no further plan of care reports were available for review. Patient was admitted on 8/17/2020. In addition, throughout the documentation there is multiple areas of no responses by a "discipline", they are blank.

Patient #3 - An area marked with "...Discharge Planning/Recommendation", did not contain documentation that family was notified or participated in planning. Area marked with signature lines does not contain a signature for patient or family members. Omission was noted for record dated 9/02/2020 - no further plan of care reports were available for review. Patient was admitted on 9/02/2020. In addition, throughout the documentation there is multiple areas of no responses by a "discipline", they are blank - for skin, nutrition, mobility, self care, communication, education, and discharge planning. The only signature noted in plan of care report is of a "nurse". There is no signatures for Physician, Case manager, Social Worker, Occupational Therapy, Speech therapy, Dietician, Wound Care, Respiratory, Physical Therapy, Pharmacist, Patient or the family.

Patient #4 - An area marked with "...Discharge Planning/Recommendation", did not contain documentation that family was notified or participated in planning. Area marked with signature lines does not contain a signature for patient or family members. Omission was noted for records dated 8/23/2020 and 8/30/2020 - no further plan of care reports were available for review. Patient was admitted on 8/18/2020. In addition, throughout the documentation there is multiple areas of no responses by a "discipline", they are blank.

Patient #5- An area marked with "...Discharge Planning/Recommendation", did not contain documentation that family was notified or participated in planning. Area marked with signature lines does not contain a signature for patient or family members. Omission was noted for records dated 8/23/2020 and 8/30/2020. Patient was admitted 8/20/2020. Throughout the documentation there is multiple areas of no responses by a "discipline", they are blank.

Patient #6 - An area marked with "...Discharge Planning/Recommendation", did not contain documentation that family was notified or participated in planning. Area marked with signature lines does not contain a signature for patient or family members. Omission was noted for records dated 9/07/2020. Patient was admitted 9/07/2020. Throughout the documentation there is multiple areas of no responses by a "discipline", they are blank. In addition there are no signatures on the form - form was obtained 9/11/2020.

Patient #16 - An area marked with "...Discharge Planning/Recommendation", did not contain documentation that family was notified or participated in planning. Area marked with signature lines does not contain a signature for patient or family members. Omission was noted for record dated 8/23/2020 and 8/20/2020. Throughout the documentation there is multiple areas of no responses by a "discipline", they are blank.

Patient #17 - An area marked with "...Discharge Planning/Recommendation", did not contain documentation that family was notified or participated in planning. Area marked with signature lines does not contain a signature for patient or family members. Omission was noted for record dated 8/09/2020. Throughout the documentation there is multiple areas of no responses by a "discipline", they are blank.

Based on review of hospital policies/procedures, documents, chart review, and staff interviews, it was determined that the hospital failed to ensure that seven of seven patients (# 11,22,23,24,29,30,31) were able to participate in the development and implementation of their care plans. This deficient practice poses a risk to the health and safety of patients, when the patient and/or family are not afforded the opportunity to contribute vital information to staff and in turn receive vital information from staff regarding the discharge process.

Findings include:

The policy titled "Discharge Planning and Interdisciplinary Process" requires that " ...The case manager/social worker will work with the patient and family to ensure there is participation in the discharge planning process and the patient and family agree with the discharge plan and goals ...."

The patient handbook titled "A Guide to Patient Services" states the following: " ...You are also an important member of the team involved in your care and discharge plans. Our case managers will meet with you after each team meeting to discuss your care and provide you with necessary information to answer your questions. If you wish to attend the team conference personally to question or interact with all of the team members involved in your care, please inform your case manager. You will be notified of the next scheduled team conference and arrangements made for your attendance. If you are unable to attend, you may have a representative at the team conference. However, if you are capable of making your own medical decisions, family members/representatives may only attend at your request ...."

During an interview conducted on 09/11/20, Employee #21 confirmed that the following information was missing from the respective patient's medical record. Additionally, Employee #21 revealed that the employee responsible for completing the missing documentation (Employee #20) was terminating employment with the hospital effective 09/14/20. Employee #20 failed to report for duty on 09/11/20 and 09/14/20.

Patient #11

Weekly Interdisciplinary Team Conference/Plan of Care Report
07/27/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

08/03/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

08/09/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

08/17/20
Patient/Family Involvement in Care: MPOA/daughter
No Patient or Family Member signature

KPC Promise Hospital Case Management Progress Notes
07/29/20 " ...First impression mtg with CM, infection prevention, nurse manager, RT, clinical liaison at bedside with patient, introductions made. Care discussed. Patient agreed to plan ...."

On 09/09/20 1200, Employee #20 documented the following as a late entry " ...Spoke with daughter on DCP for home which patient requests vs SNF. [Heidi] refers all DCP to patient. Spoke with patient at bedside on home DC. Patient ... IV antibiotics at home. Briove Infusion was selected and advised patient on 08/20/20 that home care for infusion will be $700 out of pocket. Patient did not want to pay and chose Sante of Chandler for the length of his antibiotic infusion prior to going home. Choice letter in chart ...."

Patient #22

There are no KPC Promise Hospital Case Management Progress Notes for this patient.

Weekly Interdisciplinary Team Conference/Plan of Care Report
06/15/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

06/21/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

06/28/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

07/05/20
The entire Discharge Planning/Recommendations section is blank.
No Patient or Family Member signature
No MD or Case Manager signature

IAA Social Services/Care Management
Discharge Environment-
Interdisciplinary Plan of Care reviewed with patient/family- blank
Contact with external case management and/or payor source initiated- blank
The section is crossed through and "Homeless" is written.

Discharge Information-
Documented that discharge placement options were provided and that discharge information was provided to family. However, there is no documentation in the KPC Promise Hospital Case Management Progress Notes to support this.

Patient Choice Form For Post Hospital Service
Received verbal consent from Patient #22's mother on 07/07/20, the date of discharge.

Patient Care Transfer Summary
No documentation of consent to transfer by Patient #22's mother.

Patient #23

Weekly Interdisciplinary Team Conference/Plan of Care Report
04/29/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

Patient #24

Weekly Interdisciplinary Team Conference/Plan of Care Report
No Date
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

06/07/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature
No MD signature

Patient Choice Form For Post Hospital Service
Received verbal consent from Patient #24's mother and Power of Attorney (POA) on 06/16/20, the date of discharge.

KPC Promise Hospital Case Management Progress Notes
The initial note, dated 06/08/20, contains no documentation of Patient #24's POA being involved.
The "Updated Review", dated 06/12/20, contains no mention of Patient #24's POA being involved. There is also no documentation of team involvement either.

IAA Social Services/Care Management
Patient/Family Goal For Discharge- Blank
Discharge Environment-
Interdisciplinary Plan of Care reviewed with patient/family- blank
Contact with external case management and/or payor source initiated- blank
Discharge Information-
Includes who discharge information was provided to, if discharge placement options were provided, what agency/facility the patient was referred to, and how information regarding continuum of care was provided.
This section was completely blank with no staff signature.

Patient #29

Weekly Interdisciplinary Team Conference/Plan of Care Report
No Date
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

03/08/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

03/15/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

03/22/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

03/28/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

04/05/20
Patient/Family Involvement in Care: "yes daughter"
No Patient or Family Member signature

KPC Promise Hospital Case Management Progress Notes
03/04/20- " ...first impression meeting held with patient. Patient is alert and oriented. We discussed plan of care. Patient did not have any questions at this time ...."
03/16/20- " ...spoke with patient at bedside regarding discharge care plan for 03/23/20 to next level of care. Patient chose Sante Chandler for skilled nursing facility. Choice letter signed ...."
04/07/20- " ...spoke with patient about discharge care plan home 04/10/20 to daughter's house, agreeable. Kindred Home Health Care choice letter signed ...."

There is no documentation of any communication with Patient #29's daughter in the KPC Promise Hospital Case Management Progress Notes.

Patient #30

Weekly Interdisciplinary Team Conference/Plan of Care Report
05/24/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

05/31/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

06/07/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature
No MD or Case Manager signature

KPC Promise Hospital Case Management Progress Notes
05/27/20- " ...first impression meeting with patient team of CM, PT, respiratory, house supervisor at bedside. Plan of care discussed with patient ...patient understands, no other concerns at this time ...." This is the only documentation that Patient #30 had any involvement in care/discharge planning.

Discharge Instruction Sheet
"I hereby acknowledge I have read these instructions. They were explained to me, I had the opportunity to ask questions, and I was provided a copy." This document was not signed by Patient #30.

Patient #31

Weekly Interdisciplinary Team Conference/Plan of Care Report
06/07/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

06/14/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

06/21/20
Patient/Family Involvement in Care: blank
No Patient or Family Member signature

Based on a review of current medical records, policy and procedure, and interview, it was determined the administrator failed to require that hospital personnel and medical staff followed the approved policies and procedures for restraints by documenting the alternative interventions that were initiated and the results of the use of those alternatives prior to the use of restraint. (Patient #1, 2, 3, 4, 5)

This deficient practice poses a risk to the patient for injury and loss of autonomy.

Findings include:

Hospital policy titled "Restraints", no policy number, last updated 11/2019, requires "...Restraint shall not be used when less restrictive interventions would be effective...Alternatives...placing items closer to patient...move patient closer to nursing station...bed-check alarm...provide 1:1 sitter...talking with patient...redirecting...orienting patient to surroundings...place lines out of patient's sight reach...cover IV tubing...reposition...diversional activity...adequate pain control...."

The nursing documentation note for critical care revealed a box with every hour times going horizontal and vertically there are "...type of restraint...meets...criteria...(check mark) = alternate methods used...release q 2 hr (release every 2 hours)...(check mark)=restraint safety...behavioral patient...." Telemetry documentation is similar just in a different area of the paper documentation.

Patient 1's medical record revealed the registered nurse documented in the nursing restraint notes on:
Patient #1 has been in restraints since admission to the hospital on July 10, 2020 through day of survey September 9, 2020. The following is a small representation of the documentation errors found in this current patients chart.
8/13/2020 - at 1920 hours, Nursing progress note from the telemetry unit revealed "...soft wrist restraints c (with) bilaterally...." No other documentation is present as to restraints and how long they were kept on, interventions attempted, or call to physician for renewal of order. There was no documented evidence the nursing personnel assessed the patients condition related to the need for restraints when the patient was received from ICU. Further there is no documentation in the "Restraint" area of the charting, it is blank. It is unknown if patient remained in restraints.
8/15/2020 - Nursing restraint hourly assessment with boxes revealed that the patient was in restraints both shifts with "alternatives" marked as a "...Y...." for day shift, there is no further documentation as to what alternatives were attempted. Patient was restrained with one ankle and two wrist restraints. Nursing documentation does not reveal that physicians were notified of a renewal need for restraints.
8/16/2020 - Nursing restraint hourly assessment with boxes revealed that patient was restrained both shifts entire time, day shift marked alternatives attempted with "Y", no documentation of type of alternative tried. Patient restrained with one ankle and both wrists. Nursing documentation does not reveal that physicians were notified of a renewal need for restraints.
8/17/2020 - Nursing restraint assessment documentation reveals "...Y...." for interventions attempted. No documentation is present in nursing documentation every two hours that defines the definition of Y.
8/19/2020 - Nursing restraint assessment documentation reveals "initials" of nurse for interventions attempted. No documentation is present in nursing progress note area that defines the every two hours that defines the initial. This was done both shifts. Nursing documentation reveals that the patient was "calm" and does not reveal that physicians were notified of a renewal need for restraints or why restraints were on.

Patient 2's medical record revealed the registered nurse documented in the nursing restraint notes on:
9/09/2020 - Medical record revealed that nursing obtained an order for restraints at 1930 hours. Nursing documentation does not show if patient was placed into restraints, and no documentation in progress notes as to behavior that warranted order.
9/10/2020 - at 2000 hours, Nursing restraint box area shows that patient was placed in restraints during nightshift with "alternatives" marked as a "...Y...." for day shift, there is no further documentation as to what alternatives were attempted. No nursing progress note documentation is noted as to how patient was behaving and why patient was placed into restraints after twenty three (23) days without restraints. Dayshift documented patient to be sitting in chair, "uneventful" day.

Patient #3's medical record revealed the registered nurse documented in the nursing restraint notes on:
9/02/2020 - the patient was "restrained" with "bulky mitts". A check mark is placed for alternative methods attempted but does not define the types attempted. Documentation reveals that the patient was "initiated" on restraints at 2200 hours through 0600 hours on 9/03/2020. Nursing "Progress Note" revealed patient is on a ventilator but no documentation of restraints or why continued/initiated use and no notification to physician.
9/03/2020 - the medical record reveals that the patient was not on restraints from 0700 hours through 0600 hours of the 9/04/2020. There is no documentation of why the restraints were removed.
9/08/2020 - the patient was "restrained" with "SWR (soft wrist restraints)". Documentation reveals that the patient was "initiated" on restraints at 2200 hours through 0600 hours on 9/09/2020. Nursing "Progress Note" revealed patient is on a ventilator and at "...(2345)...Pt (patient) confused last two hours soft wrist restraints placed for pt safety...." Medical record does not reveal documentation of notification to physician for order for restraints.
9/09/2020 - the patient was restrained with "wrist" or soft wrist restraints throughout day on 9/09/2020. Nursing "Progress Note" does not reveal alternatives to restraint being documented by dayshift, there is only an initial placed in form. Nightshift documented two (2) of the specified six (6) times in a progress note. Medical record does not reveal documentation of notification to physician for continuation order for restraints by either shift.

Patient #4's medical record revealed the registered nurse documented in the nursing restraint notes on:
8/18/2020 - patient was admitted at 1800 hours, restraints were placed at 2000 hours, only intervention attempted was close observation. Medical record does not contain documentation that physician was notified and the need for continued restraint was necessary.
8/19/2020 - restraints applied entire day. Dayshift documented alternatives with an "initial". Neither day or night shift documented that physician was notified.
8/21/2020 - patient was transferred to ICU. Documentation revealed "...1230 (hours) Bilat hand mitts in place per pt (patient) safety...." A check mark is placed for alternative methods attempted but does not define the types attempted for all of day shift assessments. Nursing progress note does not define attempts or check mark. No documentation to physicians as to continued need for restraints.
8/22/2020 - patient in ICU, night shift documenting interventions with a check mark, no definition of meaning of check mark in nursing progress notes, no documentation to physicians as to continued need for restraints. Nursing Progress note revealed "...basically uneventful night...." at 1900 hours.
8/23/2020 - nursing night shift documentation reveals a checkmark for all hour night shift, no defining notes for what was less restrictive attempted, and no note about why continued need or call to physician.
8/24/2020 - nursing night shift documentation reveals a checkmark for all hours both shifts, no defining notes for what was less restrictive attempted, and no note about why continued need or call to physician.
9/02/2020 - dayshift documentation revealed "Y" for interventions, no definition of the meaning of "y" in progress note, no note about why continued need for restraints or call to physicians.
9/04/2020 - dayshift documentation revealed "Y" for interventions, no definition of the meaning of "y" in progress note, no note about why continued need for restraints or call to physicians.
9/05/2020 - dayshift documentation revealed initials for interventions, no definition of the meaning of initials in progress note, no note about why continued need for restraints or call to physicians.
9/06/2020 - dayshift documentation revealed initials for interventions, no definition of the meaning of initials in progress note, no note about why continued need for restraints or call to physicians.
9/09/2020 - both day and night documentation revealed initials for interventions, no definition of the meaning of initials in progress note, no note about why continued need for restraints or call to physicians.

Patient #5's medical record revealed the registered nurse documented in the nursing restraint notes on:
8/20/2020 - Nursing note restraint assessment documentation for nightshift starting at 2000 hours revealed patient is in wrist restraints, "...Need for continual restraints met Q 8...." hours is not checked indicating need for restraints. There is not Nursing Progress note documentation stating why patient was placed in restraints behaviorally and no notification to physician note.
9/04/2020 - 2300 hours Nursing progress note revealed "...Pt. found hanging over R (right) bed rail. Pt placed in restraints...." Documentation does not reveal alternative methods were tried prior to placing restraints.
9/05/2020 - day and night shift "alternatives attempted" is marked with "initials", nursing progress notes do not reveal alternatives attempted.
9/06/2020 - day and night shift "alternatives attempted" is marked with "initials", nursing progress notes do not reveal alternatives attempted.

Medical records were reviewed with the Chief Operating Officer, Director of Quality and Risk Management, and the Nurse Manager throughout the survey process. Chief Operating Officer and Director of Quality/Risk Management confirmed in interview on September 11, 2020 at 1630 hours that the multiple patient charts were missing documentation, exhibiting incorrect documentation, or were incomplete.

Based on review of hospital polices/procedures, medical records, and staff interviews, it was determined that patients were placed in restraints without physician orders for 5 of 5 patients in restraints (Patient #1, 2, 3, 4, and 5). This deficient practice poses a risk of injury and/or harm to patients in restraints without physician direction (orders).

Findings include:

The hospital policy titled Restraints, no policy number, last revised 11/2019, requires "...Standing...orders for restraints are not valid...If the attending physician is not available, a registered nurse may initiate restraint in advance of a physician's order. The attending physician must be notified, and a restraint order requested immediately after initiation of the restraint...alternatives...shall be documented every two (2) hours...."

Medical record revealed that the patients were in restraints with no physician orders, as follows:

Patient #1:
7/16/2020 at 0001 hours through 7/17/2020 at 0001 hours,
7/17/2020 at 0001 hours through 7/18/2020 at 1400 hour,
8/15/2020 at 0001 hours through 8/16/2020 at 0001 hours,
8/16/2020 at 0002 hours through 8/17/2020 at 0001 hours.
The nursing staff maintained the patient in restraints for 86 hours with no physician order.

Patient #2:
9/10/2020 at 1930 hours through 9/11/2020 at 0001 hours - No documentation as to why the patient was placed into restraints after 24 days without restraints.

Patient #3:
9/08/2020 at 2200 hours through 2359 hours,
9/09/2020 at 0000 hours through 0600 hours - physician was not called and there is no time of authentication of physician signature - process at hospital is nurses fill in form and place in manilla folder for physicians to sign when they round. Medical record does not reveal any face to face by a qualified provider or call notification for physician. The nursing staff maintained the patient in restraints for 8 hours without an order or notification to physician.
9/10/2020 at 0001 hours through 9/10/2020 at 0600 hours.
The nursing staff maintained the patient in restraints for 14 hours with no physician order.

Patient #4:
8/23/2020 at 0002 hours through 8/23/2020 at 2359 hours,
8/29/2020 at 0000 hours through 8/29/2020 at 0010 hours,
8/31/2020 at 0001 hours though 9/01/2020 at 0001 hours,
The nursing staff maintained the patient in restraints for 48.17 hours with no physician order.

Patient #5:
8/20/2020 at 2000 hours through 8/21/2020 at 0001 hours,
8/22/2020 at 0001 hours through 8/22/2020 at 2359 hours,
8/23/2020 at 0000 hours through 8/24/2020 at 0000 hours,
8/24/2020 at 0000 hours through 2359 hours,
8/25/2020 at 0000 hours through 2359 hours,
8/26/2020 at 0000 hours through 2359 hours,
8/27/2020 at 0000 hours through 2359 hours,
8/28/2020 at 0000 hours through 2359 hours,
8/29/2020 at 0000 hours through 2359 hours,
8/30/2020 at 0000 hours through 2359 hours,
9/01/2020 at 0000 hours through 2359 hours,
9/02/2020 at 0000 hours through 2359 hours,
9/03/2020 at 0000 hours through 2359 hours,
9/04/2020 at 0000 hours through 9/04/2020 at 1830 hours,
9/09/2020 at 0000 hours through 2359 hours,
9/10/2020 at 0000 hours through 1200 (noon) hours.
The nursing staff maintained the patient in restraints 370.5 hours with no physician order.

Based on review of hospital polices/procedures, medical records, and staff interviews, it was determined that patients were placed in restraints with no attempts for release for 5 of 5 patients in restraints (Patient #1, 2, 3, 4, and 5). This deficient practice poses a risk of injury, deteriorating skin conditions, and/or harm to patients for being restrained for extended amounts of time without release or attempts at release.

Findings include:

Policy titled "Restraints", no policy number, last revised 11/2019, required "... The hospital discontinues the use of restraint at the earliest possible time, regardless of the scheduled expiration of the order...restraint shall not be used when less restrictive interventions would be effective...staff members shall receive training in the following...the use of nonphysical intervention skills...."

Patient #1 was in restraints from July 10, 2020 through September 9, 2020 - sixty four (64) days. Progress notes by physicians do not reveal why there was a continued need for restraints - they do not reveal any notes related to patient neurological status and need for restraints. A sampling of nurse progress note documentation revealed:
8/13/2020 - "...Pt (Patient) is alert to self and trying to get out of restraints. Encouraged to settle down...."
8/15/2020 - "...Pt resting in bed...No s/s (signs or symptoms) of distress...Pt is on bilateral upper extremities soft wrist restraints mitts along with right ankle restraint....", no attempts at release of restraints is documented
8/16/2020 - restraint assessment revealed close observation as only intervention attempted, nursing progress notes did not contain any other attempts at "release".
8/17/2020 - no documentation noted that showed what type of interventions were attempted other than close observation, no attempts at release of restraints is documented.

Patient #2 was placed in restraints September 9/10/2020 after 2000 hours after twenty four (24) days of no restraints. Medical record does not contain documentation from physician or nursing as to why patient was placed into restraints and release was not attempted.

Patient #3 was admitted to hospital in restraints / intubated. Nursing documentation does not reveal why restraints were on patient, why restraints continued and does not reveal any attempts made to release restraints from 9/02/2020 at 2200 hours till 9/03/2020 at 0600 hours. Medical record revealed patient not in restraints 9/03/2020 - no nursing or physician documentation as to placement or removal. Medical record 9/08/2020 at 2200 hours through 9/10/2020 at 0600 hours revealed patient in placed into and maintained on restraints. Nursing progress note does not reveal attempts or rationale for continuation of restraints after 2345 hour note until 9/09/2020 at 1930 hour note.

Patient #4 was placed in restraints from August 18, 2020 (admit) through September 7, 2020. Medical reveals no documentation of attempt releases from 8/18/2020 at 2000 hours till 8/20/2020 at 2145 hours and no further documentation until 8/21/2020 at 1230 documenting that restraints are "on". Nursing progress notes from 8/21/2020 at 1950 hours revealed "...(patient) lethargic, withdrawn...mitts on for line and tube safety...." - medical record does not contain attempts at removal. Medical record does not reveal nursing or physician attempts at release of restraints from 8/23/2020 through 9/07/2020 when bed alarm was only "restraint". Medical record from September 9, 2020 revealed that patient was in restraints from 0800 hours through 0500 the next day - no documentation of releases attempted is written.

Patient #5 was placed in restraints August 20, 2020 (admit) through September 10, 2020. Medical record revealed no attempts at release from 8/21/2020 at 0730 hours through 8/24/2020 at 1500 hours. Patient was released from restraints at 1500 hours till 8/26/2020 at 1000 hours when wrist restraints were placed. Medical record does not reveal documentation of release attempts or rationale for continuation from 8/26/2020 through 8/28/2020 0730 hours. Restraints were released August 30 through September 4, 2020. Restraints reapplied 9/04/2020 at 1830 hours due to pulling at tubes. Medical record does not reveal documentation of attempts at release from 9/4/2020 at 1830 hours through 9/09/2020 at 1300 hours when restraints were removed. Medical record does not reveal attempts at release after restraints were replaced 9/10/2020 from 0800 hour to 1200 hours, further, no documentation exists that reveals why restraints were reapplied.

Employee #2, #3, and #4 confirmed in interview on September 9, 2020 that the above patients and medical records did not reveal the attempts at release, types of release attempts, less restrictive types of restraints attempted with results as to why they did not work, and that multiple medical records were missing documentation of continuation of restraint rationale.

Based on review of hospital polices/procedures, medical records, medical staff bylaws, medical staff rules and regulations, and staff interviews, it was determined that patients were placed in restraints with no face-to-face examinations by providers for 5 of 5 patients in restraints (Patient #1, 2, 3, 4, and 5). This deficient practice poses a risk of injury, deteriorating skin conditions, and/or harm to patients for being restrained without evaluation.

Findings include:

Facility document titled "KPC Promise Hospital Medical Staff Rules and Regulations", last revised 10/2019, requires "...The use of mechanical restraints shall require clinical justification and shall be used only to prevent a patient from injuring himself or others or to prevent serious disruption of the therapeutic environment...shall not be used as a means of punishment or for staff convenience. Restraint orders shall be reviewed each calendar day, and face-to-face evaluation is required prior to renewal...."

Policy titled "Restraints", no policy number, last revised 11/2019, required "... The hospital discontinues the use of restraint at the earliest possible time, regardless of the scheduled expiration of the order...restraint shall not be used when less restrictive interventions would be effective...staff members shall receive training in the following...the use of nonphysical intervention skills...."

Medical records for Patient #1, #2, #3, #4, and #5 do not reveal face-to-face evaluation within in one (1) hour of initiation of restraint. Further, multiple medical records reveal that the the providers do not document in daily progress notes the continued need for restraints. As observed in medical records for:

Patient #1 - Admitted 7/10/2020 - restraint order dated by nurse at 0200 hours on 7/10/2020, no face to face documentation is found by provider with in one hour of initiation.

Patient #2 - Admitted 8/17/2020 - restraint order dated by nurse at 1930 hours on 9/09/2020, no face to face documentation is found by provider with in one hour of initiation. Further, no documentation is found on 9/10/2020 by the nephrology, the hospitalist, the pulmonologist, or the wound doctor that acknowledges that the patient is in restraints.

Patient #4 - Admitted 8/18/2020 - restraint order dated 8/18/2020 at 2030 hours, no face to face documentation is found by provider with in one hour of initiation. In addition order for "initial set" of restraints not authenticated by a physician until 8/22/2020. Patient has no order for restraints, yet in them, on 8/23/2020 complete day, with no evaluation by provider or re-initiation of restraint.

Patient #5 - Admitted 8/20/2020 - patient was in restraints from 2000 hours though 2400 hours, restraint order dated 8/21/2020 at 0001 hours, no face to face documentation is found by provider with in one hour of initiation of restraints on 8/20/2020 at 2000 hours or within one hour of 8/21/2020 at 0001 hours order. Further, patient is in restraints / no order 8/22, 8/23, 8/26, 8/27, 8/28, 8/29, 9/09, and 9/10 - medical record does not reveal any documentation that patient was evaluated for continual need or initiation of restraints.

Employee #2 and #3 confirmed in interview on September 11, 2020 that the above patients and medical records did not reveal the required documentation of face-to-face with in one hour of initiation of restraint or re-initiation of restraints.

Based on review of hospital polices/procedures, medical records, and staff interviews, it was determined that patients were placed in restraints with no documentation for the continued use of restraints in 5 of 5 patients in restraints (Patient #1, 2, 3, 4, and 5). This deficient practice poses a risk of injury, deteriorating skin conditions, and/or harm to patients for being restrained without evaluation of interventions.

Findings include:

Policy titled "Restraints", no policy number, last revised 11/2019, requires "...the hospital uses the least restrictive form of restraint that protects the physical safety of the patient, staff, or others...use of restraints will be monitored for appropriateness and patient safety outcomes...Restraint shall not be used when less restrictive interventions would be effective...alternatives...items closer, bed-check alarm...family...1:1...redirecting...orienting...out of bed...chair...ambulate...(secure) lines...diversional activities...decrease stimulation...adequate pain control...."

Medical record documents (paper) revealed an area in ICU paperwork labeled "Restraints" and in Medical / Telemetry paperwork as "Restraint Assessment". Both areas contain boxes to check with criteria for restraint assessment and interventions. Alternatives methods are close observation, wedge pillow, mitts, seat belt, torso belt, bed alarm, personal alarm, wheelchair at nurses station, and siderails. Further, there is a location for "Need for continual restraints met q(every) 8 hrs (hours)".

Medical records revealed lack of assessment / response of patient to interventions with:

Patient #1 - in restraints for 62 days - portion from 8/15, 8/16, 8/17, and 8/19 shows patient was restrained the with bilateral wrist, mittens, and right ankle.
8/15/2020 - revealed "Y" for intervention from 0700-1900 - no definition of "Y" in notes, and "1" from 2000-0600 hours. One (1) is close observation. Nursing progress notes do not reveal any documentation of responses / behaviors to interventions.
8/16/2020 - revealed "Y" for intervention from 0700-1900 - no definition of "Y" in notes, and "1" from 2000-0600 hours. Nursing progress notes do not reveal any documentation of responses / behaviors to interventions or of additional interventions attempted.
8/17/2020 - revealed "1" for intervention from 0700-1900, and "Y" from 2000-0600 hours - no definition of "Y" in notes. Nursing progress notes do not reveal any documentation of responses / behaviors to less restrictive interventions or of additional interventions attempted.
8/19/2020 - revealed nurse initials in place "box" for interventions, no type defined, no notes written in progress note as to patient's response to continued use.

Patient #2 -
9/10/2020 - revealed "Y" for intervention from 2000 to 0600- no definition of "Y" in notes. Nursing progress notes do not reveal any documentation of responses / behaviors to interventions or of additional interventions attempted with patient.

Patient #4-
8/18/2020 through 8/30/2020 (12 days) - revealed "1", "Y", check marks, or nurse's initials. Nursing progress notes do not reveal any documentation of responses / behaviors to interventions or of additional types interventions attempted, there are no interventions documented that are less restrictive.

Patient #5 -
8/20/2020 through 9/04/2020 (14 days) - revealed patient was in wrist restraints, at times torso belts, and mittens. Nursing progress notes do not reveal any documentation of responses / behaviors to interventions less restrictive or of additional types of interventions attempted.

Employee #2 and #3 confirmed in interview on September 11, 2020 that the above patients and medical records did not reveal the required documentation for types of less restrictive interventions used and the rationale for the continual use of restraints.

Based on review of hospital polices/procedures, medical records, medical staff bylaws, medical staff rules and regulations, and staff interviews, it was determined that physicians:

1. failed to evaluate patients after initiation of restraints with face-to-face with in one hour time requirements,
2. failed to document the required need for continuation of restraints in progress note documentation,

This deficient practice poses a risk of injury, mental anguish, deteriorating skin conditions, and/or harm to patients for being restrained without evaluation of restraint interventions. There is no medical record documentation that the medical staff followed or enforced the bylaws and rules and regulations for restraints.

Findings include:

Facility document titled "Bylaws of KPC Promise Healthcare Group", no adoption date, or approval date, provided by the Chief Operating Officer and described as current bylaws, required "The Governing board shall, in the exercise of its discretion, delegate to the Medical Staff the responsibility of monitoring and evaluating the appropriateness of professional care rendered to the Hospital's patients. The medical staff shall conduct a continuing review and appraisal of the quality of professional care rendered ...shall make recommendations regarding the Medical Staff ...concerning ...evaluations of overall patient care ....Quality Assessment and Improvement ...shall provide for ...monitoring and evaluating the quality of patient care ...."

Facility document titled "KPC Promise Hospital of Phoenix Medical Staff Bylaws", adopted 10/2019, requires " ...(Medical Staff) Abide by these Bylaws, the Rules and Regulation, and all other rules, policies and procedures, guidelines and other requirements of the Medical Staff...Abide by all local, State, and Federal laws and regulations ...and State licensure ...Prepare and complete in a timely manner the medical and other required records for patients as specified in the Rules and Regulations ...Recurring pattern of incomplete medical records may result in recommendation for termination of ...clinical privileges ....The Rules and Regulation ...shall relate to the proper conduct of Medical Staff ...and shall embody the level of practice required of each Staff ...with clinical privileges ...."

Facility document titled "KPC Promise Hospital Medical Staff Rules and Regulations", last revised 10/2019, requires " ...Pertinent progress notes shall be recorded at the time of observation sufficient to permit continuity of care ...Shall be written daily ...Orders ...All restraints, now and STAT orders must be signed, dated and timed by the practitioner ...The use of mechanical restraints shall require clinical justification and shall be used only to prevent a patient from injuring himself or others or to prevent serious disruption of the therapeutic environment. Restraint orders shall be renewed each calendar day and a face-to-face evaluation is required prior to renewal ...shall be time limited ...."

Policy titled "Restraints", no policy number, last revised 11/2019, requires " ...If the attending physician is not available, a registered nurse may initiate restraint in advance of a physician's order. The attending physician must be notified, and a restraint order requested immediately after initiation of the restraint. The attending physician shall perform an in-person assessment of the restraint patient once every calendar day, at which time restraint shall be either re-ordered or discontinued as indicated ...Physicians who order restraints shall be trained in the requirements of this policy and shall demonstrate a working knowledge of this policy ...shall receive training in ...any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation ...."

1. Medical records revealed that the physicians failed to evaluate patients after initiation of restraints with face-to-face evaluation and document within one hour time requirements for:
Patient #1 -
7/10/2020 - initiation of restraints, no documentation from physician,
7/16/2020 - Patient in restraints, no order, no documentation from physician,
7/17/2020 - Patient in restraints, no order, no documentation from physician,
7/18/2020 - Patient in restraints, new order signed, no documentation from physician,
8/15/2020 - Patient in restraints, no order, no documentation from physician,
8/16/2020 - Patient in restraints, no order, no documentation from physician,
8/17/2020 - Patient in restraints, new order signed, no documentation from physician,

Patient #2 -
9/10/2020 - Patient placed in restraints at 2000 hours, no face-to-face documentation from physician,

Patient #3 -
9/03/2020 - order signed, no documentation if patient was placed in restraints or evaluation by physician,
9/08/2020 - Patient in restraints, no order, no evaluation by physician for need for restraints,
9/09/2020 - Patient in restraints from 0700 hours till 9/10/2020 0700 hours - no face to face documentation from physician,

Patient #4 -
8/18/2020 - Patient admitted at 2000 hours, no face-to-face documentation that warranted continued restraints,
8/19/2020 - Patient still in restraints, no documentation from physician as to continuation,
8/22/2020 - Patient order for restraints signed two (2) days after initiation with no documentation from physician as to why continued,
8/23/2020 - Patient in restraints no order, no face-to-face documentation in chart,
8/24/2020 - Order started at 2400 (aka 2359), no face to face documentation done between lapse in orders,

Patient #5 -
8/20/2020 - Patient in restraints, no order, no documentation from physician, from 2000 hours through 2359 hours,
8/22/2020 - Patient in restraints, no order, no documentation from physician,
8/23/2020 - Patient in restraints, no order, no documentation from physician,
8/24/2020 - Patient in restraints, no documentation from physician as to why the initiation of order,
8/25/2020 - Patient not in restraints
8/26/2020 - Patient placed in restraints, no order, no documentation from physician, no face-to-face,
8/27/2020 - Patient in restraints, no order, no documentation from physician,
8/28/2020 - Patient in restraints, no order, no documentation from physician,
8/29/2020 - Patient in restraints, no order, no documentation from physician,
8/30/2020 - Patient in restraints, no documentation from physician, no face-to-face for initiation,
9/09/2020 - Patient in restraints, no order, no documentation from physician,
9/10/2020 - Patient in restraints, no order, no documentation from physician.

Employee #3 and Employee #4 confirmed in interview September 10, 2020 at 1630 hours that the required documentation for physician documentation of face-to-face with in one (1) hour of initiation of restraints was missing for Patient #1, #2, #3, #4, and #5's medical records.

2. Medical records revealed that the physicians failed to document in patient's progress notes the rationale for restraints, need for continuation of restraints, and/or the failure at less restrictive alternatives attempted. This was observed in charts dated from:
Patient #1 - July 10, 2020 through September 9, 2020,
Patient #2 - August 17, 2020 through September 9. 2020,
Patient #3 - September 2, 2020 through September 10, 2020,
Patient #4 - August 18, 2020 through September 7, 2020,
Patient #5 - August 20, 2020 through September 8, 2020.

Facility document titled "Restraint Log September 2020" and "Restraint Log August 2020", from Quality, revealed names of patients, date initiated, order indicated reason, time or order, restraint type, discontinued date, and signature of physician date. The information in the document does not correlate accurately with the medical record. Medical record revealed that:

Patient #3 - was placed in restraints on 9/02/2020 at 2200 hours with no order found in the chart when examined with Employee #2 and #3 on 9/10/2020. Document supplied from Quality states that medical record contained an " ...order indicate(d) reason - yes (for restraints) ...Documentation complete NA (not applicable) ...." Area that should have an answer for if the order is signed - is blank.

Patient #4 - was in restraints from 8/23/2020 at 0002 hours till 8/24/2020 at 0001 hours with no active order in the medical record at time of review with Employee #3 and Employee #4 on 9/11/2020 - Quality document indicates there was an active order. Further, the order that was signed for 8/22/2020 was date signed by the physician two (2) days after patient was placed in restraints. Document only states that order was signed.

Patient #5 - was in restraints from 8/20 through 8/24, then 8/26 through 8/29. Quality document does not reflect that the patient was in restraints for the time of 8/26 through 8/29/2020. Nursing documentation indicates patient was restrained all of this time in August.

The Quality document does not indicate when the orders were written by nursing or physicians, when they were signed - time and date, if nursing had patient in restraint and/or if the rationale for initiation or continuation was written in the chart progress notes by the physicians. Document does not accurately reflect the medical records of Patients #1 through Patient #5 - it can not be used to reflect restraint monitoring.

Employee #3 and Employee #4 confirmed in interview September 10, 2020 at 1630 hours that the required documentation for physician documentation of rationale for restraints and / or continuation of restraints, was missing in above medical records of Patient #1, #2, #3, #4, and #5.

Further Quality document on restraints cannot confirmed that there is monitoring of documentation by physicians. The document does not verify that providers are documenting as required for initiation or continuation of restraints.

Based on review of hospital polices/procedures, medical records, and staff interviews, it was determined that the hospital failed to require the nursing staff planned patient care according to physician orders for 5 of 5 patients in restraints (Patient #1, 2, 3, 4, and 5). This deficient practice poses a risk of injury and/or harm to patients in restraints without physician direction (orders).

Findings include:

The hospital policy titled Restraints, no policy number, last revised 11/2019, requires "...The hospital discontinues the use of restraint at the earliest possible time, regardless of the scheduled expiration of the order...is in accordance with the written modification of the patient's plan of care...Standing...orders for restraints are not valid...If the attending physician is not available, a registered nurse may initiate restraint in advance of a physician's order. The attending physician must be notified, and a restraint order requested immediately after initiation of the restraint...alternatives...shall be documented every two (2) hours...."

Medical record revealed that the patients were in restraints with no physician orders, as follows:

Patient #1:
7/16/2020 at 0001 hours through 7/17/2020 at 0001 hours,
7/17/2020 at 0001 hours through 7/18/2020 at 1400 hour,
8/15/2020 at 0001 hours through 8/16/2020 at 0001 hours,
8/16/2020 at 0002 hours through 8/17/2020 at 0001 hours.
The nursing staff maintained the patient in restraints for 86 hours with no physician order.

Patient #2:
9/10/2020 at 1930 hours through 9/11/2020 at 0001 hours - No documentation as to why the patient was placed into restraints after 24 days without restraints.

Patient #3:
9/08/2020 at 2200 hours through 2359 hours,
9/09/2020 at 0000 hours through 0600 hours - physician was not called and there is no time of authentication of physician signature - process at hospital is nurses fill in form and place in manilla folder for physicians to sign when they round. Medical record does not reveal any face to face by a qualified provider or call notification for physician. The nursing staff maintained the patient in restraints for 8 hours without an order or notification to physician.
9/10/2020 at 0001 hours through 9/10/2020 at 0600 hours.
The nursing staff maintained the patient in restraints for 14 hours with no physician order.

Patient #4:
8/23/2020 at 0002 hours through 8/23/2020 at 2359 hours,
8/29/2020 at 0000 hours through 8/29/2020 at 0010 hours,
8/31/2020 at 0001 hours though 9/01/2020 at 0001 hours,
The nursing staff maintained the patient in restraints for 48.17 hours with no physician order.

Patient #5:
8/20/2020 at 2000 hours through 8/21/2020 at 0001 hours,
8/22/2020 at 0001 hours through 8/22/2020 at 2359 hours,
8/23/2020 at 0000 hours through 8/24/2020 at 0000 hours,
8/24/2020 at 0000 hours through 2359 hours,
8/25/2020 at 0000 hours through 2359 hours,
8/26/2020 at 0000 hours through 2359 hours,
8/27/2020 at 0000 hours through 2359 hours,
8/28/2020 at 0000 hours through 2359 hours,
8/29/2020 at 0000 hours through 2359 hours,
8/30/2020 at 0000 hours through 2359 hours,
9/01/2020 at 0000 hours through 2359 hours,
9/02/2020 at 0000 hours through 2359 hours,
9/03/2020 at 0000 hours through 2359 hours,
9/04/2020 at 0000 hours through 9/04/2020 at 1830 hours,
9/09/2020 at 0000 hours through 2359 hours,
9/10/2020 at 0000 hours through 1200 (noon) hours.
The nursing staff maintained the patient in restraints 370.5 hours with no physician order.

Based on review of hospital policies/procedures, documents, medical record, and staff interviews, it was determined that the facility failed to ensure that Patient #11 received all medications as prescribed. This deficient practice poses a risk to the health and safety of patients, when antibiotic does are missed and therapeutic levels of the medication are not maintained.

Findings include:

On 07/24/20, Medical Staff #2 ordered the following for Patient #11: Nafcillin 2 grams IV Q 4 hr x 6 weeks. On 07/27/20, Medical Staff #6 changed the order to Nafcillin 12 grams IV as continuous infusion until 09/04/20.

Review of the Medication Administration Records (MARs) for Patient #11 revealed Naficillin was not documented as being administered on the following dates: 07/28/20, 08/10/20, and 08/20/20.

The policy titled "Incident Reporting" requires that " ...incidents shall be reported on the facility's applicable incident report form e.g. general miscellaneous, medication error, fall, treatment/test, code blue, mortality ...."

On 07/28/20, an Incident Report was completed because the wrong dose of Nafcillin was administered. Naficillin 12 grams IV 20 ml/hour continuously was ordered. However, Naficillin 2 gm IV was administered at an unknown rate. Additionally, the area to document that the patient's physician was notified of the error was left blank. Review of nursing notes and physician orders revealed that Patient #11's physician was not notified, and the missed 10 grams of antibiotics were never administered.

During an interview conducted on 09/10/20, Employee #2 confirmed that the there was no evidence that the Patient #11's physician was notified or that the missing 10 grams of Naficillin were ever administered. Additionally, Incident Reports were not completed for the missed doses on 08/10/20 and 08/20/20.

Based on review of medical records, hospital policies/procedures, documents, and staff interviews, it was determined that the hospital failed to require 15 of 15 patient medical records (Patient #11 and Patients #18-31) have a documented discharge order. This deficient practice poses a risk to the health and safety of patients, when the continuity of care post-discharge is not ensured.

Findings include:

A review of closed medical records revealed that 15 of 15 records reviewed failed to reveal a written discharge order.

During an interview conducted on 09/11/20, Employee #2 confirmed that all 15 medical records were missing discharge orders.

Review of "KPC Promise Hospital Medical Staff Rules and Regulations" revealed requirements regarding a physician Discharge Summary. However, there was no mention of discharge orders or any requirements regarding discharge orders.

Based on review of observation on tour, staff interviews, medical records, hospital polices/procedures, medical staff bylaws, and medical staff rules and regulations; it was determined that physicians failed to authenticate progress notes within time period of patients' current admission for (Patient #1, #2, #3, #4, #5 and #16). Multiple interviews were done that indicated that authentication was done after patient discharge.

This poses a risk to patients that the care that is rendered between the different teams caring for the patient may be provided based on unauthenticated progress notes / daily physician notes and / or history and physicals.

Findings include:

Observation on tour revealed that the hospital is utilizing the use of paper charting for all medical record documentation. The physicians have the option of writing their daily observations in the chart at the time of visit, dictate their notes, or "email" their notes in at a "later" time. Observations of the medical records of Patient #1 through Patient #17 revealed that there were multiple "purple" plastic tabs sticking out from the sides of multiple medical records.

Employee #2, Employee #3, and Employee #4 confirmed in various separate interviews on 9/11/2020 morning that the "purple tabs" were indications that a particular physician needed to sign their orders or dictated progress notes. All employees identified the purple tabs as belonging to Physician #1.

Medical records were reviewed 9/11/2020 that exhibited the purple tabs. Medical records revealed:

Patient #1 - only a few of the tabs were examined, as patient has been at facility for sixty four (64) - No authentication for dictated "Wound Progress Note", dictated date of 9/02/2020, 9/04/2020, and 9/07/2020./04/2020, and 9/07/2020.

Patient #2 - No authentication for dictated "Wound Progress Note" dated 9/09/2020.

Patient #3 - No authentication for dictated "Wound Progress Note" dated 9/08/2020.

Patient #4 - only a few of the tabs were examined as follows - No authentication for consultation with dictated date of 8/19/2020 (also date of admit for patient). Additionally there is no authentication for dictated "Wound Progress Note" 8/30/2020, 9/01/2020, 9/02/2020, 9/04/2020, 9/05/2020, and 9/07/2020 and 9/07/2020.

Patient #5 - only a few of the tabs were examined as follows - No authentication for dictated consultation with dictated date of 8/21/2020 (date of admit for patient 8/20/2020). Additionally there is no authentication for dictated "Wound Progress Note" 9/02/2020, 9/04/2020, 9/05/2020, 9/06/2020, and 9/07/2020 and 9/07/2020.

Medical record of Patient #5 revealed that the notes for 9/01/2020 , 9/02/2020 x 2 notes, and 9/03/2020 by Physicians #9, #10, and #11 were not authenticated. In addition, Patient #16 - No authentication for dictated Progress note of 9/02/2020 by Physician #10.

Physician #1 confirmed in interview on 9/11/2020 at 1130 hours that the purple tabs were theirs and indicated that it meant that a signature was required. Further, Physician #1 confirmed that they arrive "daily" to check on the progress of his/her patients. Physician #1 confirmed that s/he "docusigns" all

Based on observation on tour, review of hospital polices/procedures, medical records, medical staff bylaws, medical staff rules and regulations, and staff interviews, it was determined that the ordering physicians failed to authenticate orders and / or telephone orders with date, time, and signatures promptly for 5 of 5 restrained patient's medical records reviewed (Patient #'s 1, 2, 3, 4, and 5).

This failure poses a potential risk for error or patient harm when the medical record does not reveal that the physician's validated orders for care.

Findings include:

Observations on tour September 11, 2020, revealed that the facility utilizes paper charting for all medical record entries. Observations revealed that near the secretary located in the front near the main entrance has "cubbies" to the left and right of their computer. In one of these "cubbies" was a manilla envelope that contained the "days restraint orders". The process of the hospital is that the night shift fills in the "orders" and the physician signs them when they arrive.

Medical Staff Rules and Regulations requires "...The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient...Its contents shall be pertinent and current for...orders...A Practitioner's routine orders...shall be reproduced in detail on the order sheet of the patient's record, signed, dated and timed...The responsible practitioner shall authenticate such order within 48 hours...."

The following physicians failed to follow Medical Staff Rules and Regulations for medical record authentication:

Physician #1 - failed to authenticate restraint order with signature, date, or time for Patient #3 on 9/10/2020. Order was "written" by nursing on 9/10/2020 at 0001 hours. No documentation that the doctor was notified, only nursing signature is on order. Employee #4 confirmed order not signed on 9/11/2020 at 1230 hours - 36 hours after patient was placed in restraints. In addition, there is no documentation in the physician's notes documenting patient condition while in restraints.

Physician #1 failed to date and time signature authentication for Patient #3 consult on 9/4/2020 at 1600 hours and orders of 9/03/2020 at 1230 hours for lab test.

Physician #2 failed to authenticate restraint orders with date and time for Patient #1 - 7/10/2020 through 7/15/2020, 7/18/2020 through 7/20/2020, 7/22/2020 through 8/11/2020, 8/13/2020, 8/14/2020, and 8/17/2020 through 9/09/2020. Patient #2 - 9/09/2020 and 9/10/2020.

Physician #2 - the nursing staff filled in time and date of doctor restraint order for Patient #1, not physician, on - 7/13/2020, 7/14/2020, 7/23/2020, 08/03/2020, 08/06/2020, 8/07/2020, 8/12/2020, 8/20/2020, 8/21/2020, 8/22/2020, 8/24/2020, 8/27/2020 through 9/01/2020, and 9/04/2020 through 9/06/2020.

Physician #2 - No authentication/signature, date, or time on order for restraints on 7/21/2020 - Patient #1 attending for this time period.

Physician #12 failed to authenticate restraint order with time for Patient #4 on 8/18/2020 through 8/24/2020, 8/26/2020 through 8/30/2020, 9/01/2020 through 9/07/2020.

Physician #12 - the nursing staff filled in time and date of doctor restraint order, on 8/26/2020, 9/05/2020, 9/06/2020, and 9/07/2020.

Physician #12 failed to sign restraint orders within time period of 48 hours on - 8/18/2020 and 8/20/2020 - five different orders for restraints were written by nursing between 8/18/2020 and 8/20/2020 and all are signed as 8/22/2020 by physician -but no time indicated. Nursing indicates their signature as 0001 hours.

Physician #13 failed to authenticate restraint order with date and time for Patient #5 on 8/21/2020, 8/24/2020, 9/04/2020, 9/05/2020, 9/06/2020, 9/07/2020, and 9/08/2020.

Physician #13 - failed to sign restraint orders within time period of 48 hours - no authentication/signature, date, or time on order for restraints on 9/07/2020 and 9/08/2020 - Patient #5 attending for this time period. Employee #4 confirmed order not signed as required on 9/11/2020 at 1230 hours. In addition, there is no documentation in the physicians notes there is no documentation in the physician's notes documenting patient condition while in restraints.

Further, the following Physicians failed to authenticate telephone or verbal orders within 48 hours:

Physician #6 - Patient #5 - 9/03/2020 - for downgrade to different unit.


Physician #13 - Patient #5 - 8/20/2020 at 1723 hours - for change in CODE status,
Physician #13 - Patient #5 - 8/20/2020 at 1700 hours - change of insulins,
Physician #13 - Patient #5 - 8/21/2020 at 0115 hours - for X-ray,
Physician #13 - Patient #5 - 8/21/2020 at 1320 hours - for tube feeds,
Physician #13 - Patient #5 - 8/21/2020 at 1730 hours - for insulin sliding scale,
Physician #13 - Patient #5 - 8/22/2020 at 1723 hours - for dialysis orders,
Physician #13 - Patient #5 - 8/26/2020 at 0755 hours - for haldol,
Physician #13 - Patient #5 - 8/26/2020 at 1648 hours - for COVID test,
Physician #13 - Patient #5 - 8/282020 at 0755 hours - for haldol,
Physician #13 - Patient #5 - 9/04/2020 at 1800 hours - for valium,
Physician #13 - Patient #5 - 9/07/2020 at 1650 hours - for insulin,
Physician #13 - Patient #5 - 9/09/2020 at 0855 hours - for speech therapy.

Physician #13 - Patient #4 - 8/292020 at 0800 hours - downgrade to telemetry, was signed 9/01/2020 - no time indicated.

Employee #4 confirmed during examination of medical records that the required authentication is missing in all records for Patients #1, #2, #3, #4, and #5 as listed above, on 9/11/2020 at 1230 hours.

Employee #3 confirmed missing authentication of medical records for Physician #1, Physician #2, Physician #12, and Physician #13 during examination of records on 9/11/2020 at 1630 hours.

Based on review of observation on tour, staff interviews, medical records, hospital polices/procedures, medical staff bylaws, and medical staff rules and regulations; it was determined that physicians failed to authenticate progress notes within time period of patients' current admission for (Patient #1, #2, #3, #4, #5 and #16). Multiple interviews were done that indicated that authentication was done after patient discharge.

This poses a potential risk to patients that the care that is rendered between the different teams caring for the patient may be provided based on unauthenticated progress notes / daily physician notes and / or history and physicals.

Findings include:

Observation on tour revealed that the hospital is utilizing the use of paper charting for all medical record documentation. The physicians have the option of writing their daily observations in the chart at the time of visit, dictate their notes, or "email" their notes in at a "later" time. Observations of the medical records of Patient #1 through Patient #17 revealed that there were multiple "purple" plastic tabs sticking out from the sides of multiple medical records.

Employee #2, Employee #3, and Employee #4 confirmed in various separate interviews on 9/11/2020 morning that the "purple tabs" were indications that a particular physician needed to sign their orders or dictated progress notes. All employees identified the purple tabs as belonging to Physician #1.

Medical records were reviewed 9/11/2020 that exhibited the purple tabs. Medical records revealed:

Patient #1 - only a few of the tabs were examined, as patient has been at facility for sixty four (64) days - No authentication for dictated "Wound Progress Note" by Physician #1, dictated date of 9/02/2020, 9/04/2020, and 9/07/2020./04/2020, and 9/07/2020.

Patient #2 - No authentication for dictated "Wound Progress Note" dated 9/09/2020, by Physician #1.

Patient #3 - No authentication for dictated "Wound Progress Note" dated 9/08/2020, by Physician #1.

Patient #4 - only a few of the tabs were examined as follows - No authentication for consultation with dictated date of 8/19/2020 (also date of admit for patient). Additionally, there is no authentication for dictated "Wound Progress Note" 8/30/2020, 9/01/2020, 9/02/2020, 9/04/2020, 9/05/2020, and 9/07/2020 and 9/07/2020, by Physician #1.

Patient #5 - only a few of the tabs were examined as follows - No authentication for dictated consultation with dictated date of 8/21/2020 (date of admit for patient 8/20/2020). Additionally, there is no authentication for dictated "Wound Progress Note" 9/02/2020, 9/04/2020, 9/05/2020, 9/06/2020, and 9/07/2020 and 9/07/2020, by Physician #1.

Medical record of Patient #5 revealed that the notes for 9/01/2020, 9/02/2020 times 2 notes, and 9/03/2020 by Physicians #9, #10, and #11 were not authenticated. In addition, Patient #16 - No authentication for dictated Progress note of 9/02/2020 by Physician #10.

Physician #1 confirmed in interview on 9/11/2020 at 1130 hours that the purple tabs were theirs and indicated that it meant that a signature was required. Further, Physician #1 confirmed that s/he arrives "daily" to check on the progress of his/her patients. Physician #1 confirmed that it was "customary" for the HIMS (medical records) department to sent the records that needed to be signed to him/her via "DocuSign". Physician #1 confirmed that they would then sign them and return them via the "DocuSign portal". Further, s/he showed on personal phone the "signed" documents that had recently been submitted back to medical records. Physician #1 was unable to locate the medical records requested on their phone that indicated signing of the above mentioned documents. S/he also confirmed unsure why the "purple tabs" weren't removed from the active / current patients.

Employee #29 confirmed in interview on September 14, 2020 that the only medical records that are sent to the physicians via "DocuSign" are the records of discharged patients. This is done to allow the closure / archival of medical records. S/he further confirmed that the signing of the current patients dictated records should be done by the physicians while the patient is in the hospital. S/he stated that the dictated progress notes have approximately a twenty-four (24) hours turn around from dictation time to time that the report is sent to the hospital. The progress notes arrive "usually" in the morning and are physically placed in the charts with the corresponding "color tab" that goes to the particular physician that indicates a need to authenticate the documents. Further confirming that dictated documents are not sent via "DocuSign" to the doctors while the patient is currently an active patient.

Based on review of hospital policies/procedures, observations on tour, and staff interviews, it was determined that the Administrator failed to ensure outdated, mislabeled, or otherwise unusable drugs were not available for patient use. This deficient practice poses a risk to the health and safety of patients, when patients are potentially administered expired or mislabeled medications with questionable safety and efficacy.

Findings include:

The following was observed on 09/09/20 while on tour of the facility:

Telemetry North Medication Room
-Nutricia Pro Stat Sugar Free Grape: opened 08/19, partially filled
-Nutricia Pro Stat Sugar Free Cherry: no open date, partially filled
Manufacturer instructions state to:
Store at room temperature.
Discard 3 months after opening.
Record date opened on bottom of container.

Telemetry South Medication Room
-Nutricia Pro Stat Sugar Free Grape: no open date, partially filled
-Lantus: opened with no open or discard date (patient label printed on 07/28/20), found on counter
-Lantus: opened with a discard date of 08/23/20, found in the alcohol wipe bin
-Lantus: opened with no open or discard date, found on counter
Manufacturer instructions indicate that the Lantus 10 ml multidose vial should be discarded after 28 days.
-Levemir: opened with a discard date of 08/27/20, no patient label, found in the alcohol wipe bin
Manufacturer instructions indicate that after initial use, vials should be stored in a refrigerator.
-Nine doses of oral Vancomycin 250 mg/5 ml, expiration date of 09/07/20, found in medication refrigerator

Intensive Care Unit Medication Room
-Nutricia Pro Stat Sugar Free Grape: no open date, partially filled

The policy titled "Medication Storage Temperatures" requires that " ...all drugs shall be stored at temperatures that are within the manufacturer's recommendations ...."

Employee #4 verified that the medications found in the Telemetry South Medication Room and the Telemetry North Medication Room were either expired, not labeled correctly, or stored incorrectly.

Employee #7 verified that the medications found in the Intensive Care Unit Medication Room were either expired or not labeled correctly. All expired or mislabeled items given to Employee #7 to appropriately discard.