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Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to discontinue patient's restraints at the earliest possible time for two of two applicable medical records reviewed (MR14 and MR15).

Findings include:

Review on October 15, 2019, of the facility's "Restraints Policy," last revised February 5, 2018, revealed "I. Purpose: A. The purpose of this policy is to: a. Direct the care necessary to maintain the safety and dignity of the patient should restraints be deemed necessary. b. Comply with regulations set forth by the Pennsylvania Department of Health, Centers for Medicare and Medicaid Services (C.M.S.) ... II. Policy: A. Regional Hospital of Scranton recognizes patient's rights to be treated with dignity and respect and to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. ... III. Procedures: ... 1. Physical Restraints: Include any type of physical or mechanical device used to limit the patient's ability to move in order to protect the patient or others from injury when other less restrictive interventions are not sufficient or not available. a. A physical restraint is any manual method, article, device or equipment attached to or adjacent to the patient's body that he or she cannot easily remove and that restricts movement or normal access to one's body. ... F. The Registered Nurse will: ... 7. The condition and response of the restrained patient must continually be assessed, reassessed, monitored and re-evaluated, with supportive documentation in the medical record. If the reassessment by the qualified RN indicates that the restraint criteria no longer apply, the patient will be removed from restraints. ... 11. The Registered Nurse/designee may release a patient from a restraint or reduce the level of the restraint if a change in the patient's condition so warrants and the patient meets criteria for discontinuation of restraints. ..."

Review of MR14 on October 16, 2019, revealed this patient was admitted to the facility on June 25, 2019. Nursing documented MR14's behavior as calm and sedated and nursing staff applied soft wrist restraints to MR14's both wrists on June 25, 2019, at 1:00 PM.

Interview with EMP4 on October 16, 2019, at approximately 11:15 AM confirmed MR14 was admitted to the facility; nursing documented MR14's behavior as calm and sedated and nursing applied soft wrist restraints to both of MR14's wrists on June 25, 2019, at 1:00 PM. EMP4 revealed there was no documentation in MR14 to support nursing applying bilateral soft wrist restraints and nursing staff did not attempt to remove MR14's wrist restraints when this patient's behavior was calm.

Review of MR15 on October 16, 2019, revealed this patient was admitted to the facility on July 25, 2019. Nursing documented MR15's behavior as resisting and refusing care, aggressive and physically abusive and applied soft wrist restraints to MR15's both wrists on July 27, 2019, at 10:00 PM. Nursing documented MR15's behavior as calm, sedated, friendly and watching television on July 28, 2019, at midnight, 2:00 AM, 4:00 AM and 6:00 AM. There was no documentation nursing staff attempted to remove MR15's soft wrist restraints when this patient's behavior was calm, sedated and friendly.

Interview with EMP4 on October 16, 2019, at approximately 11:30 AM confirmed MR15 was admitted to the facility on July 25, 2019; nursing documented MR15's behavior as resisting and refusing care, aggressive and physically abusive and applied soft wrist restraints to MR15's both wrists on July 27, 2019, at 10:00 PM. EMP4 confirmed on July 28, 2019, at midnight, 2:00 AM, 4:00 AM and 6:00 AM nursing documented MR15's behavior as calm, sedated, friendly and watching television. EMP4 confirmed there was no documentation nursing attempted to remove MR15's soft wrist restraints when this patient's behavior was calm, sedated and friendly.

Cross reference:
482.13 (e)(5) Patient Rights: Restraint or Seclusion

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to obtain a physician order for restraints for one of two applicable medical records reviewed (MR14).

Findings include:

Review on October 15, 2019, of the facility's "Restraints policy," last revised February 5, 2018, revealed "I. Purpose: A. The purpose of this policy is to: a. Direct the care necessary to maintain the safety and dignity of the patient should restraints be deemed necessary. b. Comply with regulations set forth by the Pennsylvania Department of Health, Centers for Medicare and Medicaid Services (C.M.S.) ... II. Policy: A. Regional Hospital of Scranton recognizes patient's rights to be treated with dignity and respect and to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. ... III. Procedures: ... 1. Physical Restraints: Include any type of physical or mechanical device used to limit the patient ' s ability to move in order to protect the patient or others from injury when other less restrictive interventions are not sufficient or not available. a. a physical restraint is any manual method, article, device or equipment attached to or adjacent to the patient's body that he or she cannot easily remove and that restricts movement or normal access to one's body. ... F. The Registered Nurse will: ... 4. Obtain a Physician's order for a restraint when the least or nonrestrictive alternative has not been effective within one hour after the initiation of restraints ... "

Review of MR14 on October 16, 2019, revealed this patient was admitted to the facility on June 25, 2019. Nursing documented MR14's behavior as calm and sedated and nursing applied soft wrist restraints to both of MR14's wrists on June 25, 2019, at 1:00 PM. MR14's physician orders revealed the facility obtained an order to apply MR14's bilateral soft wrist restraints at 2:24 PM on June 25, 2019.

Interview with EMP4 on October 16, 2019, at approximately 11:00 AM confirmed nursing documentation MR14's behavior as calm and sedated and nursing staff applied soft wrist restraints to both of MR14's wrists on June 25, 2019, at 1:00 PM. EMP4 confirmed nursing obtained a physician order to apply MR14's bilateral soft wrist restraints at 2:24 PM on June 25, 2019. EMP4 confirmed the facility did not obtain a physician's order for MR14's bilateral soft wrist restraints within one hour after application.

Cross reference:
482.13 (e) Patient Rights: Restraint or Seclusion

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the Quality Improvement monitoring was performed for all contracted services.

Findings include:

Review on October 16, 2019, of the facility's "Quality Improvement Plan for 2019" approved January 8, 2019, revealed "I. Mission Statement: To support an organizational-wide approach to providing quality care that is patient-centered, effective, efficient, safe, timely, and equitable. II. Vision: To improve patient outcomes through evidence-based care and collection across the continuum of care and by all disciplines. III. Purpose: The Quality Improvement Plan is designed to provide a systematic and organized mechanism to promote safe and quality focused patient care and services. Through an integrated, interdisciplinary process, patient care and services shall be continuously monitored and evaluated to promote optimum outcomes. The Quality Improvement Plan is augmented by the facility's Patient Safety Plan that supports improving patient safety and reducing risk to patients through an environment in which patients, their families and organizational and medical staff and leaders can identify and manage actual and potential risks to patient safety. ... V. Scope of Activities and Services: The scope of Quality Improvement Program and Plan covers measurements and assessment activities of the Medical Staff; Patient Care Services, and ancillary and support services of the facility. All clinical and non-clinical departments are included. Quality improvement activities will address both clinical and organizational functions. These activities are designed to assess key functions of patient fare and to identify, study, and correct problems and improvement opportunities found in the processes of care delivery. ... VI. Organization and Responsibility: Quality improvement is the responsibility of everyone employed by, on the medical staff, or contracted with Regional Hospital of Scranton. ..."

Review on October 16, 2019, of the facility's contract folder, identified by EMP1 as active facility contracts, revealed contracts for patient care services which included: Acute Dialysis, Speech and Language Therapy, Lithotripsy, Laser Therapy, Mobile X-ray and Oncology.

Review on October 16, 2019, of the facility's Quality Improvement Committee Meeting Reporting Schedule for Calendar Year 2019 revealed no documentation the contracted patient care services of Acute Dialysis, Speech and Language Therapy, Lithotripsy, Laser Therapy, Mobile X-ray and Oncology reported Quality improvement activities for the 2019 calendar year.

Interview with EMP1 on October 16, 2019, at approximately 1:30 PM confirmed the active facility contracts for patient care services for Acute Dialysis, Speech and Language Therapy, Lithotripsy, Laser Therapy, Mobile X-ray and Oncology. EMP1 confirmed facility's Quality Improvement Committee Meeting Reporting Schedule for Calendar Year 2019 contained no documentation the contracted patient care services of Acute Dialysis, Speech and Language Therapy, Lithotripsy, Laser Therapy, Mobile X-ray and Oncology reported Quality improvement activities for the 2019 calendar year. EMP1 revealed Acute Dialysis, Speech and Language Therapy, Lithotripsy, Laser Therapy, Mobile X-ray and Oncology have never reported Quality improvement activities to the facility's Quality Improvement Committee Meeting.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure a clean and sanitary environment for the next patient and minimize cross-contamination on the fourth, seventh, and ninth floor nursing units.

Findings include:

Review on October 16, 2019, of facility "Discharge Room Cleaning-[name] Process Policy," revised January 27, 2018, revealed "Purpose: To detail the correct steps for cleaning a discharged patient room using the [name] cleaning system to ensure a clean and sanitary environment for the next patient and minimize cross-contamination. ...Sanitize the restroom Shower (all surfaces) ...Inspect your work, correcting any deficiencies before leaving."

Observation on October 15, 2019, of room 408 revealed a clear plastic bag with an oxygen mask and tubing that was attached to the oxygen set up on the wall. EMP5 and EMP6 revealed this oxygen mask and tubing was from a previous patient.

Interview on October 15, 2019, with EMP5 and EMP6, at the time of the observation confirmed in room 408 a clear plastic bag with an oxygen mask and tubing that was attached to the oxygen set up on the wall. EMP5 and EMP6 revealed this patient room was clean and ready for patient admission.

Observation on October 15, 2019, of room 417 revealed an intravenous (IV) pump hanging on an IV pole with three clear plastic caps sitting on the IV pump. EMP5 and EMP6 revealed the IV pump and IV pole with three clear plastic caps sitting on the IV pump were from a previous patient and not removed when cleaned.

Interview on October 15, 2019, with EMP6, at the time of observation confirmed in room 417 an IV pump hanging on an IV pole with three clear plastic caps sitting on the IV pump. EMP6 revealed this patient room was clean and ready for patient admission.

Observation on October 15, 2019, of room 718 revealed an accumulation of a black substance measuring the size of a quarter in two areas of the shower basin.

Interview on October 15, 2019, with EMP5, at the time of observation confirmed in room 718 an accumulation of a black substance measuring the size of a quarter in two areas of the shower basin. EMP5 revealed this patient room was clean and ready for patient admission.

Observation on October 15, 2019, of room 905 revealed a wet bar of soap in the shower.

Interview on October 15, 2019, with EMP6, at the time of observation confirmed in room 905 a wet bar of soap in the shower. EMP5 revealed this patient room was clean and ready for patient admission.