HospitalInspections.org

Based on review of policies/procedures, medical staff bylaws, medical staff departmental rules and regulations, provider credential files, contract for Crisis Preparation and Recovery, Inc, delineation of privileges for crisis counselors and interview, it was determined the governing body failed to ensure the medical staff be accountable for the quality of care provided to patients as evidenced by failing to require the medical staff conducted focused and ongoing professional practice evaluations as required by the medical staff medicine departmental rules and regulations for the Licensed Professional Counselors (LPC) and Emergency Department (ED) providers.

Findings include:

Review of Medical Staff Bylaws adopted 05/13/10, revealed: "...Department Rules and Regulations...Each department and section will formulate written rules and regulations for the conduct of its affairs and the discharge of its responsibilities...."

Review of the Medicine Department Rules and Regulations adopted 05/12/11, revealed: "...The Department of Medicine will report directly to the Medical Executive Committee and include physicians granted privileges in the following...Emergency Medicine...Non Physician Practitioners...Privileges may be granted to non-physician practitioners...Focused Professional Practice Evaluation (FPPE)/Ongoing Professional Practice Evaluation (OPPE)...Refer to Banner Health Policies and Procedures...Three to six months after a practitioner's initial appointment or initial granting of privileges...Practitioner-specific data will be collected and evaluated for the FPPE and OPPE in the areas of six general competencies...."

Review of the Banner Health Policy titled Medical Staff Ongoing Professional Practice Evaluation, approved 02/07/12, revealed: "...On-going Professional Practice Evaluation (OPPE) is a process to identify professional practice trends and provide on-going evaluation of performance impacting clinical care and patient safety...This policy applies to all Providers who are privileged through Medical Staff privileging process..."

Review of the Banner Health Policy titled Medical Staff Focused Professional Practice Evaluation, approved on 02/07/12, revealed: "...Focused Review or Focused Professional Practice Evaluation (FPPE) is a time-limited process whereby the Medical Staff evaluates the privilege-specific competency of the Providers or the Providers' ability to provide safe, high quality patient care...The Medical Staff will assess Provider performance and support patient safety and quality improvement initiatives. This applies to all Providers privileged through the Medical Staff process at Banner Health...."

Review of the Crisis Counselors' delineation of practice form revealed: "...Supervision: The Crisis Counselor must have a Sponsoring Physician who is a member, in good standing, of the BIMC (Banner Ironwood Medical Center) and has appropriate clinical privileges...."

Review of the hospital's document titled Allied Health Professional Statement of Sponsoring/Supervising Physician revealed: "...I hereby request the above-referenced allied health practitioner, who is applying for permission to provide patient care services as a 'Crisis Counselor' (written in on the line for specialty)...I further agree to supervise and to assume responsibility for supervision of the Applicant for services as set forth in this section...Monitoring and reporting of the Applicant's performance will be performed...I will return a completed evaluation form to attest to current competency as requested...."

A review of the hospital ED medical director's (Provider #6) credential file was conducted on 10/11/12, with the CMO and Medical Staff Manager. During the review they confirmed that Physician #6 did not have any OPPE since 12/11. The CMO explained the computer software is not available for the ED to obtain data and the OPPE would have to be conducted manually. Both verified that no OPPE has been conducted since 12/11 for any of the ED providers as required by the medical staff medicine departmental rules and regulations.

A review of the Licensed Professional Counselors (LPC) credentialing files for Providers #8 and 9, was conducted with the CMO and Medical Staff Manager on 10/12/12. During the review they confirmed that Provider #9 has not had any FPPE or OPPE. Provider #8 was recently credentialed within 6 months and has not had any FPPE. When asked how many LPC's are credentialed with the hospital they responded that approximately 8 LPC's are on the medical staff. When asked how many of the currently privileged LPC's have had any FPPE or OPPE the staff confirmed they have not conducted any evaluations. They also confirmed the supervising physician for all of the LPC's was the same provider (#10) and no FPPE or OPPE has ever been conducted for the LPC's, as required by the supervising physician and medical staff medicine departmental rules and regulations. The contract for the LPC's was initiated in 01/12. The LPC's provide crisis counseling for patients in the ED.

Based on review of hospital policy/procedure, Rules and Regulations of the Medical Staff, medical record and interview, it was determined that the hospital failed to require that the use of restraints be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient for 1 of 2 patients restrained in a non violent situation (Pt #3).

Findings include:

Review of hospital policy/procedure titled Restraint Use in Non Violent Situations revealed: "...application...obtain an order for restraint from a physician or other LIP as soon as possible after application of restraint...orders for restraints must be obtained daily or with each new episode of restraint...obtain an order with each new episode of restraint and daily if patient restrained greater than 24 hours...."

Review of the Rules and Regulations of the Medical Staff of the hospital revealed: "...Med/Surg Restraint...as per medical center policy, restraints needed to maintain a patient's safety and integrity of medical therapy require a physician order for initiation with renewal every twenty- four (24) hours. This category applies to soft restraints for intubated patients and to prevent invasive device removal such as NG or IV as well as cognitively impaired patients at risk...every 24 hours: perform face to face assessment of patient and enter a new order for restraints if need continues...."

Review of Pt #3's electronic medical record revealed:

Pt #3 was initially placed in bilateral soft wrist restraints on 10/4/2012 at 1915. At that time the patient was on a ventilator and was attempting to remove lines and/or dressings and/or equipment. The patient remained in restraints until 10/10/12 at 1638 hours. There was no physician order for restraints for 10/7/2012.

Employee #15 confirmed in an interview conducted on 10/10/12 at 1530 hours, that patient #3 was in restraints on 10/7/12 without a physician order.

Based on review of hospital policy/procedure, medical record and interviews, it was determined that the hospital failed to require that restraints be discontinued at the earliest possible time for 1 of 2 patients restrained in a non violent situation (Pt #3).

Findings include:

Review of hospital policy/procedure titled Restraint Use in Non Violent Situations revealed: "...Staff shall promote the safety, rights, dignity and well being of patients through the use of preventive strategies and alternative interventions whenever possible...Restraint will be an intervention of last resort to prevent interference with medical treatment...Restraints will be discontinued as soon as possible...Re-assess the patient every 2 hours and/or based on the individual needs of the patient...."

Review of Pt #3's electronic medical record revealed:

Pt #3 was initially placed in bilateral soft wrist restraints on 10/4/2012 at 1915, due to her attempts at removing lines and/or dressings and/or equipment. She was on a ventilator at the time. The patient remained in restraints until 10/10/12 at 1638 hours.

Nursing documented that the patient was restrained and sleeping on the following dates:

10/5/12 at 0400, 1206, 1424, 1600, 1800;
10/6/12 at 0800, 1000, 1200, 1400, 1600 and 1800;
10/7/12 at 0800, 1000, 1200, 1400, 1600, 1800 and 2000;
10/8/12 at 2200;
10/9/12 at midnight, 0047, 0254, 2000 and 2200;
10/10/12 at 0200, 0400, 0600, 0800, 1000, 1200 and 1400.

RN # 15 confirmed during an interview conducted on 10/10/12 and RN #7 confirmed during an interview conducted on 10/11/12, that Pt #3 remained in restraints while sleeping with no specific patient behavior identified for the continued use of restraints. They confirmed that restraints were not discontinued as soon as possible as required by hospital policy/procedure.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that the condition of the patient who is restrained be monitored and/or assessed by trained staff at the interval determined by hospital policy as evidenced by:

1. failing to monitor 1 of 3 patients restrained for the management of violent or self-destructive behavior as required by hospital policy/procedure (Pt #40); and

2. failing to assess 1 of 2 patients restrained for a non-violent situation as required by hospital policy/procedure (Pt #30).

Findings include:

1. Review of hospital policy/procedure titled Restraint Use in Violent Situations revealed: "...5. Monitor the patient for appropriateness and necessity of restraints...restraint safely applied, risks associated with the intervention, level of distress or agitation, cognitive status and vital signs if able to obtain (TRAINED STAFF)...a. Restraint or Seclusion: Minimum of every 15 minutes, more frequent or continuous depending on assessment of patient...c. Continuous monitoring, and documentation of the following, includes but is not limited to: Patient's condition...Cognitive status...Risks associated with the chosen intervention...Type of intervention used...Other relevant factors...Circulation and range of motion in restrained extremities...Nutrition...Hydration...Hygiene...Elimination...Comfort...Psychological status...Readiness for discontinuation of restraints...."

Review of Patient #40's medical record revealed:

Pt #40 was placed in 4-point locked restraints after being combative with staff. Restraints were initiated at 2010 on 9/9/12, and removed on 9/10/12 at 0240.

An RN documented assessment of the patient while in restraint at the following times: on 9/9/12 at 2020, 2135, 2240 and 2340; 9/10/12 at 0035, 0140, 0210 and 0240.

Pt #40's medical record contained a form titled 1 to 1 or Direct Observation Form. A staff member recorded entries every 15 minutes on this form, however these entries were not related to restraints or the condition of the patient in restraints.

The Interim CNO confirmed, during interview conducted on 10/11/12, that Pt #40's medical record did not contain documentation that the patient was monitored every 15 minutes for the issues related to restraints as required by policy/procedure.

2. Review of hospital policy/procedure titled Restraint Use in Von Violent Situations revealed: "...Re-assess the patient every 2 hours and/or based on the individual needs of the patient...."

Pt #30 was admitted on 9/18/12 at 0114. On 9/18/12 he was receiving care in the Intensive Care Unit and required soft restraints to both arms to prevent him from removing lines, dressings, or equipment. Restraints were initiated on 9/18/12 at 0300 and discontinued at 1000. An RN completed restraint assessments at 0330, 0451, 0804, and 1000.

RN #13 confirmed during interview conducted on 10/11/12, that assessments were required every 2 hours and the interval between 0451 and 0804 exceeded this requirement.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that a physician, licensed independent practitioner, or trained RN conduct a face-to-face evaluation of the patient within one hour after restraint used for the management of violent or self-destructive behavior for 2 of 3 patients (Pts # 21 and 40).

Findings include:

Review of hospital policy/procedure titled Restraint Use in Violent Situations revealed: "...Perform a face-to-face evaluation of the patient as soon as possible, but no later than 1 hour after the initiation of violent restraint or seclusion. (PHYSICIAN, LIP, OR TRAINED RN)...Include in the evaluation...The patient's immediate situation...The patient's reaction to the intervention...The patient's medical and behavioral condition...The need to continue or terminate the restraint or seclusion...."

Review of medical records revealed:

Pt #21 was admitted to the Emergency Department (ED) on 8/28/12 at 0655. The physician completed a Review of Systems and a Physical Examination and ordered several diagnostic tests at 0700. At 1024, an RN documented that the patient became physically aggressive toward staff and bit an ED Technician. Four-point locked restraints were initiated on 8/28/12 at 1120. The patient remained in restraints until 1600 when they were removed. The ED record did not contain a face-to-face evaluation after the initiation of restraints.

RN #15 confirmed, during interview conducted on 10/10/12 at 1500 that the medical record did not contain documentation of the required evaluation.

Pt #40 was admitted to the ED on 9/9/12 at 1949. The physician documented the patient's History of Present Illness at 1952 and included that the patient was in 4-point restraints after being combative with staff. He completed a review of systems and a physical examination at that time and ordered Ativan and Haldol intramuscularly at 2008. Nursing documented that restraints were initiated at 2010 and removed on 9/10/12 at 0240. An RN completed an electronic record entry that a Face to Face Evaluation was completed at 2004: "...see progress note...."

The medical record contained the review of systems and physical examination of the patient, as mentioned above, however, it did not contain documentation by an LIP or trained RN of the patient's response to the restraint, reaction to the immediate situation and whether continued restraint was necessary.

RN #13 confirmed, during interview conducted on 10/11/12, that the medical record did not contain the required elements of the one-hour face-to-face evaluation.

Based on review of policies/procedures, medical staff bylaws, medical staff departmental rules and regulations, provider credential files, contract for Crisis Preparation and Recovery, Inc, delineation of privileges for crisis counselors and interview, it was determined the medical staff failed to enforce its bylaws, rules and regulations by failing to conduct focused and ongoing professional periodic evaluations for the Licensed Professional Counselors (LPC) and the Emergency Department (ED) providers.

Findings include:

See 482.12(a)(5): Tag 0049 for failing to require the medical staff conduct focused and ongoing professional practice evaluations as required by the medical staff medicine departmental rules and regulations for the Licensed Professional Counselors (LPC) and Emergency Department (ED) providers.