HospitalInspections.org

Based on interviews, medical record review, and document review, it was determined the facility staff failed to notify the patient's representative of the patient's discharge to a skilled nursing facility.

Findings:

During an interview on 03/04/2024 at 1:30 p.m., Staff Member #1 confirmed that Patient #1 had dementia, was not able to make decisions, and had a Power of Attorney (POA) designating the patient's child and child's spouse as the POAs.

A Nursing Note from 10/16/2023 at 3:00 p.m. stated that the patient was discharged to a skilled nursing facility by transportation via stretcher with all required paperwork and documentation. There was no documentation that the patient's POAs/representatives were notified of the patient's discharge.

A Social Worker progress note from 10/16/2023 at 12:08 p.m. contained the documentation "Communication to Patient/Family: Met with patient and they are agreeable to the transition plan." There was no other documentation in this note that the social worker spoke with the patients POA/representative about the patient's discharge.

On 03/04/2024, Staff Member #9 confirmed that there was no other documentation in Patient #1's medical record that any staff notified the patient's POAs/representatives that the patient would be discharged on 10/16/2023.

During an interview on 03/05/2024 at 9:35 a.m., Staff Member #15 confirmed that Staff Member #15 did not document any of the attempts to contact the patient's POAs or that Staff Member #15 left a message for either POA about the patient's discharge date.

A review of the admission packet "A patient's guide to inpatient services and facilities" states in part:
... You have the right to make decisions about your care ... You have the right to identify a surrogate decision maker should you become unable to make decisions related to your health care...."

The above concerns were discussed at the exit conference on 03/05/2024 at 3:30 p.m.

Based on interview, medical record review, and facility document review, it was determined the facility staff failed to discontinue violent restraints at the earliest possible time for one (1) of two (2) patients with violent restraints ordered (Patient #6).

Findings:

The restraint record for Patient #6 from 03/02/2024 while the patient was in the emergency department contained documentation that the patient had an order for violent restraints. The restraint order started at 1:18 a.m. and expired at 5:18 a.m. The restraint order for "violent/self destructive behavior" stated "... Continue restraints, and discontinue at earliest possible time..." Additionally, the "Violent or Self-Destructive Restraints" flow sheet contained the documentation "... Clinical Justification: Imminent risk of harm to self and others... Discontinuation Criteria: Absence of behavior that required restraint ..."

The "Violent or Self-Destructive Restraints" flow sheet contained the documentation of restraint from 03/02/2024 at 1:20 a.m. until 03/02/2024 at 5:05 a.m. It was documented that the patient was "asleep" every fifteen (15) minutes on the monitoring documentation from 2:05 a.m. through 4:50 a.m. There was no monitoring documented at 5:05 a.m. when the restraints were discontinued. There was no other "assessment" documentation noted on the "Violent or Self-Destructive Restraints" flow sheet. There was nothing documented for "Assess Violent Restraints: Restraint Removal from 1:35 a.m. through 5:05 a.m.

During an interview on 03/05/2024 at 10:36 a.m., Staff Member #17 stated that the patient may have been left asleep in restraints for the safety of the patient since the patient was in restraints for being "suicidal".

A review of the facility's policy titled "Restraint and Seclusion" effective date 07/28/2022 states in part:
... Procedure ... 3. Assessment and Removal: 3.1. All restraints: The need for restraints is frequently evaluated and restraints are discontinued at the earliest possible time based on a reassessment of the patient's condition. A trained RN discontinues restraints when the criteria for release are met....