HospitalInspections.org

This condition is not met as evidenced by:

Based on a review of facility documents, medical records (MR), and employee interviews (EMP), it was determined that the facility failed to provide a safe environment for a non-verbal, autistic patient which resulted in an airway obstruction for one of eight medical records reviewed (MR1).


It was determined that the facility failed to provide the Important Message from Medicare (IMM) on admission in two of ten inpatient medical records (MR6 and MR11); and failed to provide the Important Message from Medicare (IMM) on both admission and discharge for one of ten medical records (MR4).

It was determined that the facility failed to document the ongoing assessment of the patient in restraints every two hours in five of eight medical records (MR1, MR4, MR6, MR8 and MR12). In addition, the facility also failed to document the time and criteria used for the discontinuation of the restraint in four of eight medical records (MR4, MR6, MR8 and MR12)

Cross reference
482.13(c)(2) Patient Rights: Care in Safe Setting
482.13(a)(1) Notice of Rights
482.13(e)(4)(ii) Restraint or Seclusion

Based on a review of facility documents, medical record review (MR), and staff interview (EMP), it was determined that the facility failed to provide the Important Message from Medicare (IMM) on admission for two of 10 medical records reviewed (MR6 and MR11); and failed to provide the IMM on both admission and discharge for one of 10 medical records reviewed (MR4).

Findings include:

On January 29, 2024, a review of Policy: HS-QM0884: Medicare Hospital Issued Notices of Financial Liability and Discharge Appeal" (Last Approved: December 20, 2023) was completed and revealed the following: "V. Procedure C. Important Message from Medicare (IMM) 1. All Medicare/Medicare Advantage plan enrollees who are hospital inpatients must receive the IMM. 2. The IMM informs hospitalized inpatient beneficiaries/representatives of their rights as a hospital patient, including discharge appeal rights. 3. The IMM must be delivered within 2 calendar days of admission, must obtain the signature of the beneficiary or his/her representative, and a copy must be provided to the beneficiary/representative. Hospitals will also deliver a copy of the signed notice as far in advance of discharge as possible, but not more than 2 calendar days before discharge."


On January 29, 2024, a review of MR4 (admitted 05/24/2023) revealed no evidence that either the admission or discharge IMM had been signed by the patient. On May 26, 2023, the care coordination notes stated that "IMM second signature" was completed. However, neither the admission or discharge IMM could be located by the facility.


On January 29, 2024, a review of MR6 (admitted 1/21/2024) revealed that the admission IMM was not included in the medical record. The facility could not locate the admission IMM.


On January 29, 2024, a review of MR11(admitted 01/14/2024) revealed that the admission IMM was not included in the medical record. The facility could not locate the admission IMM.


On January 29, 2024, between 12:00 PM and 2:00 PM, EMP1 confirmed the above findings.

Based on a review of facility documents, medical records (MR) and employee interviews (EMP), it was determined that the facility failed maintain a safe environment by not maintaining adequate communication between members of the clinical team and not providing adequate observation and supervision for one of eight medical record reviewed (MR1).


Findings include:


On January 26, 2024, a review of Policy HS-HD-PR-01: "Patient's Notice and Bill of Rights and Responsibilities" (Last Approved: December 20, 2023) was completed.
"Attachment A: Staff and Environment- You have a right to: 1. Receive respectful care given by competent personnel in a setting that: a. is safe and promotes your dignity, positive self image and comfort... Quality, Support, Advocacy- You have the right to: ...2. Quality care and high professional standards that are continually maintained and reviewed."


On January 26, 2024, a review of MR1 revealed the patient was admitted via the Emergency Department on January 16, 2024, from a group home with generalized weakness and difficulty ambulating. It is noted that MR1 has a developmental/cognitive disability and was nonverbal. MR1 was assessed as a Fall Risk Level 2 and the following interventions were initially implemented: Bed alarm, Yellow Fall Risk arm band, ... Focused rounding pain, toilet, position, placement of items, Orientation to call light ... Personal items in reach, safe bed exit."


On January 16, 2024 at 09:39 AM, a canopy bed was ordered for MR1 to prevent patient injury based upon behaviors noted and observed while in the emergency department,"uncooperative, combative and attempting to self harm (attempting to self removed from bed) patient attempting to self transfer/throw self from stretcher."
Further review of MR1 revealed that while awaiting the arrival of the canopy bed, a second order was placed for "nonviolent" restraints on January 16, 2024 at 11:15 AM. MR1 was placed in a vest restraint due to "patient's attempts to self transfer and possibly harm self\... ."


MR1 was placed in the canopy bed on 1/16/2024, at 17:24, and transferred to a monitored unit at 19:28.


On January 18, 2024, at 03:49 AM, EMP15 documented, "[MR1] took off brief and shredded the brief and was attempting to eat it. BM smeared all over canopy bed." This information was not communicated to either the on coming nurse or the physician nor was there a change to the plan of care. On January 26, 2024, at 11:00 AM, EMP5 confirmed that EMP17 was not aware of the incident. EMP5 stated that the team,"realize we have gaps in communication."


On January19, 2024, at 08:58 AM, MR1 was found unresponsive and pulseless. Advanced cardiac life support was initiated. During the attempt at intubation (establishing an airway), it was noted that MR1's "mouth and airway were occluded with large amount of fibrous material of his hospital brief. Suction was inadequate to clear the material from the airway, ultimately partially dislodged with Magill forceps, following which [MR1] was orotracheally intubated." MR1 received 10 epinephrine and 2 bicarbonate without return of spontaneous circulation. Resuscitative efforts were terminated on 1/19/2024, at 9:32 AM.



On January 26, 2024, the above findings were confirmed by EMP1, EMP2, and EMP5.

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to document the on going assessment of the patient in restraints every two hours in five of eight medical records (MR1, MR4, MR6, MR8 and MR12) reviewed and failed to document the time and criteria used for the discontinuation of the restraint in four of eight medical records (MR4, MR6, MR8 and MR12) reviewed.

Findings include:

On January 26, 2024, a review of Policy HS-NA0416- "Restraint and Seclusion" (Last Approved: July 10, 2023) was completed and revealed the following: "Section VIII. Use of Restraint for Non Violent/Non Self Destructive Behavior B. Initial Patient Assessment: 1. An assessment of the patient at the initiation of the restraint is required and will include the following and be documented in the medical record ...g. Type of restraint, reason, time and date of application. 2. Only staff that has completed the required training on restraint use may apply or remove restraints or perform restraint assessment. D. Ongoing Patient Assessment and Care Interventions: 4. The continued need for the use of restraints for Non Violent/Non Self Destructive behavior will be reassessed and documented in the medical record at the following frequencies or ore often as the patient condition requires. a. Non Violent/Non Self Destructive behavior- every 2 hours. E. Discontinuation of Restraint 1. The RN or physician, CRNP, or PA may discontinue the restraint if the criteria for discontinuation has been met. 2. The time and criteria for release will be documented when the restraint is removed."

On January 26, 2023, a review of MR1 revealed that MR1 was ordered "nonviolent" restraints on 1/16/2024. Initially, a chest vest was applied and later, a canopy bed. There is no evidence of the required two hour assessment on 1/16/2024 at 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM. On 1/17/2024, there is no evidence of the required two hour assessment at 4:00 AM and 6:00 AM. EMP1 confirmed these findings on January 26, 2023 at 12:00 PM.

On January 29, 2024, a review of MR4 revealed that MR4 was ordered "nonviolent" restraints on 5/28/2023. Soft wrist restraints were applied. There is no evidence of the required two hour assessment on 5/28/2023 at 4:00 PM, 6:00 PM; or 2:00 AM on 5/29/2023. There is no evidence that the restraint was removed or discontinued noted in MR4.

On January 29, 2024, a review of MR6 revealed that MR6 was ordered "nonviolent" restraints on 1/21/2024 at 4:00 PM. Soft wrist restraints were applied. There is no evidence of the required two hour assessment on 1/24/2024 at 6:00 PM. Restraints were discontinued on 1/25/2024 at 2:37 PM. Restraints were re-ordered and reinitiated on 1/26/2024 at 8:00 AM. On 1/27/2024, at 2:00 AM, the required two hour assessment is noted. There is no required two hour assessment for 4:00 AM, 6:00 AM, 8:00 AM and 10:00 AM. There is no evidence/documentation that the restraint was removed or discontinued noted in MR6

On January 29, 2024, a review of MR8 revealed that MR8 was ordered "nonviolent" restraints on 6/23/23 at 8:00 AM. Soft wrist restraints were applied. There is no evidence of the required two hour assessment on 6/23/2023 after 6:00 PM. There is no evidence that the restraint was removed or discontinued noted in MR8.

On January 29, 2024, a review of MR12 revealed that MR12 was ordered "nonviolent" restraints on 1/21/2024 at 9:07 AM. Soft wrist restraints were applied. There is no evidence of the required two hour assessment on 1/24/2024 after 10:00 PM. There is no evidence that the restraint was removed or discontinued noted in MR12.

On January 29, 2024, EMP1 confirmed the above findings between 11:55 AM and 1:33 PM.

Based on a review of facility documentation, medical record (MR), personnel files (PF), and staff interview (EMP), it was determined the facility failed to ensure staff completed restraint training for canopy beds for four of four personnel files reviewed (PF1, PF2, PF3, and PF4).


Findings include:



On January 26, 2024, a review of Policy HS-NA0416: "Restraint and Seclusion" (Last Approved: July 10, 2023) was completed and revealed the following: " V. EDUCATION AND TRAINING ... B. Staff Education and Training. 1. Orientation to the Restraint and Seclusion Policy will be provided to all newly hired staff and agency staff, who have direct patient care responsibilities, responsibilities for application of restraint or seclusion or the monitoring or assessment of patients in restraint or seclusion. ...2. All staff who may be involved in the use of restraint and seclusion will have ongoing education to maintain competency in the proper and safe use of restraints and seclusion. ...3. The education and training provided is to be based on the specific needs of the patient population in at least the following: ...d. The safe application and use of all types of restraint or seclusion used including training in how to recognize and respond to signs of physical and psychological distress ...f. Monitoring the physical and psychological well-being of the patient who is restrained or secluded ... 4. Documentation of successful completion of training and demonstration of competency is to be present in the staff personnel records. ... ".

On January 26, 2024, a review of MR1 revealed the patient was admitted via the Emergency Department on January 16, 2024, from a group home with generalized weakness and difficulty ambulating. It is noted that MR1 has a developmental/cognitive disability and was nonverbal. MR1 was assessed as a Fall Risk Level 2 and the following interventions were initially implemented: Bed alarm, Yellow Fall Risk arm band, ... Focused rounding pain, toilet, position, placement of items, Orientation to call light ... Personal items in reach, safe bed exit," Additionally, MR1 was placed in a canopy bed.



On January 26, 2024 a review of PF1, PF2, PF3, and PF4 revealed that the staff provided care to MR1. Further review revealed that PF1, PF2, PF3, and PF4 did not have restraint training specific to canopy beds.



On January 26, 2024, the above findings were confirmed by EMP1 at 2:20:PM.