HospitalInspections.org

Based on interview and record review the facility failed to ensure that all patients were informed of their patient rights in advance of furnishing patient care if the patient was admitted with an isolation status for 1 of 1 (#2) patients. Findings include:

On 9/22/10 at approximately 1045 upon review of patient #2's medical record it was noted that the patient was admitted on 8/18/2010 and on the form titled "An Important Message for Medicare About Your Rights" had written on the bottom underneath the line for the patient's signature "Airborn 8/18 unable and initials". In addition, another form titled "An Important Message for Medicare About Your Rights" had written on the bottom underneath the line for the patient's signature "ISOL. ISOL. 9-1-10".

On 9/22/10 at approximately 1600 an interview with the Director of Revenue Cycle revealed that it has come to his attention that the registration personnel that have the form titled "An Important Message for Medicare About Your Rights" signed by the patients upon admission are uncomfortable about going into isolation rooms.

On 9/23/10 at approximately 0830 review of the facility's policy and procedure titled "Medicare IM" it is written "Obtaining a signature on the Medicare IM; There will be two attempts based on the following reasons: If the patient is off the floor for any reason; If the medical staff is with the doctor; If the chart is not available; On your report write a specific reason as to why you were not able to obtain a signature."

Based on record review interview and policy review, the facility failed to provide written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for the resolution for 5 of 5 grievances reviewed (Patient ' s # 7, #11, #12, #13, & #14). Findings include:


Patient #7's grievance was first documented on 08/ 07/ 10. As of 09/23/10 the grievance was documented as "Not closed".

Patient #11's grievance was first documented on 07/13 /10. The patient asked a question regarding his prescription, and asked that someone get in touch with him. The patient left a phone number. According to an email dated 08/24/10 with the description of " follow-up feedback " it includes: "Showing this case as still open. Can you please review and advise on the outcome/resolution so that I can get it closed out?" As of 09/23/10 the grievance was documented as" not closed".

Patient #12's grievance was first documented on 08/20 /10. A call to patient # 12 was placed on 09/15/10. He had requested a " face to face meeting with each one of his providers" . The facility informed him by phone call that they "could not accommodate his request" . There was no documentation that a letter was sent. As of 09/23/10 the grievance was documented as"closed".

Patient #13's grievance was first documented on 08/16/ 10. An email stated that " this complaint was called to our office. Could you please review and advise on the resolution?" A second email was dated 08/24/10 and includes the following: "Have you had a chance to address this concern? Please let me know if there is anyway I can assist in getting it closed out?" As of 09/23/10 the grievance was documented as " not closed".

Patient #14 ' s grievance was first documented on 08/06/10. The email states " ...the patient's wife included her number which means she needs a response to her concerns. Can you take a look at the final page re:d/c when you have a chance? Please provide me with any necessary feedback/follow up and I will get a response to her." A following email was sent on 08/17/10 stating " have you had a chance to look at this case?"' As of 09/23/10 the grievance was documented as"not closed".

Interview with the Patient Relations Coordinator, on 09/23/10 at approximately 1300 revealed that the 5 cases did not contain a letter of closure that contained all the elements listed in the policy titled "RadicaLogic Online Blueform: Feedback (Compliment, Comment, Complaint, Service Recovery, Grievance)".

Based on observation, interview, and record review the failed to ensure that the mitts that are applied to patients that inhibit the use of their hands are were considered a restraint device and thus not adhering to their restraint policy and procedure for 2 of 2 (#3, # 9) patients identified as wearing mitts. Findings include:

On 9/22/10 at approximately 1700 review of the facility's policy and procedure titled "Restraint Policy for Management of the Non violent/Non Self Destructive and Violent Self Destructive Patient" it is written "Adaptive / Supportive Device: Devices used for postural support, to assist with, maintain or enhance normal body functioning or to compensate for a specific physical deficit. The care of the patient and specific use of the device should follow customary care practices, patient plan of care, or clinical pathway." Then applied in the Table titled "Table of Physical Restraints compared with Adaptive/Supportive Devices" listed under the heading "Adaptive/Supportive Devices" it is written "Mitts - padded / unpadded not tied down".

On 9/22/10 at approximately 1130 during the observational tour of the Medical Intensive Care Unit staff #B and #C were queried about the use of mitts and indicated that at the facility mitts are not considered restraints if they are not attached to the bed, and are used as an alternative method prior to restraints.

On 9/22/10 at approximately 1200 during the observational tour patient #3 was observed wearing a mitt on the left hand and a soft restraint applied to his left wrist. The physician's restraint order indicated soft wrist right and soft wrist left only.

Based on observation, interview, and record review the facility failed to ensure that the least restrictive restraint intervention that will be effective to protect the patient or others from harm was ordered appropriately for 1 of 1 (#8) patients. Findings include:

On 9/22/10 at approximately 1700 review of the facility's policy and procedure titled "Restraint Policy for Management of the Non Violent/Non Self Destructive and Violent Self Destructive Patient" it is written "Re-Assessment: Includes the evaluation of the use of restraint to determine whether the need for restraint is still present. This evaluation is used to decide whether restraint is still meeting the patient's need, if a less restrictive method is appropriate of if removal can be safely achieved." and "Monitoring is intended to evaluate the physical and emotional well being of the patient and the continued protection of his or her rights and dignity throughout the restraint process. Monitoring is accomplished by observation, interaction with the patient or related direct observation by qualified staff...."

On 9/23/10 at approximately 0830 during the medical record review of patient #8 it was noted that the physician's restraint order for 9/22/10 was side rails x4, 4-point soft restraints, and a Posey vest. On 9/23/10 at approximately 0900 an interview with staff #B verified the restraint order and when queried regarding the necessity of all the restraint types and levels she stated "that is excessive".

Based on interview and record review the facility failed to ensure that all patients placed in restraints had a complete order from a physician for 1 of 5 (#2) restraint patients. Findings include:

On 9/22/10 at approximately 1700 review of the facility's policy titled "Restraint Policy for Management of the Non violent/Non Self Destructive and Violent Self Destructive Patient" it is written "All restraint orders must ... include the following: .... date and time of order, physician signature and pager number..."

On 9/22/10 at approximately 1100 during an observational tour in the medical intensive care unit patient #2's medical record was reviewed for restraint orders. Staff #E was operating the computerized restraint order and monitoring program utilized in the intensive care units and revealed that patient #2 had been in left and right soft wrist restraints per the nurse's documentation since 9/16/2010 at 2050 and the first physician's order was noted in the documentation on 9/19/10.

Based on record review and interview the facility failed to ensure orders for the use of restraints are ordered as necessary for 1 of 5 (#1) restraint patients. Findings include:

On 9/22/10 at approximately 1700 review of the facility's policy titled "Restraint Policy for Management of the Non violent/Non Self Destructive and Violent Self Destructive Patient" it is written "Whenever necessary or PRN orders are not acceptable".

On 9/22/10 at approximately 1045 during an observational tour of the medical intensive care unit, review of patient #1's medical record revealed that the physician ordered the left and right soft wrist restraints on 9/14/2010 at 0826 and the nursing documentation indicated the nurse did not apply the restraints until 9/14/2010 at 1400. This finding was verified by staff #B, #C, and #E.

Based on interview and record review the facility failed to ensure the identification of patients in need of discharge planning according to the facility's policy and procedure for 5 of 5 (#3, #4, #5, #6, #7) patients records specifically reviewed for timeliness of the social assessment. Findings include:

On 9/22/10 at approximately 1245 an interview with staff #I revealed that the facility's policy indicates that that all patients are to be screened for discharge planning needs within 24 hours of admission or the first business day following the patient's admission.

On 9/22/10 at approximately 1645 upon review of the facility's policy and procedure titled "Discharge Planning Policy-Case Management & Social Work Division" it is written "All patients will be screened for discharge planning needs within 24 hours of admission or on the first business day following admission."

On 9/22/10 throughout the observational tour of the medical intensive care unit the patient medical records reviewed revealed the following:

Patient #3 - was admitted on 9/6/2010 and no screening for discharge planning needs is documented to this date.

Patient #4 - was admitted on 9/18/2010 and no screening for discharge planning needs is documented to this date.

Patient #5 - was admitted on 9/16/2010 and an assessment note was first created on 9/20/2010 stating "....The patient is not stable for active discharge planning at this time. Case manager will continue to follow." and no screening for discharge planning needs is documented to this date.

Patient #6 - was admitted on 9/17/2010 and an Adult Social Assessment (screening tool) was completed on 9/22/2010.

Patient #7 - was admitted on 7/26/2010 and an Adult Social Assessment (screening tool) was completed on 7/30/2010.

The above findings were confirmed by staff #F, #H. and staff #N.

Based on interview and record review the facility failed to establish an appropriate discharge plan and discuss the results of the evaluation with the patient or individual acting on his or her behalf for 1 of 1 (# 7) discharged patients. Findings include:

On 9/23/10 review of the facility's policy and procedure titled "Documentation: Nursing Process" under the section titled "Discharge Planning" it is written "Potential discharge needs or concerns will be addressed in collaboration with the health care team and with referrals to other health care team members as appropriate." and "The Registered Nurse will review the Patient Discharge Instructions with the patient and family prior to discharge."

On 9/23/10 review of the facility's policy and procedure titled "Discharge Planning Policy-Case Management & Social Work Division it is written "Case Manager will coordinate discharge plans in collaboration with patient, family and medical staff."

On 9/23/10 at approximately 0900 during the review of patient #7's medical record the following was revealed:
1) The Adult Social Assessment form that case managers fill out upon admission dated 7/30/10 had documentation under the section titled Anticipated Discharge Needs" will monitor for social work and discharge planning needs and coordinate care as indicated.

2) A note from dietary dated 8/5/10 was reviewed and it was documented "At home patient has limited access to food as evidenced by report of only eating sandwiches from his delivery truck, no fruits or veggies consumed. Encouraged variety and provided handout on places for possible assistance."

3) Another entry for case management dated 8/8/10 on the Case Management (CM) and Social Work Services - Assessment Notes had documented "Case management spoke with Physician #P resident for P5, who states patient will be ready to go home maybe today and will need meds paid for by EMNF (prescription program). CM explained that we can only pay for BP (blood pressure) meds and Ngl. CM did ECIN EMNF form and faxed to pharmacy... CM placed info into Careplus regarding EMNF for patient and found there was no CHASS clinic appointments made. CM called physician #P to find out if anyone has made a follow up CHASS appointment. CM gave doctor above the phone number to call for appointment and informed that they are not likely available until tomorrow. CM will continue to follow for discharge planning needs.

4) The next entry for case management dated 8/9/10 on the Case Management and Social Work Services - Assessment Notes has documented "Case management patient discharged 8/8/10 to home with HFHHC per HFH Emergency Medical Needs Fund for meds and HHC (Home Health Care), per family for transportation, with bedside nurse explaining all meds, med regime, answering questions, and no other needs known. Case closed.

5) A psychiatric consult was ordered for competency and was performed on 8/6/2010 at 1740 the Assessment and Plan section had documented "not competent for medical decisions at this time. Need time and/or collateral damage to distinguish dementia v. delirium or learning/mental deficit. Will follow up to reassess. Team informed at 17:45. Under the section Teaching/Attending Physician Note it is documented "Pt. has significant cognitive deficits. We'll try to contact his family to assess his baseline cognitive functioning. Dg (diagnosis) Cognitive Disorder nos s/d dementia s/d delirium (baseline unknown) He lacks decisional capacity family should be involved in decision making. Does not have capacity at this time, see consult.

6) A nursing progress note was noted to be documented on 8/7/10 at 1730. It is written "Pt. cleared for discharge by primary team. Family previously raised concerns regarding pt's current residence in hotel. Psyche eval completed 8/6/10 reads pt. lacks decisional capacity. Teaching team aware. Physician #Q made aware - instructed resident to continue with discharge. Weekend case manager made aware called to bedside to speak with both writer and patient. Safety concerns discussed with both writer and resident given psyches recent evaluation. Patient refusing placement. Spoke with both mother (name) and sister (name) who are unwilling to act as legal guardians. Pt. stated psyche eval was biased b/c he refused to cooperate. On call psyche resident paged to assess pt. writer witness to conversation. Pt. able to articulate plan of action in case of emergency and plan for maintaining compliance with home medications with pill dispenser and family resources should he have questions or problems. Pt. also described lrg (large) community of friends at place of residence that would assist him if necessary. Pt. able to complete ADL's in hospital independently. Medications did not arrive from pharmacy in time and pharmacy now closed. Pt. to be dc'd tomorrow. Resident aware."

7) The medical record was absent documentation of psychiatric followup or clearance.

8) A progress note was written on 8/8/10 at 1320, it was written "pt. A& O x 3 , vss. Received discharge orders. Clear discharge instructions regarding follow-up and medications were given. Social worker spoke to pharmacy regarding patient's insurance. Medications were received from pharmacy. Patient was sent to discharge lobby on wheelchair, patient's mother comes to pick him, and patient has been discharged."

On 9/22/10 at approximately 1015 staff #C stated to surveyor "I know what this is about and investigated this and realized there were issues with communication with the family."

On 9/23/10 during the exit conference Nursing Administrator #2 stated " he was left in the discharge lobby and the nursing supervisor had seen him still sitting there a couple hours later. The complainant said he would call and see if someone else could pick him up. "