HospitalInspections.org

Based on a review of policy and procedures, medical records, and staff interviews it was determined that the facility failed to ensure that patients' rights were promoted and protected when four (P#1, P#2, P#3, and P#4) of four sampled patients (P#1, P#2, P#3, and P#4) were not given the opportunity to formulate an advanced directive upon admission.

Findings Included:

A review of the facility's policy titled "Advance Directives for Healthcare (Durable Power of Attorney for Healthcare and Living Will)", effective 7/8/2018, revealed that the facility recognized the right of an adult patient to execute an Advance Directive for Health Care. That facility staff shall notify adult patients upon admission of their rights to formulate an advance directive.

A review of the facility's policy titled "Patient's Rights and Responsibilities", effective 9/8/2021, revealed the following:
* Patients had a right to make informed decisions regarding their care.
* To participate in the development and implementation of their plan of care.
* Accept the consequences and responsibility for refusing treatment or not following their prescribed treatment plan.
* The right to request and/or refuse treatment with the right to receive a clear explanation of the consequences of refusal of treatment.

During a review of Patient (P) #1's medical record, it was revealed that the Advanced Directive was not completed or signed by P#1 or a patient representative. Continued review of P#1's medical record revealed that the patient was admitted on 12/17/23 and the patient's consent for treatment was illegibly signed and unwitnessed on 1/4/24.

During an interview on 3/27/24 at 1:33 p.m. in the medical-surgical unit, 51, Registered Nurse (RN) PP stated that she reviewed patient rights with new admission patients by asking them if they would like a copy of the documentation. When RN PP was asked if there was anything else she did to educate patients on patient rights, RN PP stated that she would physically point out to the patient where the patient rights information was located on the unit. When asked if she could show the surveyor where the rights were posted, RN PP was unable to locate it.

A telephone interview was conducted on 3/27/2024 at 4:07 p.m. with Senior Patient Access Manager (PAC) LL in the boardroom. PAC LL stated that she had worked at the facility for 21 years. She explained that patients were notified about the Medicare Important Message when they completed and signed the Rights of Responsibilities at registration. She said the forms were electronically scanned into the facility's electronic medical record system. PAC LL also explained that patients were asked whether they had an Advanced Directive, and if so, a copy was scanned into the electronic medical record system. However, she stated it was not common to ask patients about Advance Directives at registration because the system did not prompt staff to do so. She further said that if patients did not have an Advanced Directive, they were provided with resources to obtain one.

A review of three additional medical records (P#2, P#3, P#4) failed to reveal documentation that the patient or representative received information about advanced directives or provided the opportunity to formulate an advanced directive.

Based on a review of policy and procedures, medical records, and staff interviews it was determined that the facility failed to ensure that restrained patients were monitored in intervals of two hours as per the facility's policy. Specifically, the facility failed to conduct and document restraint assessments for one (P#3) of four (P#1, P#2, and P#4) sampled patients.

Findings Included:

A review of the facility's policy titled "Patient's Rights and Responsibilities", effective 9/8/2021, revealed the following:

* Be free from restraint/seclusion used as a means of coercion, discipline, convenience, or retaliation by staff.
* Be free from any restraint or seclusion that was not clinically necessary or necessary in an emergency to ensure their immediate physical safety or the safety of others.

A review of a policy, "Restraint", effective 4/12/2023, revealed the following:

* All patients would receive notice of rights related to restraints.
* Before restraints were initiated, restraint use must be explained to the patient and/or family/significant other to make the restraint/seclusion experience less traumatic.
* Restraint devices included but were not limited to wrist-soft limb restraint (soft, non-rigid, cloth-like material), and ankle-soft limb restraint.
* All staff designated by the hospital as having direct patient care responsibilities or participating in the application of restraints, implementation of seclusion, monitoring, assessment, or care of a patient in restraint or seclusion must be trained and able to demonstrate competency prior to applying restraints, in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion.

A review of P#3's medical record (MR) revealed that an order was entered on 3/13/24 at 6:55 a.m. for soft limb restraints of the right and left upper extremities. The order was continuous for 24 hours. A review of "Flowsheets" revealed that restraints were applied on 3/13/24 at 6:00 a.m. by Registered Nurse (RN) BB. Further review revealed that restraints were to be discontinued at 5:00 p.m. RN CC assessed the restraints every two hours until 12:00 p.m. P#3's MR failed to reveal restraint assessments at 2:00 p.m. and 4:00 p.m. Further review of the "Flowsheets" under the tab "Clinical Indication", failed to reveal a clinical indication documented at 10:00 a.m. and 12:00 p.m. Additionally, there was not a less restrictive alternative documented at 10:00 a.m.

An interview was conducted with RN BB on 3/27/24 at 3:15 p.m. in the conference room. RN BB had been employed with the facility for 27 years. RN BB explained the procedure for the placement and documentation of soft restraints. RN BB stated that she did not initially look at the time the restraint order was entered. Once restraints were placed on the patient, charting would start on the hour. RN BB said that restraints were assessed every two hours, and results were documented under the restraint tab on the nurse's flow sheet.

A telephone interview was conducted with RN CC on 3/27/24 at 6:20 p.m. RN CC had been employed with the facility for four or five months. RN CC explained the procedure for placement and documentation of soft restraints. RN CC stated that the Electronic Portfolio of International Credentials (EPIC) system (facility's electronic medical record) initiated a prompt every 12 hours to complete restraint education, which was done before restraints were placed on a patient except in the case of an emergency such as intubation (placement of a plastic tube into the windpipe to maintain an open airway and assist with breathing). RN CC also stated that once education was completed and restraints were placed, the restraints were checked and documented every two hours on the hour. RN CC further said that there should never be a time when restraints were not documented because the EPIC system would usually prompt you to chart restraint information. All documentation was placed under the restraint tab