The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BROOKWOOD BAPTIST MEDICAL CENTER 2010 BROOKWOOD MEDICAL CENTER DRIVE BIRMINGHAM, AL 35209 Sept. 1, 2016
VIOLATION: MEDICAL STAFF - BYLAWS AND RULES Tag No: A0048
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of personnel files, review of medical records, policies and procedures, event reports and interview with staff, it was determined the facility failed to:

1. Accurately complete incident/ event reports. This had the potential to affect all staff and patients and did affect Patient Identifier (PI) # 2.

2. Follow their Employee Health policy for TB (Tuberculosis) testing and Hepatitis B vaccine in 5 of 13 personnel files reviewed. This had the potential to affect all staff and patients.

Findings include:


Subject: Infection Prevention/ Employee Health Responsibilities Defined

II. Purpose:
To define shared responsibilities between the Infection Prevention Department and the Employee Health Department.

III. Policy:

"A. The duties of the Employee Health Staff, as they relate to the Infection Prevention program, are as follows:

1. Pre-employment physical:

a) History of immunizations and/or communicable disease.
b) Administration of vaccines as needed based on serological screening.
c) Initial instruction concerning Hepatitis B Vaccine. Initiation and completion of the vaccine series as appropriate.

2. Annual Employee TB Assessment: (TB skin test or questionnaire)."

Subject: Employee Screening and Immunization for Communicable Diseases

III. Policy:

" A. Health-care personnel (HCP) have the potential for exposure to patients and/or infectious materials and should be immunized to prevent the spread of infectious diseases...

C. At the time of employment, all employees will be asked for history of the above diseases, proof of vaccination, or copies of previous labwork showing a positive titer. Employees who cannot show evidence of immunity or vaccination will receive a vaccine prior to being scheduled for a work shift.

D. All new employees will be tested for TB by the two-step Mantoux method. "

A review of personnel files conducted 9/1/16 at 2:00 PM revealed the following:


1. A PCA (Patient Care Associate) date of hire 4/25/16 failed to have a Hepatitis B vaccination or titer in the personnel folder reviewed.

2. A PCA date of hire 10/13/14 failed to have a Hepatitis B vaccination or titer in the personnel folder reviewed.

3. A Patient Care Technician (PCT) date of hire 4/13/15 failed to have a Hepatitis B vaccination or titer in the personnel folder reviewed.

4. A Licensed Practical Nurse (LPN) date of hire 12/16/14 failed to have a Hepatitis B vaccination or titer in the personnel folder reviewed.

5. A RN (Registered Nurse) date of hire 5/19/03 failed to have a current TB test.


In an interview 9/1/16 at 2:00 PM with Employee Identifier (EI) # 5, Human Resource Manager, confirmed the missing information.

****
Policy & Procedure Directive
Subject: Event Reporting

I. Scope: This policy applies to Brookwood Medical Center (Hospital) and its Medical Staff.

II. Purpose:

The purposes of this policy are to:
A. Clarify and delineate the responsibilities of Hospital Staff Members, as defined in Section III. below, with respect to reportable events involving patients and/or visitors;

B. Provide a system for promptly reporting and investigating reportable events and integrating risk reduction strategies into the patient safety activities;

C. Comply with requirements of applicable federal and state law and the standards of applicable accrediting organizations as they relate to reportable event requirements;

D. Establish a process to validate documentation and investigation is conducted appropriately to the type and level of severity of reportable events; and

E. Support a culture of shared accountability for the identification, reporting and management of reportable events that may impact the quality of care provided.

III. Definitions:

A. " Reportable Events" means an event that is not consistent with the routine operation of the Hospital or the routine care of a patient or patients. The potential for accident, injury, illness or property damage commonly referred to as a " NearMiss " is sufficient for an event to be considered a Reportable Event...

B. " Patient Safety Reporting System" or "PSRS" is the mechanism for the Hospital Staff Member to complete an Event Report for patient safety events or near misses required under this policy...

E. "Sentinel Event" means an unexpected occurrence involving death or serious physical or psychological injury not relate to the natural course of the patient's illness or underlying condition, or the risk thereof...

V. Procedure:
A. Time Frame for Completing an Event Report:
1. After providing for the needs of the individual involved, Hospital Staff Members must complete and submit an Event Report as soon as possible. Preferably, the report should be submitted before leaving the Hospital at the end of the work shift, but no later than (24) twenty-four hours from the time the event occurred.


Medical Record findings:

Patient Identifier (PI) # 2 was admitted to the psychiatric unit of the hospital 4/7/15 with diagnoses of Dementia, Delusional Paranoia, Psychotic Disorder, not otherwise specified.


Code Blue Note:
Date of service: 5/6/15
Time: at 2026 (8:26 PM).
History of present illness: " PI # 2 was an inpatient on the geriatric psychiatry unit. He/she is a [AGE] year old (gentleman/woman) who was standing at the nurse's station eating when he/she choked and fell to the floor and could not breathe. Nurses attended to him/her quickly, but the patient lost his/her pulse and was not spontaneously breathing. Upon my arrival the patient was receiving CPR (Cardiopulmonary Resuscitation) from the nurses and receiving ventilation by mask. An IV (Intravenous) had been established... The patient was intubated at this point by the CRNA (Certified Registered Nurse Anesthetist) without difficulty and it was noticed that there was food and bloody secretions in his/her airway, which were removed..."

In an interview conducted 8/31/16 at 9:55 AM with Employee Identifier (EI) # 2, Patient Care Associate (PCA) confirmed PI # 2 had been inappropriately restrained by another PCA 5/6/15 with a band around him/her and a knot tied to the chair. EI # 2 stated, "When she came on duty the patient was in a chair up at the nurses station. Patient was not verbal, dementia, don't know why the patient was in the chair tied, techs (PCA) don't get report on geri psych unit. The trainee gave the patient a sandwich and he/she choked on it, they had to use the scissors to cut him/her out of the chair."

A review of the Patient Safety Report/ Actual Death Event Report date/Time: 05/13/15 14:15 (2:15 PM):

" What: Actual Event [AGE] year old white male admitted on [DATE] to Geri Psych with a diagnosis of early onset dementia. The patient was nonverbal and able to make unintelligible speech. On the evening of 05/06/15, the patient was given a sandwich (patients ordered diet was soft mechanical) for a bedtime snack (the patient was seated in front of the nurses station in a chair at the time the sandwich was administered). The patient choked on the sandwich and the Heimlich maneuver was unsuccessful and Code Blue had to be called. Patient was resuscitated and transferred to Critical Care. Subsequently the patient was mad a DNR (Do Not Resuscitate) on 04/16. Due to the DNR status the patient was taken off of the ventilator in the evening of 05/07/2015 and was pronounced a few hours after."

Was the person restrained or secluded? The answer placed on the event report was, "no".

The incident was not completed timely per policy and was not accurate in that the patient was restrained.

PI # 2 was restrained inappropriately with a lap band or vest restraint.

In an interview with EI # 1, RN Director Geriatric unit, on 9/1/16 at 9:30 AM regarding the, timeliness of completion of the incident report on PI # 2, she stated she knew the event happened between 8:00 PM and 8:30 PM on 5/6/15 but was not made aware of the incident by the staff involved until 4:00 AM on 5/7/15. EI # 1 provided no answer as to why the incident report was not dated until 5/13/15.

The hospital staff failed to complete an accurate account of the incident/event with PI # 2 and failed to assure the report was completed timely. Following this incident the hospital terminated the PCA who restrained the patient without a physician's order.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, review of policy and procedures, review of medical records and interview it was determined the hospital failed to:

1. Provide care to psychiatric patients in a safe environment and ensure the safety of patients on the Geriatric Psychiatric unit.

2. Have orders for use of restraints.

3. Have signed orders for restraints within 24 hours per hospital policy.

4. Have Restraints applied appropriately.

5. Document a report of a death associated with the use of a restraint within 24 hours after the patient was removed from a restraint to CMS (Centers for Medicare and Medicaid Services).

This had the potential to affect all patients served and did affect Patient Identifier (PI) # 2.

Findings include:

Refer to A 144, A 167, A 168, and A 213.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of Medical Records (MR), observations and interview it was determined the facility failed to provide care to psychiatric patients in a safe environment, prevent the use of cords which could cause self harm and ensure the safety of patients on the Geriatric Psychiatric unit. This had the potential to affect all patient served in this facility and did affect Patient Identifier (PI) # 2.

Findings include:

1. PI # 2 was admitted to the psychiatric unit of the hospital 4/7/15 with diagnoses of Dementia, Delusional Paranoia, Psychotic Disorder, not otherwise specified.

The nursing note documentation from 4/20/15 at 6:19 PM noted, " Patient escorted to geri psych without difficulty."

The nursing note documentation from 4/21/15 at 10:29 PM noted, " Patient in geri chair across from nursing stations. Patient nonverbal but makes sounds at times..."

The nursing note documentation from 4/23/15 at 12:45 AM noted, " Sitting in the geri chair during most of the early PM...Close observation ongoing for safety."

The nursing note documentation from 4/28/15 at 9:47 PM noted, " He/she has a mechanical soft diet order..."

The nursing note documentation from 5/2/15 at 1:03 AM noted, " Lethargic this PM sitting in front of nursing station safe in a geri chair..."

The nursing note documentation from 5/6/15 noted, " @ (at) 2000 (8:00 PM) hr (hour), pt (patient) seated in a chair in front of nursing station eating a sandwich when he/she aspirated. Heimlich Maneuver was initiated but unsuccessful @ 2003 hr CPR (cardiopulmonary resuscitation) started...@ 2204 hr Rapid Response called followed by a Code Blue @ approximately 2015 hr code team arrived...@2035 hr patient was transferred via stretcher by code team to CVSICU (Cardiovascular Surgical Intensive Care Unit). Patient was being ventilated and CPR was continued...Presently we have been unable to contact patient's family for notification."

In an interview conducted 8/31/16 at 9:55 AM with Employee Identifier (EI) # 2, Patient Care Associate (PCA) confirmed PI # 2 had been inappropriately restrained by another PCA 5/6/15 with a band around him/her and a knot tied to the chair. EI # 2 stated, "When she came on duty the patient was in a chair up at the nurses station. Patient was not verbal, dementia, don't know why the patient was in the chair tied, techs (PCA) don't get report on geri psych unit. The trainee gave the patient a sandwich and he/she choked on it, they had to use the scissors to cut him/her out of the chair."

In an interview conducted 8/31/16 at 3:05 PM with EI # 3, PCA confirmed PI # 2 had been inappropriately restrained by another PCA 5/6/15, " He/she was in a geri chair at start of shift. Patient starting jumping up, he/she was a fall risk. Tied him/her to chair- not sure how many knots in strap, not sure strap or bed sheet."

In an interview conducted 9/1/16 at 7:45 AM with EI # 4, PCA stated that they restrained with a Velcro restraint and tied them in knots, " didn't use properly ".

A review of PI # 2's medical record failed to provide any documentation of an order for physical restraint on 5/6/16. EI # 1, RN (Registered Nurse) Director of Geriatric Unit confirmed their was no order for a restraint in the medical record.

The facility failed to ensure PI # 2 received safe care on the Geriatric Psychiatric unit.

The hospital staff failed assure PI # 2 was appropriately and safely restrained with a physician's order. The restraint was a Velcro lap band which should not have been tied to the chair with a knot. Following this incident the hospital terminated the PCA who restrained the patient without a physician's order.








A tour was conducted on the IMCU 1 (intermediate care unit) (for psychiatric patients) on 8/30/16 at 9:45 AM. The surveyor observed two telephones on either side of the patients' hallway with retracted stretchable cords approximately 2 1/2 feet long, which was long enough to cause self harm to patients.

An interview was conducted on 8/30/16 at 9:50 AM with Employee Identifier (EI) # 9, Registered Nurse Director of IMCU 1 and IMCU 2. EI # 9 verified the above observations.

A tour was conducted on the IMCU-1 (for psychiatric patients) on 8/30/16 at 10:00 AM, which revealed an electric bed in room 126 with the electric cord curled under the mattress. The cord was approximately 5 feet long, which was long enough to cause self harm to patients.

EI # 9 was present during the tour, verified the cord was not a shortened cord and had the bed removed immediately.

A tour was conducted on the IMCU 2 (for psychiatric patients) on 8/30/16 at 10:30 AM. The surveyor observed a VCR (videocassette recorder) cord approximately 6 feet long, which was long enough to cause self harm to patients. EI # 9 removed the cord.

An interview was conducted on 8/30/16 at 10:35 AM with EI # 9, who verified the above observations.

A tour was conducted on the IMCU 2 (for psychiatric patients) in rooms 19 and 21 on 8/30/16 at 10:40 AM. The surveyor observed a 2 inch protruding metal object approximately 1/2 cm (centimeter) in diameter with sharp edges coming from the top of the open ended cabinet.

On 8/30/16 at 10:40 AM, EI # 9 stated she/he was going to have the metal object covered that day.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on review of medical records, hospital policy and procedure and interview it was determined the facility failed to apply restraints appropriately and per a physician's order. This affected Patient Identifier (PI) # 2 and had the potential to affect all patients served in this facility.

Findings include:

Subject: Restraint & Seclusion

I. Scope: This policy applies to Brookwood Baptist Medical Center. It is a hospital-wide policy that would apply to any department providing patient care.

III. Definitions:
A. " Restraint" means any method , physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. If the effect of using an object fits the definition of restraint for a specific patient at a specific time, then for that patient at that time the device is a restraint...

V. Procedure:
A. Methodology:

1. If indicated, apply restraints using the guideline documented in the manufacturer's instructions.

2. Document the physician's order for restraint on the Physician's Order Sheet for Restraint or Seclusion.

3. Once the patient is under control and safe, begin documentation on the Restraint Flowsheet.

4. As early as feasible in the restraint process, make the patient aware of the rational for the intervention.

5. RN (Registered Nurse) assessments are documented on the Restraint and Seclusion Flowsheet following the Observation and Monitoring guidelines.

6. Once the patient meets the criteria for release, the restraint is discontinued...

7. When a restraint is implemented, the patient's plan of care must be modified to reflect this change.

8. Document in the patient's medical record any injuries that occur during the restraint or seclusion episode, as well as the treatment provided for those injuries.

B. Authorization and Ordering of Restraints:
1. Restraint is initiated only upon the order of a physician or other licensed independent practitioner (LIP).

Medical Record Findings:

1. PI # 2 was admitted to the psychiatric unit of the hospital 4/7/15 with diagnoses of Dementia, Delusional Paranoia, Psychotic Disorder, not otherwise specified.

The nursing note documentation from 4/8/15 at 11:24 PM noted, " Unable to express him/herself but he/she appears to know his/her name... vocalizations are unintelligible..."

The nursing note documentation from 4/9/15 at 1:32 PM noted, " Pacing up and down hallway, agitated, unable to redirect, PRN (as needed) Geodon given IM (intramuscular) in upper right arm..."

The nursing note documentation from 4/10/15 at 6:24 PM noted, " Paces back and forth and intermittently makes noise...participates in no group activities...patient eats food very fast- family requests pureed diet..."

The nursing note documentation from 4/11/15 at 4:02 PM noted, " Patient with frontal lobe dementia. He/she is unable to speak...he/she was given an injection of Geodon 10 mg (milligram) IM. He/she is 1:1 (within arm length of employee) will continue to monitor for safety."

The nursing note documentation from 4/12/15 at 12:45 PM noted, " He/she is nonverbal, anxious and difficult to redirect. He/she does not follow commands...he/she does not socialize and he/she cannot attend groups due to his/her behavior...
The nursing note documentation from 4/15/15 at 6:30 PM noted, " Poor judgement, poor insight...Participates in no group activities..."

The nursing note documentation from 4/17/15 at 12:00 PM noted, " He/she is non-verbal...Dr (doctor)...was in this evening and did make the patient a DNR (Do Not Resuscitate)."

The nursing note documentation from 4/18/15 at 10:04 PM noted, " Pt (patient) remains confused, no attempts to communicate in any way. Unable to follow commands..."

The nursing note documentation from 4/20/15 at 6:18 PM noted, " Patient escorted to geri psych without difficulty."

The nursing note documentation from 4/21/15 at 10:29 PM noted, " Patient in geri chair across from nursing stations. Patient nonverbal but makes sounds at times..."

The nursing note documentation from 4/23/15 at 12:45 AM noted, " Sitting in the geri chair during most of the early PM...Close observation ongoing for safety."

The nursing note documentation from 4/28/15 at 9:47 PM noted, " He/she has a mechanical soft diet order..."

The nursing note documentation from 5/2/15 at 1:03 AM noted, " Lethargic this PM sitting in front of nursing station safe in a geri chair..."

The nursing note documentation from 5/6/15 noted, " @ (at) 2000 (8:00 PM) hr( hour), pt seated in a chair in front of nursing station eating a sandwich when he/she aspirated. Heimlich Maneuver was initiated but unsuccessful @ 2003 (8:03 PM) hr CPR (cardiopulmonary resuscitation) started...@ 2004 (8:04 PM) hr Rapid Response called followed by a Code Blue @ approximately 2015 (8:15 PM) hr code team arrived...@2035 (8:35 PM) hr patient was transferred via stretcher by code team to CVSICU (Cardiovascular Surgical Intensive Care Unit). Patient was being ventilated and CPR was continued...Presently we have been unable to contact patient's family for notification."

In an interview conducted 8/31/16 at 9:55 AM with Employee Identifier (EI) # 2, Patient Care Associate (PCA) confirmed PI # 2 had been inappropriately restrained by another PCA 5/6/15 with a band around him/her and a knot tied to the chair. EI # 2 stated, "When she came on duty the patient was in a chair up at the nurses station. Patient was not verbal, dementia, don't know why the patient was in the chair tied, techs (PCA) don't get report on geri psych unit. The trainee gave the patient a sandwich and he/she choked on it, they had to use the scissors to cut him/her out of the chair."

In an interview conducted 8/31/16 at 3:05 PM with EI # 3, PCA confirmed PI # 2 had been inappropriately restrained by another PCA 5/6/15, " He/she was in a geri chair at start of shift. Patient starting jumping up, he/she was a fall risk. Tied him/her to chair- not sure how many knots in strap, not sure strap or bed sheet."

In an interview conducted 9/1/16 at 7:45 AM with EI # 4, PCA stated, " They restrained with a Velcro restraint and tied them in knots didn't use them properly ".

In an interview conducted 9/1/16 at 9:30 AM with EI # 1, RN Director Geriatric unit stated that she was not made aware of the incident with PI # 2 until about 4:00 AM the next morning even though it happened about 8:00 or 8:30 PM.

A review of PI # 2's medical record failed to provide any documentation of an order for restraint on 5/6/16.

Following this incident the hospital terminated the PCA who restrained the patient without a physician's order.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, policy and procedures and interview it was determined the facility failed to have signed physician orders for the placement of restraints in 2 of 3 restraint records reviewed. This affected Patient Identifier (PI) # 2, # 8 and had the potential to affect all patients served in the facility.


Findings include:


Subject: Restraint & Seclusion

I. Scope: This policy applies to Brookwood Baptist Medical Center. It is a hospital-wide policy that would apply to any department providing patient care.

III. Definitions:
A. " Restraint" means any method , physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. If the effect of using an object fits the definition of restraint for a specific patient at a specific time, then for that patient at that time the device is a restraint...

V. Procedure:


B. Authorization and Ordering of Restraints:
1. Restraint is initiated only upon the order of a physician or other licensed independent practitioner (LIP).

C. Documentation
1. Each episode of restraint use shall be documented in the patient's medical record and shall include but not be limited to:

a) Assessment and reassessment, including:
1. Significant change in the patient's condition that warranted restraint use.
2. Patient's response to restraint.

b) Relevant orders for use of restraints...

c) Results of monitoring will occur at regular intervals... not to exceed two hours between intervals.

d) Use of restraints must be addressed in the patient's modified plan of care...

D. Death Reporting Requirements:

The Hospital must report deaths associated with the use of restraint or seclusion...

1. The Hospital will report the following information to CMS (Centers for Medicare and Medicaid Services) by telephone, facsimile, or electronically as determined by CMS, no later than the close of business on the next business day following knowledge of the patient's death:

a) Each death that occurs while a patient is in restraint or seclusion.

b) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion.

c) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient's death, regardless of the type(s) of restraint used on the patient during this time...

d) The staff must document in the patient's medical record the date and time the death(s) was reported to CMS.


Medical Record Findings:

1. PI # 2 was admitted to the psychiatric unit of the hospital 4/7/15 with diagnoses of Dementia, Delusional Paranoia, Psychotic Disorder, not otherwise specified.

The nursing note documentation from 5/2/15 at 1:03 AM noted, " Lethargic this PM sitting in front of nursing station safe in a geri chair..."

The nursing note documentation from 5/6/15 noted, " @ (at) 2000 (8:00 PM) hr (hour), pt (patient) seated in a chair in front of nursing station eating a sandwich when he/she aspirated. Heimlich Maneuver was initiated but unsuccessful @ 2003 (8:03 PM) hr CPR (cardiopulmonary resuscitation) started...@ 2004 (8:04 PM) hr Rapid Response called followed by a Code Blue @ approximately 2015 (8:15 PM) hr code team arrived...@2035 (8:35 PM) hr patient was transferred via stretcher by code team to CVSICU (Cardiovascular Surgical Intensive Care Unit). Patient was being ventilated and CPR was continued...Presently we have been unable to contact patient's family for notification."

In an interview conducted 8/31/16 at 9:55 AM with Employee Identifier (EI) # 2, Patient Care Associate (PCA) confirmed PI # 2 had been inappropriately restrained by another PCA 5/6/15 with a band around him/her and knotted to the chair.

EI # 2 stated that when she came on duty a patient was in a chair up at the nurses station. The patient was not verbal, demented, EI # 2 did not know why the patient was tied in the chair. The techs (PCA) don't get report on the geri psych unit. The trainee gave the patient a sandwich and he/she choked on it. EI # 2 stated that they had to use the scissors to cut him/her out of the chair.

In an interview conducted 8/31/16 at 3:05 PM with EI # 3, PCA confirmed PI # 2 had been inappropriately restrained by another PCA 5/6/15, " He/she was in a geri chair at start of shift. Patient starting jumping up, he/she was a fall risk. Tied him/her to chair- not sure how many knots in strap, not sure strap or bed sheet."

In an interview conducted 9/1/16 at 7:45 AM with EI # 4, PCA stated that PI # 2 was restrained with a Velcro restraint, the other PCA would tie them in knots and didn't use them properly.


Code Blue Note:
Date of service: 5/6/15
Time: at 2026.
History of present illness: " PI # 2 was an inpatient on the geriatric psychiatry unit. He is a [AGE] year old (gentleman/woman) who was standing at the nurse's station eating when he/she choked and fell to the floor and could not breathe. Nurses attended to him/her quickly, but the patient lost his/her pulse and was not spontaneously breathing. Upon my arrival the patient was receiving CPR from the nurses and receiving ventilation by mask. An IV (Intravenous) had been established... The patient was intubated at this point by the CRNA (Certified Registered Nurse Anesthetist) without difficulty and it was noticed that there was food and bloody secretions in his airway, which were removed..."

A review of PI # 2's medical record failed to provide any documentation of an order for restraint on 5/6/16. In an interview with EI #1 RN (Registered Nurse) Director of the Geriatric unit, 9/1/16 at 9:30 AM confirmed their was no order for a restraint in the medical record.

Following this incident the hospital terminated the PCA who restrained the patient without a physician's order.

2. PI # 8 was admitted on [DATE] with diagnoses including Multiple Substance Dependence and Substance Abuse Psychosis.

Review of the medical record revealed a Restraint Order (Behavior) dated and timed 8/20/16 at 6:15 PM with no physician's signature, date or time.

Review of the Restraint Order dated and timed 8/20/16 at 10:15 PM revealed no physician's signature, date or time.

Review of the Restraint Order dated and timed 8/21/16 at 10:15 PM revealed no physician's signature, date or time.

An interview conducted on 8/31/16 at 2:30 PM with EI # 9, Registered Nurse Director of IMCU (Intermediate Care Unit) confirmed the above findings.
VIOLATION: PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT Tag No: A0213
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, review of policy and procedure and interview it was determined the facility failed to document a report of a death associated with the use of a restraint within 24 hours after the patient was removed from a restraint in 1 of 1 record reviewed with a death in a restraint. This affected Patient Identifier (PI) # 2 and had the potential to affect all patients served by this facility.

Findings include:

Subject: Restraint & Seclusion

I. Scope: This policy applies to Brookwood Baptist Medical Center. It is a hospital-wide policy that would apply to any department providing patient care.

III. Definitions:
A. " Restraint" means any method , physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. If the effect of using an object fits the definition of restraint for a specific patient at a specific time, then for that patient at that time the device is a restraint...

V. Procedure:
A. Methodology:

1. If indicated, apply restraints using the guideline documented in the manufacturer's instructions...


D. Death Reporting Requirements:

The Hospital must report deaths associated with the use of restraint or seclusion...

1. The Hospital will report the following information to CMS (Centers for Medicare and Medicaid Services) by telephone, facsimile, or electronically as determined by CMS, no later than the close of business on the next business day following knowledge of the patient's death:

a) Each death that occurs while a patient is in restraint or seclusion.

b) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion.

c) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient's death, regardless of the type(s) of restraint used on the patient during this time...

d) The staff must document in the patient's medical record the date and time the death(s) was reported to CMS.


Medical Record findings:


1. PI # 2 was admitted to the psychiatric unit of the hospital 4/7/15 with diagnoses of [DIAGNOSES REDACTED]

The nursing note documentation from 5/6/15 noted, " @ (at) 2000 (8:00 PM ) hr (hour), pt seated in a chair in front of nursing station eating a sandwich when he/she aspirated. Heimlich Maneuver was initiated but unsuccessful @ 2003 (8:03 PM) hr CPR (cardiopulmonary resuscitation) started...@ 2004 (8:04 PM) hr Rapid Response called followed by a Code Blue @ approximately 2015 (8:15 PM) hr code team arrived...@2035 (8:35 PM) hr patient was transferred via stretcher by code team to CVSICU (Cardiovascular Surgical Intensive Care Unit). Patient was being ventilated and CPR was continued...Presently we have been unable to contact patient's family for notification."

In an interview conducted 8/31/16 at 9:55 AM with Employee Identifier (EI) # 2, Patient Care Associate (PCA) stated, " PI # 2 had been inappropriately restrained by another PCA 5/6/15 with a band around him/her and knotted to the chair. EI # 2 stated that when she came on duty PI # 2 was in a chair up at the nurses station. Patient was not verbal, dementia, don't know why the patient was in the chair tied, techs (PCA) don't get report on geri psych unit. The trainee gave the patient a sandwich and he/she choked on it, they had to use the scissors to cut him/her out of the chair."

Code Blue Note:
Date of service: 5/6/15
Time: at 2026.
History of present illness: " PI # 2 was an inpatient on the geriatric psychiatry unit. He is a [AGE] year old (gentleman/woman) who was standing at the nurse's station eating when he/she choked and fell to the floor and could not breathe. Nurses attended to him/her quickly, but the patient lost his/her pulse and was not spontaneously breathing. Upon my arrival the patient was receiving CPR from the nurses and receiving ventilation by mask. An IV (Intravenous) had been established... The patient was intubated at this point by the CRNA (Certified Registered Nurse Anesthetist) without difficulty and it was noticed that there was food and bloody secretions in his airway, which were removed..."

The review of the medical record provided to the surveyor 8/31/16 failed to reveal any documentation of the date and time the reportable death associated with the use of restraint or seclusion was reported to the CMS Regional Office.

The surveyor requested the report of the death and the log of the death in restraints on 9/1/16 from Employee Identifier (EI) # 12, Accreditation and Safety.

The following report was provided to the surveyors 9/1/16:

The Report of a Hospital Death Associated With Restraint or Seclusion form documents Cause of death:

" Due to nature of illness, patient had history of gorging and eating voraciously. To prevent patient from also taking food away from other patients, a Velcro belt was across the patient's thighs and secured under the dining room chair seat out of the patient's reach. Patient was given a meat sandwich during evening snack. Patient was directly across from the nursing station and under direct observation of staff. Patient became choked on sandwich. Heimlich maneuver attempted while Velcro belt removed. When unable to dislodge food bolus and patient unconscious, patient lowered to floor where resuscitation efforts continued. Cardiac rhythm restored and able to ventilate patient after full ACLS (Advanced Cardiac Life Support) effort. Transferred to Critical Care where patient exhibited signs of anoxic [DIAGNOSES REDACTED] and family elected to withdraw life support."

The report does not have a date of submission to CMS.

Following this incident the hospital terminated the PCA who restrained the patient without a physician's order.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of medical records (MR), facility policies and interviews with the staff, it was determined the facility failed to ensure:

1. Care plans were updated weekly, as needed, and when change in goals and interventions were required.

2. The Registered Nurse (RN) made the shift assignments for unlicensed nursing personnel in the geriatric psychiatric unit.

This affected the geriatric unit for the psychiatric program and had the potential to affect all patients served.

Findings include:

Refer to A 396 and A 397 for findings.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, policy and procedure and interview it was determined the facility failed to update care plans weekly, as needed and when change in goals and interventions were required in 3 of 11 records reviewed. This affected Patient Identifier (PI) # 2, # 8 and # 1.

Findings include:

Policy & Procedure
Subject: Master Treatment Plan

I. " This memorandum should be used in conjunction with the policy on Implementation of the Nursing Process...

II. Purpose:
The purpose of this policy is to establish guidelines for the development and implementation of the master treatment plan for psychiatric patients.

III. Policy:
The Interdisciplinary Treatment Team may consist of Psychiatrist, Nursing Staff...

IV. Procedure:
A. Assessment:
Each patient will have a written, individualized treatment plan that is based on the assessment of his or her needs...the master treatment plan is a joint effort of the treatment team as approved by the attending physician.

B. Master Treatment Plan
1. The treatment plan will be initiated on admission by the admitting nurse and/or twenty-four hours following admission...
4. The treatment plan will contain the patient's identified problems, objectives, goals (short-term and discharge), interventions and the responsible team members...
8. The plan of care will be reviewed by the treatment team as the patient's condition warrants and will be updated appropriately.
9. The treatment team will review the master treatment plan every seven days (and as needed)."


Medical Record Findings:

1. PI # 2 was admitted to the psychiatric unit of the hospital 4/7/15 with diagnoses of Dementia, Delusional Paranoia, Psychotic Disorder, not otherwise specified.

The Behavioral Health Interdisciplinary Care Plan was developed 4/7/15 with the following Problem/ Diagnosis identified:

1. Safety: Altered Mental Status
Wandering Behavior/ Elopement Risk
2. Psychiatric Symptoms Interfering with Ability to Function:
Mood Swings
Impulsiveness
Depression
Anxiety
Agitation
9. Chronic or New Onset of Acute Medical Condition requiring treatment:
Elevated Lipids
Hypertension

The form Prioritization of goals are listed as 1, 2, 9 dated from 4/8/15 through 5/5/15 with no changes documented to any goal.

The page of Review/Update of the Behavioral Health Interdisciplinary Care Plan attached as page 9 of 10 all areas are blank.

The page of Goals and Objectives of the Behavioral Health Interdisciplinary Care Plan attached as page 10 of 10 all areas are blank.

In an interview 8/31/16 at 2:00 PM with Employee Identifier (EI) # 6 , RN (Registered Nurse) Director confirmed the care plans had not been updated.

2. PI # 8 was admitted on [DATE] with diagnoses including Multiple Substance Dependence and Substance Abuse Psychosis.

Review of the Behavioral Health Interdisciplinary Care Plan revealed no signature and date by the physician.

An interview conducted on 8/31/16 at 2:30 PM with EI # 9, RN Director confirmed the attending physician had not signed the master treatment plan.






3. PI # 1 was admitted to the psychiatric unit of the hospital on [DATE] with an admitting diagnoses of Schizoaffective Disorder Bipolar Type.

The Behavioral Health Interdisciplinary Care Plan was developed 3/4/16 with the following Problem/ Diagnosis identified:

1. Safety: Altered Mental Status
High Risk Falls
Wandering Behavior/ Elopement Risk

2. Chronic or New Onset of Acute Medical Condition(s) requiring treatment:
Type II Diabetes
Cholesterol

3. Psychiatric Symptoms Interfering with Ability to Function:
Depression
Agitation
Hallucinations-Visual
Delusional

5. Psychosocial Needs:
Court hold

Review of the Nursing Documentation dated 3/20/16 at 8:50 PM revealed the following, "staff went to check patient's blood sugar, patient became hostile and was attempting to attack staff. patient very paranoid. when addressing (her/his) behavior patient denies striking out at staff. patient currently redirectable."

Review of the Nursing Documentation dated 3/20/16 at 9:05 PM revealed the following, "patient screaming at staff and is currently attempting to hurt (herself/himself) by hitting (herself/himself) in the head and scratching self. patient yelling at staff..."

Review of the Nursing Documentation dated 3/20/16 at 9:10 PM revealed the following, "ativan 0.5 mg (milligrams) IM (intramuscular) given in Left arm. patient screaming the entire times. multiple abrasions noted to patient's right arm. patient stated staff attempted to choke her and beat her. patient not redirectable, very tearful."

The form Prioritization of goals are listed as 1, 2, 3 dated from 3/7/16 through 4/17/16 with no changes documented to any goal. There was no documentation the staff addressed the behaviors on the patient care plan.

Review of the page of Review/Update of the Behavioral Health Interdisciplinary Care Plan revealed no documentation of a review between 3/7/16 and 4/7/16, which was 4 weeks.

The page of Goals and Objectives of the Behavioral Health Interdisciplinary Care Plan attached as page 10 of 10, all areas are blank. The patient did not sign this form.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on confidential interview with workers in the psychiatric unit it was determined the Registered Nurse (RN) failed to make the shift assignments for unlicensed nursing personnel in the geriatric area. This affected the geriatric unit for the psychiatric program and had the potential to affect all patients served.

Findings include:

During the onsite survey to investigate patient care complaints regarding nursing services the survey team conducted confidential employee interviews with Registered Nurses and Patient Care Assistants (PCA).

In a confidential interview on 8/31/16 at 8:30 AM, Employee Identifier (EI) # 13, an employee working on the geriatric unit, was asked to describe how shift assignments are determined. EI # 13 stated that the RNs are " low, we don't make decisions anymore."

In a confidential interview on 9/01/16 at 9:30 AM, EI # 1, an employee working on the geriatric unit, was asked to describe how shift assignments are determined. EI # 1 stated the RNs decide which patients they want and the PCAs decide which patients they want. EI # 9 stated the Clinical Coordinator would only assign the staff that were to provide one to one care for patients.

The hospital failed to assure all nursing related patient care assignments for patients on the geriatric unit were made by a RN taking into consideration the patient needs, complexity of the patients, competence of nursing personnel and education and experience level of nursing personnel working in the geriatric unit.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and interview it was determined the facility failed to obtain and document weekly weights for the geriatric psychiatric patients and failed to document alternative therapies for patients who did not attend group therapy sessions. This affected 3 of 11 records reviewed and observations of 2 unsampled patients. This affected Patient Identifier (PI) # 2, # 3 and # 1 and had the potential to affect all patients served by the facility.

Findings include:


Medical Record Findings:

1. PI # 3 was admitted to the psychiatric unit of the hospital 8/9/16 with a diagnosis of Agitated Dementia.

PI # 3 was observed 8/30/16 at 11:30 AM go to the meal cart outside day room # 1 open the cart and take a tray out. The Patient Care Associate (PCA) called for him/her to put the tray down. PI # 3 sat the tray on the desk top of the nurses station and turned away turning back around lifted the cover of the plate and started to pick up the turkey with his/her hand. The PCA rushed to his/her side picked up the tray and escorted PI # 3 into the day room to eat.

A review of the medical record on 8/31/16 revealed the patient had been eating well while hospitalized . The weight on admission 8/9/16 was recorded as 63.9 Kg (kilograms 2.2 kg/pound).

PI # 3 had not been weighed since admission.

PI # 3 was weighed 8/31/16 with a recorded weight of 71.68 Kg per surveyor request. A weight gain of 8 Kg in 22 days.

Employee Identifier (EI) # 1, RN (Registered Nurse), Director states the patients are to be weighed every Sunday.

Based on a review of the medical record, the facility failed to have weekly weights recorded.

An unsampled patient admitted to the geri-psych unit 6/16/16 with a weight of 130 pounds/ 59 Kg. The patient was placed on a Mechanical Soft Nectar Thickened diet 7/29/16. The patient failed to have any other documented weights in the chart from 6/16/16 through 8/31/16 when transferred to another hospital.

An unsampled patient was admitted to the psychiatric unit 1/5/16 with a weight of 130 pounds/59 Kg. The patient had a documented weight 5/22/16 of 61.81 Kg and weighed 8/31/16 with a recorded weight of 140.2 pounds/63.72 Kg.

Based on a review of the medical record, the facility failed to have weekly weights recorded.

In an interview 8/31/16 at 2:40 PM with EI # 1, it was confirmed weights are to be done weekly on Sundays and they had not been completed.

2. PI # 2 was admitted to the psychiatric unit of the hospital 4/7/15 with diagnoses of Dementia, Delusional Paranoia, Psychotic Disorder, not otherwise specified.

The Psychiatric Services Adjunctive Therapy Progress Note has three separate areas for documentation of Group Therapy, Topic/Focus, Level of Participation, Behaviors/Symptoms and Patient (pt) Response.

PI # 2 had Psychiatric Services Adjunctive Therapy Progress Notes dated: 4/8/15 with one entry- Pt declined.
4/9/15 with one entry- Pt in bed.
4/10/15- absent
4/10/15- refused written times three
4/11/15- blank
4/12/15- with one entry declined
4/13/15-refused written times three
4/13/15- absent
4/14/15-refused written times three
4/14/15 attended one session on anger at 11:00 AM then declined a 1:00 PM session.
4/15/15 refused written times three
4/15/15- absent and declined
4/16/15 refused written times three
4/16/15 11:00 AM inappropriate absent then declined at 1:00 PM
4/17/15 refused written times three
4/17/15 11:00 AM sleep then declined at 3:00 PM declined
4/18/15 declined
4/19/15 declined
4/20/15 blank and refused times two
4/20/15 11:00 AM refused and a second declined unable to read a time
4/21/15 11:00 AM declined
4/22/15 declined
4/23/15 11:00 AM declined and 2:30 PM sleep
4/27/15 declined
4/28/15 declined and 2:30 PM inappropriate
4/29/15 declined
4/30/15 declined and 2:30 PM sleep
5/4/15 declined
5/5/15 declined
5/6/15 declined.

There was no documentation of any individual therapy conducted with this patient whom the Psychiatrist noted in the admission 4/7/15, History and Physical, " He does not interact verbally with us, needs constant redirection, constantly pacing, clearly psychotic, here for stabilization."







3. PI # 1 was admitted to the psychiatric unit of the hospital on [DATE] with an admitting diagnoses of Schizoaffective Disorder Bipolar Type.

Review of the Body Measurements dated 3/4/16 revealed a current weight of 102 kg (kilograms). Further review of the Body Measurements revealed no documentation the patient was weighed again until 4/3/16, which was 4 weeks later. The patient's dosing weight for 4/3/16 was 97.2 kg, which was a 4.8 kg weight loss.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records (MR) and interview it was determined the Registered Nurses (RN) failed to document and complete rounds on the psychiatric patients every two hours in 7 of 11 records reviewed. This affected Patient Identifier (PI) # 2, 1, 9, 6, 4, 8, 5 and had the potential to affect all patients in the psychiatric units.

Findings include:

1. PI # 2 was admitted to the psychiatric unit of the hospital 4/7/15 with diagnoses of Dementia, Delusional Paranoia, Psychotic Disorder, not otherwise specified

Review of the Psychiatric Precaution Round Sheets dated 5/5/15 to 5/6/15 revealed printed on the top of the form the RN must initial every 2 hours.

Review of the Precaution Round Sheets revealed the RN failed to document rounds every 2 hours on both the day and the night shifts.

Further review of the Precaution Round Sheets revealed the signatures and initials were illegible at times and some of the initials did not include a signature and title.







2. PI # 1 was admitted to the psychiatric unit of the hospital on [DATE] with an admitting diagnoses of Schizoaffective Disorder Bipolar Type.

Review of the Psychiatric Precaution Round Sheets dated 3/5/16 to 4/18/16 revealed printed on the top of the form the RN must initial every 2 hours.

Review of all the Precaution Round Sheets revealed the RN failed to make rounds every 2 hours on both the day and the night shifts.

Further review of the Precaution Round Sheets revealed the signatures and initials were illegible at times, some of the initials did not include a signature and title and not every day listed two different Registered Nurses for a 24 hour period.

An interview was conducted on 8/31/16 at 3:00 PM with EI # 8, Vice President of Quality who confirmed the above mentioned findings.

3. PI # 9 was admitted to the psychiatric unit of the hospital on [DATE] with an admitting diagnoses of Depression with Suicidal Ideations, Post Traumatic Stress Disease, and Poly Substance Abuse.

Review of the Psychiatric Precaution Round Sheets dated 8/28/16 to 8/30/16 revealed printed on the top of the form the RN must initial every 2 hours.

Review of all the Precaution Round Sheets revealed the RN failed to make rounds every 2 hours on both the day and the night shifts.

Further review of the Precaution Round Sheets revealed the signatures and initials were illegible at times, some of the initials did not include a signature and title and not every day listed two different Registered Nurses for a 24 hour period.

An interview was conducted on 8/31/16 at 3:00 PM with EI # 8, Vice President of Quality who confirmed the above mentioned findings.

4. PI # 6 was admitted to the psychiatric unit of the hospital on [DATE] with an admitting diagnoses of Major Depression and Anxiety Disorder.

Review of the Psychiatric Precaution Round Sheets dated 7/30/15 to 8/3/15 revealed printed on the top of the form the RN must initial Q 2 hrs.

Review of all the Precaution Round Sheets revealed the RN failed to make round every 2 hours on both the day and the night shifts.

Further review of the Precaution Round Sheets revealed the signatures and initials were illegible at times, some of the initials did not include a signature and title and not every day listed two different Registered Nurses for a 24 hour period.

An interview was conducted on 8/31/16 at 3:00 PM with EI # 8, who confirmed the above mentioned findings.






5. PI # 4 was admitted on [DATE] with an admitting diagnoses of Schizoaffective disorder, bipolar type, currently severly depressed and psychosis.

Review of the Psychiatric Precaution Round Sheets dated 7/27/16 to 8/30/16 revealed printed on the top of the form the RN (Registered Nurse) must initial every 2 hours.

Review of all the Precaution Round Sheets revealed the RN failed to make round every 2 hours on both the day and the night shifts.

An interview was conducted on 8/31/16 at 3:00 PM with EI # 8, who confirmed the above mentioned findings.





6. PI # 8 was admitted on [DATE] with diagnoses including Multiple Substance Dependence and Substance Abuse Psychosis.

Review of the Psychiatric Precaution Round Sheets dated 8/15/16 to 8/30/16 revealed printed on the top of the form the RN must initial every 2 hours.

Review of all the Precaution Round Sheets revealed the RN failed to document rounds every 2 hours on both the day and the night shifts.

Further review of the Precaution Round Sheets revealed the signatures and initials were illegible at times and some of the initials did not include a signature and title.

An interview was conducted on 8/31/16 at 3:00 PM with EI # 8, who confirmed the above mentioned findings.

7. PI # 5 was admitted on [DATE] with diagnoses including Agitation, History of Dementia, History of Schizophrenia, and Mental Retardation.

Review of the Psychiatric Precaution Round Sheets dated 8/20/16 to 8/30/16 revealed printed on the top of the form the RN must initial every 2 hours.

Review of all the Precaution Round Sheets revealed the RN failed to document rounds every 2 hours on both the day and the night shifts.

Further review revealed Precaution Round Sheets with only 1 RN signature for the 24 hour period.

An interview was conducted on 8/31/16 at 3:00 PM with EI # 8, who confirmed the above mentioned findings.