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.

HUNTINGTON MEMORIAL HOSPITAL 100 W CALIFORNIA BLVD PASADENA, CA 91109 June 20, 2012
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, interview and record review, the facility failed to provide the patient privacy during the provision of care and treatment for 1 of 34 patients (Patient 29).

Findings:

During the tour of the Critical Care Unit on June 13, 2012, at 3:10 p.m., Clinical Staff 11, a respiratory therapist, was observed performing a blood withdrawal on Patient 29's wrist. The procedure was in view from the hallway.

Clinical Staff 11 was interviewed immediately after the procedure. He stated the blood draw was for arterial blood gas (a test that measures the levels of oxygen and carbon dioxide in the blood to determine how well your lungs are working.) When Staff 11 was asked when he would close the privacy curtains during blood draw, he stated "If someone is out there (hallway), I would draw the curtains. If no one is there, I leave the curtain as it is (open)."

A review of the personnel file for Clinical Staff 11 revealed he signed a "New Employee Acknowledgement" on June 19, 2007 that he had received and will comply with Patient Rights.

The facility policy and procedure titled "Patient Rights and Responsibilities" dated June 2011 indicated the patient have the right to have his or her personal privacy respected.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the facility failed to ensure Patient 34 ([AGE] year-old female) had the right to be free from all forms of abuse or harassment. On April 27, 2012, a male nurse (Clinical Staff 20) entered Patient 34's room and touched her inappropriately. Clinical Staff 20 put his hand down the back of her shirt, put his hand down her panties, played with her legs and sexually touched her.

Findings:

According to the facility's letter to the Department dated May 1, 2012, Patient 34, [AGE] year-old female, was admitted to the facility on on [DATE], with diagnosis of disabling epilepsy. The letter indicated Patient 34's grandfather reported to the pediatric department charge nurse, that on April 27, 2012, a male nurse (Clinical Staff 20) entered Patient 34's room and touched her inappropriately. The letter further indicated Patient 34 reported to the grandfather, that the male nurse put his hand down the back of her shirt and put his hand down her panties.

A review of the Neurological/Epilepsy Consultation note dated April 3, 2012, and updated April 23, 2012, indicated the chief complaint was "the parents are seeking a second opinion regarding the patient's seizures". Patient 34's first seizure occurred when she was four years old, then she started to have frequent seizures three to four times a day and now, over the previous week the seizures increased on average to fifty seizures a day. The consultation note indicated Patient 34 lived with her mother, the parents were separated and the patient underwent home schooling. The patient's current medications for the treatment of seizure disorder were Depakote (divalproex sodium) 500 mg twice daily, topiramate (Topamax) 25 mg and 50 mg at night, Keppra (levetiracetam) 1125 mg twice daily, and
Trileptal (oxcarbazepine) 300 mg twice daily. The recommended plan included "five day inpatient video-EEG monitoring telemetry to complete a fast taper of Trileptal and also to classify localize the seizure". {Video EEG (electroencephalography - electrical activity that is generated in the brain) monitoring is a way of simultaneously recording a child's behavior and brain electrical activity.}

A review of the facility's Patient Rights and Responsibilities dated March 2008, indicated the facility respected the rights of the patient, recognized each patient as an individual with unique health care needs and was committed to providing considerate, respectful care focused upon the patient's individual needs. The Patients Rights also indicated the patient had the right to receive care in a safe setting, free from physical, sexual abuse and neglect, exploitation or harassment.

A review of the Nurses Notes dated April 29, 2012 at 4:10 p.m., (approximately 48 hours after the alleged incident), indicated the grandfather stated, Patient 34 told him that the male nurse (Clinical Staff 20) that worked Friday night, touched her in the "pee-pee area." Patient 34 told the grandfather the male nurse thought she was asleep, but she just had her eyes closed. The nurses notes also indicated the Pediatric Unit Manager (Clinical Staff 21), the house supervisor, the social worker, and the physician were notified.

A review of the Social Worker's assessment dated [DATE] at 5:27 p.m., indicated a presenting problem to rule out abuse. The assessment indicated Patient 34's physician was aware and asked the EEG technician to review the video tape of the patient during the time of the alleged sexual abuse incident. The assessment indicated, per the patient, the male nurse did this twice (put his hands down her shirt while she was sleeping and his hand down her panties) and the patient stated, "I just don't want this to happen to any other kids and he needs to be fired." The assessment further indicated law enforcement was called and a police officer would be meeting with the family. However, further review of the Social Worker's Assessment indicated Patient 34 did not receive a physical examination.

During an interview with the Director of Risk Management on June 20, 2012 at 11:45 a.m., she stated Patient 34 did not receive a physical examination after the alleged sexual abuse incident because there was no penetration of a genital.

A review of the facility's "Administrative Policy and Procedure" subject: "Abuse, Neglect and Exploitation (Suspected)" dated January 2009, defined "sexual abuse" as acts of sexual assault on and sexual exploitation of minors. Sexual abuse encompasses a broad spectrum of behavior and may include many counts of many acts over a long period of time or a single incident. Sexual assault is defined as rape, rape in concert, incest, sodomy, lewd or lascivious act upon a child under 14 years of age, oral copulation, penetration of a genital or anal opening by a foreign object, and child molestation. The procedure indicated if the suspected sexual abuse occurred within 72 hours of presentation, he/she should be examined by physician without delay, to minimize loss or deterioration of evidence. The policy indicated police would be contacted and a thorough examination would be done for both treatment and evidentiary purposes. The policy further indicated to refer patient to Child Sexual Abuse Follow-Up Clinic when sexual abuse allegedly occurred more than 72 hours from presentation and the child was asymptomatic, to schedule appointment for exam with a physician and clinical social worker with expertise in child sexual abuse. Patient 34 was not referred to Child Sexual Abuse Follow-Up Clinic.

During an interview with the Executive Director of Children and Ancillary Services on May 3, 2012 at 3:30 p.m., she stated the camera in Patient 34's room was moved for a period of 30 minutes, and we could see the patient's leg being pushed open.

During an interview with Clinical Staff 21 (Pediatric Unit Manager) on the same day at 4:10 p.m., she stated there was no reason for the camera to be moved. The camera needed to be stationary in order to monitor Patient 34's seizure activities.

A review of the facility's Meeting Notes dated May 2, 2012 at 3:30 p.m., indicated the participants were Clinical Staff 20 (the alleged perpetrator), Clinical 21 (Pediatric Unit Manager) and the Executive Director of Children and Ancillary Services. The meeting notes indicated Clinical Staff 20 stated, "yeah, I played with her legs." When Clinical Staff 20 was asked to clarify what he ment by "play", Clinical Staff 20 stated he played with her legs and sexually touched her. When Clinical Staff 20 was asked if he moved the camera in Patient 34's room, he stated "yes". The meeting notes further indicated the police department was called, and Clinical Staff 20 confessed to the police that he inappropriately touched Patient 34 and the police arrested him.

A review of a letter from the facility to Clinical Staff 20 dated May 3, 2012, indicated Clinical Staff 20 was terminated that same day.

A review of Clinical Staff 20's personnel file indicated a 2012 annual update for computer based learning (CBL) was completed on April 16, 2012. There was no documentation in the Abuse Section of the CBL training to indicate that the prevention, protection, intervention and detection of abuse was discussed.

Further review of the facility's policy and procedure titled Abuse, Neglect and Exploitation (Suspected) dated January 2009, indicated necessary components, regarding training staff for effective abuse protection, was missing from the policy. The policy did not include prevention, protection or training for staff.

The facility failed to ensure that Patient 34 was free from sexual abuse or harassment by Clinical Staff 20.
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to protect and promote each patient's. The facility failed to meet condition of participation for Patient Right as follows:

1. The facility failed to ensure Patient 34 ([AGE] year-old female) had the right to be free from all forms of abuse or harassment. On April 27, 2012, a male nurse (Clinical Staff 20) entered Patient 34's room and touched her inappropriately. Clinical Staff 20 put his hand down the back of her shirt, put his hand down her panties, played with her legs and sexually touched her. (Refer to A145)

2. The facility failed to ensure appropriate staff had education and training on the use of nonphysical intervention skills. Twelve of 12 personnel files did not contain documentation regarding staff training on the use of nonphysical intervention skills (alternative techniques to redirect a patient, engage the patient in constructive discussion or activities to help the patient maintain self-control and avert escalation). (Refer to A200)

3. The facility failed to ensure the staff had education, training and demonstrated knowledge in monitoring physical and psychological well-being of a restrained or secluded patient. Twelve of 12 personnel files reviewed with no documentation to indicate staff demonstrated competency in monitoring circulatory status, skin integrity or vital signs for a restrained patient. (Refer to A205)

4. The facility failed to document in the staff personnel records that the training and demonstration of competency for the use of restraint was successfully completed for 11 of 11 clinical staff files. (Refer to A208)

The cumulative effect of these systemic problems resulted in the facility's inability to provides a safe patient care environment.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the facility failed to inform the patient or the patient's representative of the patient's rights for 16 of 34 sampled patients (Patient 1, 8, 15, 16, 19, 21, 22, 23, 24, 25, 27, 28, 30, 31, 33, and 34)

Findings:

a. A review of the record indicated Patient 1 was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated the Patient Rights and Responsibility was given to the patient/family. However, there was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date when the Patient Rights and Responsibility was provided to the patient or the patient's representative.

b. A review of the record indicated Patient 8 was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated the Patient Rights and Responsibility was given to the patient/family. However, there was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date when the Patient Rights and Responsibility was provided to the patient or the patient's representative.

c. Patient 16's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated a check mark on the box "Patient was unable to provide any information. No one else is present" dated May 10, 2012. In addition, a check mark was on the box "Patient Rights and Responsibility was given to the patient/family." There was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date when the Patient Rights and Responsibility was provided to the patient or the patient's representative.

d. Patient 19's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" dated May 16, 2012, indicated a check mark on the box "Patient was unable to provide any information. No one else is present". In addition, a check mark was on the box "Patient Rights and Responsibility was given to the patient/family." There was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date when the Patient Rights and Responsibility was provided to the patient or the patient's representative.

e. Patient 21's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated the Patient Rights and Responsibility was given to the patient/family. However, there was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date when the Patient Rights and Responsibility was provided to the patient or the patient's representative.

f. Patient 22's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated the Patient Rights and Responsibility was given to the patient/family. However, there was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date when the Patient Rights and Responsibility was provided to the patient or the patient's representative. The patient was discharged on [DATE] and readmitted to the facility on on [DATE]. There was no documentation the patient rights and responsibilities were provided for this admission.

g. Patient 23's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated the Patient Rights and Responsibility was given to the patient/family. However, there was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date when the Patient Rights and Responsibility was provided to the patient or the patient's representative.

h. Patient 24's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" dated April 1, 2012, indicated a check mark on the box "Patient was unable to provide any information. No one else is present". In addition, a check mark was on the box "Patient Rights and Responsibility was given to the patient/family." There was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date when the Patient Rights and Responsibility was provided to the patient or the patient's representative.

i. Patient 25's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated a check mark on the box "Patient was unable to provide any information. No one else is present" dated May 4, 2012. In addition, a check mark was on the box "Patient Rights and Responsibility was given to the patient/family." There was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date when the Patient Rights and Responsibility was provided to the patient or the patient's representative.

j. Patient 27's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated the Patient Rights and Responsibility was not given to the patient/family. The box indicating the "Patient was unable to provide any information. No one else is present" was checked. However, the space after "Date/Staff Name" was blank. The portion in the bottom of the form under "Information obtained from:" a check mark was placed on the box indicating the information was obtained from a family member with the family members' name and phone numbers.

k. Patient 28's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated a check mark on the box "Patient was unable to provide any information. No one else is present" dated June 12, 2012. In addition, a check mark was on the box "Patient Rights and Responsibility was given to the patient/family." There was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date of when the Patient Rights and Responsibility was provided to the patient or the patient's representative.

l. Patient 30's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated the Patient Rights and Responsibility was given to the patient/family. The box indicating the "Patient was unable to provide any information. No one else is present" was checked. However, the space after "Date/Staff Name" was blank. In addition, a check mark was on the box "Patient Rights and Responsibility was given to the patient/family." The portion in the bottom of the form under "Information obtained from:" a check mark was placed on the box indicating the information was obtained from a family member with the family member's name and phone number.

m. Patient 33's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated a check mark on the box "Patient was unable to provide any information. No one else is present" dated June 8, 2012. In addition, a check mark was on the box "Patient Rights and Responsibility was given to the patient/family." There was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date when the Patient Rights and Responsibility was provided to the patient or the patient's representative.

n. Patient 34's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated the Patient Rights and Responsibility was given to the patient/family. However, there was no documentation of acknowledgement of the patient or the patient's representative that the Patient Rights and Responsibility was received. There was no date when the Patient Rights and Responsibility was provided to the patient or the patient's representative.

Staff 14, Manager of Patient Access, was interviewed on June 14, 2012, at 3:35 p.m. Staff 16 stated the registration office is responsible for having the Self Determination Statement filled out. If the patient is unable to provide the information, the registration staff marks the box "Patient unable to provide any information ..." Nursing is responsible to complete the form when the patient goes to the unit.

A review of the facility policy and procedure titled "Patient Rights and Responsibility" dated June 2011 indicated the patient is offered the statement of patient rights and responsibilities upon registration or admission.





o. Patient 31's record indicated the patient was admitted to the telemetry unit of the facility on June 14, 2012. The form "Self Determination Statement" indicated by an "x" in the box, that the patient was unable to provide any information, no one else was present and was signed and dated by a facility staff member. The form also indicated the Patient Rights and Responsibilities was given to the patient/family, however there was no documentation of acknowledgement by patient/family that the Patient Rights and Responsibility was received.

A review of the Physical Assessment of Patient 31 dated June 14, 2012 at 10:30 a.m., indicated the patient was alert and oriented to person, place, time and date and had no neurological deficits.

Further review of the form "Self Determination Statement" indicated under Staff Notes, dated June 15, 2012, Patient 31 was unable to sign and no family was available at this time.

During an interview with the charge nurse of the unit (Clinical Staff 17) on June 15, 2012 at 11:50 a.m., he stated upon review of Patient 31's medical record, there was a discrepancy between the Self Determination form and the admission assessment.

p. Patient 15's record indicated the patient was admitted to the facility on on [DATE], with diagnoses of mouth infection and status post oral surgery. A review of the medical record indicated the form Self Determination was not found in the medical record.

During an interview with the charge nurse (Clinical Nurse 19) on June 15, 2012 at 11:05 a.m., she stated Patient 15 did not have a Self Determination form completed.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure that Patient 9's parents had the right to make informed decisions regarding his care. Patient 7's representative signed "the condition of admission form" to give consent to the general medical care.

Findings:

a. The medical record was reviewed on June 15, 2012. The face sheet indicated Patient 9 was a 1 month 30 day old infant, admitted to the facility on on [DATE] with diagnosis which included fever.

A review of the physician's order dated June 13, 2012 at 12:34 p.m., indicated Patient 9 had a CSF (cerebral spinal fluid) procedure for gram stain.

A review of the Pediatric History and Physical form dated June 13, 2012 at 12:41 p.m., indicated Patient 9's chief complaint was fever, irritability and poor feeding. The history and physical also indicated the source/historian were the parents, primary care provider.

During an interview with the charge nurse (Clinical Staff 4) on June 15, 2012 at 10:50 a.m., she stated the physician's order for CSF was for a lumbar puncture procedure (relieves intracranial pressure in children, important in the diagnosis of various infections and neurologic conditions), which required an informed consent. Clinical Staff 4 also stated the informed consent was not found in Patient 9's medical record.

There was no documentation to indicated the facility utilized an informed consent process to assure the parents were given the information and disclosure needed to make an informed decision whether to consent to a procedure or intervention.

A review of the facility's policy and procedure titled, "Informed Consent" dated July 2010 indicated informed consent was required for procedures that involve material risks that were not commonly understood. The policy also indicated the physician was responsible for providing the information the patient needed in order to make an informed decision and the patient's physician must document in the patient record that they have conveyed the information required for an informed decision.

b. Patient 7's medical record was reviewed on June 15, 2012. The face sheet indicated Patient 7 was admitted to the facility on on [DATE] with diagnosis which included septic shock. The face sheet also indicated under contact information, the person to notify was the patient's son.

A review of the Conditions of Admission form indicated Patient 7 was unable to sign due to patient's physical condition.

During an interview with Clinical Nurse 18 on June 15, 2012 at 10:30 a.m., she stated, after she reviewed the patient's medical record, that Patient 7 did not have any documentation indicating the condition of admission form was signed. There was no documentation to indicate Patient 7 was asked to give consent to the general medical care by the facility.

A review of the facility's policy and procedure titled Informed Consents dated July 2010 indicated upon admission or as soon thereafter as reasonably possible, the patient or an incompetent patient's surrogate decision-maker would be asked to give consent to the general medical care and the general terms and conditions for receiving care from the hospital. The policy indicated this would be presented in the form of the "Conditions of Admission." and that this form authorized general medical and nursing care to be provided.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the facility failed to inform the patient or the patient's representative of his or her right to formulate an advance directive and failed to ensure that the hospital staff and practitioners complied with these directives for 14 of 34 sampled patients (Patient 1, 8, 16, 19, 21, 23, 24, 25, 27, 28, 30, 31, 33, and 34.)

Findings:

a. Patient 1's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated Patient 1 does not have an advance directive. There was no documentation to indicate a brochure was offered to the patient regarding advance directives or a social worker referral was made if the patient would like to have assistance in making an advance directive.

b. Patient 8's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated Patient 8 does not have an advance directive. There was no documentation that a brochure was offered to the patient regarding advance directives or a social worker referral was made if the patient would like to have assistance in making an advance directive.

c. Patient 16's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated Patient 16 does not have an advance directive. There was no documentation that a brochure was offered to the patient regarding advance directives or a social worker referral was made if the patient would like to have assistance in making an advance directive.

d. Patient 19's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated that Patient 19 has an advance directive naming an agent. There was a failure to complete the follow-up steps in the process. "Part IV: If there is an advance directive, RN (registered nurse) completes the following" was not completed.

e. Patient 21's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated that Patient 21 has an advance directive naming an agent. There was a failure to complete the follow-up steps in the process. "Part IV: If there is an advance directive, RN completes the following" was not completed.

f. Patient 23's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated that Patient 23 has an advance directive naming an agent. There was a failure to complete the follow-up steps in the process. "Part IV: If there is an advance directive, RN completes the following" was not completed.

g. Patient 24's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated Patient 24 does not have an advance directive. There was no documentation that a brochure was offered to the patient regarding advance directives or a social worker referral was made if the patient would like to have assistance in making an advance directive.

h. Patient 25's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated Patient 25 does not have an advance directive. There was no documentation that a brochure was offered to the patient regarding advance directives or a social worker referral was made if the patient would like to have assistance in making an advance directive.

i. Patient 27's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated Patient 27 does not have an advance directive. There was no documentation that a brochure was offered to the patient regarding advance directives or a social worker referral was made if the patient would like to have assistance in making an advance directive.

j. Patient 28's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated Patient 28 does not have an advance directive. There was no documentation that a brochure was offered to the patient regarding advance directives or a social worker referral was made if the patient would like to have assistance in making an advance directive.

k. Patient 30's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated Patient 30 does not have an advance directive. There was no documentation that a brochure was offered to the patient regarding advance directives or a social worker referral was made if the patient would like to have assistance in making an advance directive.

l. Patient 33's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated Patient 33 does not have an advance directive. There was no documentation that a brochure was offered to the patient regarding advance directives or a social worker referral was made if the patient would like to have assistance in making an advance directive.

m. Patient 34's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated the patient does not have an advance directive for health care. However, the section of the form "patient has an advance directive and patient states agent on advance directive" is filled out naming an agent. Part IV of the form, "If there is an advance directive, RN completes the following", was not completed.

Staff 14 was interviewed on June 20, 2012, at 10:18 a.m. She stated the admitting clerk should have filled out the portion on advance directive whether a brochure was given or referral to the social worker was made for assistance on making an advance directive. Clinical Staff 15 was interviewed on June 20, 2012, at 10:40 a.m. Clinical Staff 15 stated the RN is to complete Part IV if the patient has an advance directive.

The facility policy and procedure titled "Patient Rights and Responsibility" dated June 2011 indicated the patient has the right to formulate an advance directive. This includes designating a medical decision-maker. The hospital staff and practitioners who provide care in the hospital shall comply with these directives.





n. Patient 31's record indicated the patient was admitted to the facility on on [DATE]. The form "Self Determination Statement" indicated Patient 31 did not have an advance directive. There was no documentation that a brochure was offered to the patient regarding advance directives or a social worker referral was made if the patient would like to have assistance in making an advance directive.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on observation, interview, and record reviews, the facility failed to train the staff on the application of restraints and the provision of care for a patient in restraints or seclusion on a periodic basis consistent with the hospital policy. Three of 12 registered nurses (Clinical Staff 1, 2 and 3) did not have education or training on restraints since 2008.

Findings:

On June 13, 2012 at 2:55 p.m., during the initial tour of the facility, Clinical Staff 1, 2 and 3 were observed working in cardiothoracic unit (CTU). Clinical Staff 1 was a charge nurse.

On June 14, 2012, a review of the personnel files indicated Clinical Staff 1, 2 and 3 did not have updated training on restraints or seclusion of patients. The documentation in the personnel file indicated last restraint training dated 2008.

During an interview on June 14, 2012 at 1:40 p.m., with the Clinical Nurse Specialist of the cardiac care unit (Clinical Staff 13) and review of the Skills Day 2008 competency sign off sheet, she stated the last restraint training for these staff members was in 2008. Clinical Staff 13 stated there were no unit specific training regarding restraints and that they follow the facility wide policy and procedure on restraints. There was no documentation to indicate Clinical Staff 1, 2 and 3 were educated or trained on the appropriate and safe management of patients who were restrained on an ongoing basis.

A review of the facility's policy and procedure titled, "Restraints and Seclusion" dated September 2010 indicated, under the Staff Training Requirements, the facility provided education for staff that had direct patient care responsibility, on an ongoing basis and at least annually.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
Based on interview and record review, the facility failed to ensure appropriate staff had education and training on the use of nonphysical intervention skills. Twelve of 12 personnel files did not contain documentation regarding staff training on the use of nonphysical intervention skills (alternative techniques to redirect a patient, engage the patient in constructive discussion or activities to help the patient maintain self-control and avert escalation).

Findings:

Twelve personnel files were reviewed on June 14, 2012, and all of twelve personnel files did not have documentation to indicate that the staff were trained on the use of "nonphysical intervention skills".

During an interview on June 14, 2012 at 1:50 p.m., the Registered Nurse Educator stated the training on nonphysical intervention skills entailed a review of the alternative measures to the restraint use.

A review of the facility's 2008, 2009 and 2010 Annual Restraints Review and Update training materials indicated the review of alternatives to restraint use included the use of mittens, elbow splints and torso support belt.

On the same day at 1:55 p.m., the Nurse Educator was asked if the alternatives were the same as nonphysical intervention skills. She stated no, the alternatives to restraint use did not include nonphysical intervention skills.

A review of the facility's policy and procedure titled Restraints and Seclusion dated September 2010 indicated under the Staff Training Requirements section, that appropriate staff were to have education and training in the use of non physical intervention skills.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0205
Based on observation, interview, and record reviews, the facility failed to ensure the staff had education, training and demonstrated knowledge in monitoring physical and psychological well-being of a restrained or secluded patient. Twelve of 12 personnel files reviewed with no documentation to indicate staff demonstrated competency in monitoring circulatory status, skin integrity or vital signs for a restrained patient.

Findings:

During the initial tour of the facility on June 13, 2012, Clinical Staff 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 were observed working on the units.

Twelve personnel files were reviewed on June 14, 2012. All twelve personnel files, including the nurse educator, did not have documentation to indicate the staff had education, training and demonstrated knowledge in monitoring physical and psychological well-being of a restrained or secluded patient.

During an interview with the Registered Nurse Educator on June 14, 2012 at 3:10 p.m., she stated the "Restraint Validation Competency Checklist" did not indicate that monitoring and assessment of the restrained patient was addressed.

A review of the facility's policy and procedure titled Restraints and Seclusion dated September 2010 indicated under the Staff Training Requirements section, that staff were trained and demonstrated competency in the application of restraints, monitoring, assessment and providing care for a patient in restraint or seclusion. The policy indicated that the facility would document in the staff record that the training and demonstration of competency were successfully completed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0208
Based on observations, interviews, and record reviews, the facility failed to document in the staff personnel records that the training and demonstration of competency for the use of restraint was successfully completed for 11 of 11 clinical staff files.

Findings:

a. During the initial tour of the facility on June 13, 2012, Clinical Staff 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 were observed working on the units.

Eleven personnel files were reviewed on June 14, 2012. All eleven personnel files did not have documentation to indicate training and demonstrated knowledge of competency for the use of restraint.

During an interview with the Director of Clinical Education on June 14, 2012 at 1:55 p.m., she stated the staff competencies were kept in the soft file located on the unit.

A review of the facility's policy and procedure titled Restraints and Seclusion dated September 2010 indicated under the Staff Training Requirements section, the facility would document in the staff record that the training and demonstration of competency were successfully completed.





b. During the tour of the Critical Care Unit (CCU) on June 13, 2012, at 3:02 p.m., Clinical Staff 10 was observed working in the unit.

During the review of the personnel file for Clinical Staff 10 on June 14, 2012, at 10:30 a.m., there was documentation that an annual review for restraints was done by Clinical Staff 10 on February 23, 2011, and a unit restraint in-service was done in September 3, 2011. However, there was no documentation in the staff's personnel records that demonstration of competency was successfully completed.

During an interview with the Clinical Staff 13, Clinical Nurse Specialist for the CCU, on June 14, 2012, at 12:25 p.m., she stated the unit has not had any issues with restraints; therefore, the last skills lab regarding restraints was last done in 2008. The annual restraint training is performed under the "computer based learning" module.