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.

HOLMES REGIONAL MEDICAL CENTER 1350 S HICKORY ST MELBOURNE, FL 32901 July 13, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to ensure 2 of 13 sampled patients admitted to the hospital received proper notification of rights (#12 & 13).

Findings included:

1. On 07/12/2011, medical record review for patient #12, [AGE], admitted on [DATE] with a diagnosis of pregnancy, did not show documentation that the patient received notice of rights at admission.

During an interview on 07/12/2011 at 9 a.m., the birthing unit charge nurse said patients only receive notice of rights on the patient's first admission. The charge nurse confirmed there was no documentation in patient #12's medical record of the patient receiving notice of rights and there was no signage in any of the birthing rooms with patient rights information.

2. During an interview on 07/12/2011 at 9:30 a.m. in the emergency department (ED), patient #13 said she received patient rights information on prior visits, but did not think she received the patient rights information this time. Review of the medical record showed patient #13 presented to the ED with a chief complaint of abdominal pain on 07/12/2011. There was no documentation in the medical record that patient #13 received patient rights information.

During an interview on 07/12/2011 at 9:40 a.m., the Registration Coordinator said patients receive notice of rights once at first admission, but confirmed the medical record does not have any place to document the information.

Review of the facility policy titled "Patient's Bill of Rights and Responsibilities" dated as revised 03/15/2011, stated in the policy-"The Patient's Bill of Rights and Responsibilities" will be provided to each patient/family at the time of service.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to ensure 2 of 13 patients received notification of the complaint/grievance process at admission to the hospital (#12 & 13).

Findings included:

During tour and observation of the facility units, the grievance information was found to be located on the patient rights signs posted on the wall. The sign instructs patients on who and how to contact to report a complaint.

1. Medical record review for patient #12, [AGE], admitted on [DATE] with a diagnosis of pregnancy, did not show documentation that the patient received information on how and who to file a grievance to in the hospital.

During an interview on 07/11/2011 at 9 a.m., the birthing unit charge nurse confirmed there are no patient rights signs in any of the patient rooms. There was no documentation on patient #12's medical record documenting if the patient received notice on how and who to file a grievance to in the hospital.

2. Review of the medical record for patient #13 showed the patient presented to the emergency department with a chief complaint of abdominal pain. There was no documentation in the medical record that patient #13 received information on how and who to file a grievance to in the hospital.

Review of the facility policy titled "Patient and Family Complaint and Grievance Policy" dated as revised 03/15/2011 referenced that patients will be informed of their rights according to policy CP 1.07. This policy, the "Patient's Bill of Rights and Responsibilities", dated as revised 03/15/2011, stated that "The Patient's Bill of Rights and Responsibilities will be provided to each patient/family at the time of service."
Review of both patient #12 and #13's medical record did not provide evidence that they received the "Patient's Bill of Rights and Responsibilities."
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, the facility failed to provide 3 non-sampled patients and families grievances with written notice of resolution.

Findings included:

1. Review of one emailed grievance dated 04/18/2011 from a father bringing his sixteen year old son to the emergency department with blood in the urine showed the father complained he left the emergency department after a five hour wait. The facility report stated the complaint will be filed. The report documented a call to the father, but no letter was found in the file showing the complainant received a letter describing the investigation, who to contact, or any resolution.

2. During an interview on 07/13/2011 at 08:28 p.m. the Information Privacy Auditor and Health Information Management (HIM) Regulatory Compliance Analyst said a complaint was received on 05/15/2009 by a patient through the corporate compliance department complaining their medical record was accessed without authorization. The Information Privacy Auditor said she ran audits at that time, but was not able to determine any breaches at that time and does not know if the complaint was filed as a grievance and if the complainant received a letter describing the investigation, who to contact, or any resolution.

3. During an interview on 07/13/2011 at 8:28 p.m., the Information Privacy Auditor said another complaint was referred to her on 08/01/2010 by a patient complaining their medical record was accessed without authorization from the risk manager at Palm Bay Hospital, again complaining of a breach in their medical records. The Information Privacy Auditor said she ran audits at that time, but was not able to determine any breaches at that time. The Information Privacy Auditor does not know if the complaint was filed as a grievance and if the complainant received a letter describing the investigation, who to contact, or any resolution.

Review of the facility policy titled "Patient and Family Complaint and Grievance Policy", dated as revised 03/15/2011 defines a grievance as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative regarding the patient's care (when the complaint is not resolved at the time of the complaint by the staff present), abuse or neglect, issues related to the hospital ' s compliance with the CMS (Centers for Medicare and Medicaid Services Hospital Condition of Participation or a Medicare beneficiary billing complaint related to rights and limitations provided. The policy further stated, "An initial acknowledgement response will occur within 72 hours with a follow-up resolution response within 7 days when possible. If the grievance cannot be resolved, or if the investigation is not or will not be completed within 7 days the patient or the patient's representative will be notified that the hospital is still working to resolve the grievance.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on interview and record review, the facility failed to ensure staff responsible for the application of restraints were trained in first aide techniques for four of six staff reviewed (B, C, D & E).
Findings included:
Review of personnel file documentation titled "Health First Competency Checklist-Application of Restraints" for security officers, staff B, C, D and E all showed the officers were trained in the application of restraints for patients. However, none of the four security officers had documented first aide training in their personnel files.

During an interview on 07/12/2011 at 11:30 a.m. Security Department Manager said at present there is no first aide training provided for the security staff. There are a total of 21-22 security staff and all would be expected to respond to the nursing units if staff required assistance to hold and apply restraints to a patient.
VIOLATION: PATIENT RIGHTS: SECLUSION OR RESTRAINT Tag No: A0214
Based on record review and interview, the facility failed to report patients who died while in restraints to the Centers for Medicare and Medicaid Services (CMS) in the required timeframe.

Findings included:

During an interview on 07/12/2011 at 1:40 p.m. Risk Manager staff G said he does not think any deaths related or unrelated to restraints have been reported to CMS since 02/2011. At that time, he thinks there was some type of frequently asked questions (FAQ) information that was reviewed by the legal department, and subsequently the facility revised the policy to state the only reported restraint deaths would be those the facility determined to be directly related to the restraints.

Review of the document provided on 07/13/2011 by the Senior Risk Manager, staff H, showed there have been sixteen patient deaths, while in restraints from 04/30/2011 to present, but not reported to CMS. On 07/13/2011 at 08:20 a.m., the Senior Risk Manager said this list is for the past sixty days, but there have been no restraint deaths have been reported since 02/2011. The Senior Risk Manager said the way the restraint deaths are reported to the risk management department would be determined by the death checklist the nursing staff fill out when a patient expired. The form contains a statement related to restraints and the patient's death and allows the nurse to make the decision as to whether or not the patient died directly from restraints.

Review of the facility document titled "CMS Restraint Death Reporting" dated as revised 02/2011 states Death Reporting Requirements-In these restraint or seclusion situations (violent or self-destructive behavior) the death of any patient where it is reasonable to assume that the use of restraint seclusion contributed directly or indirectly to a patient's death.