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.

PASSAVANT AREA HOSPITAL 1600 W WALNUT ST JACKSONVILLE, IL 62650 Feb. 2, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and interview, it was determined for 1 of 2 (Pt #2) patient, reviewed for following of the grievance process, the Hospital failed to ensure its Complaint/Grievance policy was followed. This has the potential to affect all patients serviced by the Hospital which services an average of approximately 53 inpatients and approximately 272 outpatients daily.

Findings include:

1. The Hospital policy titled "Customer Complaint/Grievance Management, Policy Number 9000-033" (effective May 20, 2016) was reviewed on 1/31/17 at approximately 11:40 AM. The policy stated "Grievance Management: E. After receiving a grievance, a "Response" letter will be mailed by the GPE (Great Patient Experience) Department to the complainant to notify the complainant the grievance has been received and will be investigated... will be mailed, on average, within 7 calendar days after the GPE Department's receipt of the grievance. The "Response" letter will include" the point-of-contact person available during the investigation and "F. A final "Resolution" letter will be mailed to the complainant within the "Response" letter's stated timeframe and will include" the completion of the investigation, steps taken, results of the resolution, and the date of the resolution.

2. Pt #2's grievance was reviewed on 2/1/17 at approximately 1:30 PM with the Director of Compliance, Risk, and Revenue Integrity (E#2). Pt #2 submitted a grievance, in person, to the previous Administrator (E#4) on 12/22/16. The document stated the following:
a. E#4 emailed the various departments identified and requested follow up (investigation into the respective department's portion of the grievance) and requested E#2) to "prepare a follow up letter outlining our apologies and adjustment of any outstanding bill associated with this stay."
b. The "follow up letter" was sent to Pt #2 on 12/22/16.
c. The investigative portion of the grievance was initiated on 12/28/16 and completed on 12/29/16, after the "follow up letter" was sent to Pt #2.

3. An interview was conducted with E#2 during the grievance review. E#2 stated "Since the... (E#4) took this grievance in person... (E#4) asked me to send this letter and felt it (the grievance) was resolved because... (E#4) talked with them. No, I didn't send any other letter than this and we hadn't completed the investigation before sending the letter."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0159
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, document review, and interview, it was determined the Hospital failed to ensure staff were knowledgeable and competent in the use of restraint/seclusion. This has the potential to affect all inpatient and Emergency Department (ED)patients serviced daily, 53 patients and 88 patients respectively.

Findings include:

1. An observational tour of the 3rd Floor Medical Surgical Unit was conducted on 1/31/17 at approximately 2:00 PM. Three chairs (Geri Chairs) with attached lap tops and one chair with a locking lap top were observed in the Storage Room, available for patient use.

2. The Hospital policies titled "Restraints and/or Seclusion for Violent Behavior", Policy Number 9000-035A and "Restraints for Non-Violent Behaviors", Policy Number 9000-035B, (both effective June 10, 2016) were reviewed on 1/31/17 at approximately 11:55 AM. The policies both stated orders for "restraint and/or seclusion" and for "restraints" "require an order from a physician or Allied Health Professional (APN [Advance Practice Nurse] or PA [Physician Assistant] credentialed through the Medical Staff Office) with competency in monitoring, assessment, and care of the restrained patient."


3. Pt #1's record was reviewed on 2/1/17 at approximately 10:50 AM. Pt #1 was admitted to the Emergency Department (ED) on 11/29/16 with the Chief Complaint of Abdominal Pain, was admitted to "Outbed (Outbed status was utilized by the Hospital for short term patients to provide short term care/services)" status at 9:36 PM with Constipation for enemas until clear. Pt #1 remained in "Outbed" status until 11/30/16 at 7:50 PM, at which time Pt #1 was converted to "Observation" status for Constipation and was then discharged to a nursing home on 12/2/16. The record lacked documentation of the use of a Geri chair restraint.

An phone interview was conducted with Registered Nurse (RN) (E#3) on 2/1/17 at approximately 3:40 PM with the Director of Clinical Practice (E#1) present. E#3 stated Pt #1 "was in the Geri Chair around 4:30 ish (about 4:30 PM)... was crawling out of bed and taking off (Pt #1) clothes, staff replacing them and (Pt #1) would rip them off again. The Geri Chair was for safety. We were in there constantly. I didn't realize the Geri Chair was a restraint until (3 South, Nurse Manager-E#8) told me later on. Like I said, I was using it for safety." E#3 was unable to state the use of companionship as an intervention to prevent the use of the Geri Chair.

4. Pt #3's record was reviewed on..... at approximately.... Pt #3 was admitted on [DATE] with the diagnosis of Evaluation, History Schizophrenia. ED "Documentation of Restraint/Seclusion" stated Pt #3 was in restraints from 1:45 PM to 2 :45 PM. Under "Type", the form stated "Seclusion" and further stated "Violent q (every 30 min (minutes)... Soft Cloth skin/circulation... Wrist R right) Wrist L (left)" with checks every 30 minutes by E#6.
An interview was conducted on 2/1/17 at approximately 3:00 PM with the ED RN (E#6) with the Nurse Manager ED (E#7) present. E#6 had reviewed Pt #3's record and stated Pt #3 had required the use of soft wrist restraints and was in a room with a staff member observing (Pt #3). E#6 stated "When a patient is in restraints and in a room and unable to get out because of the restraints, it's also seclusion because even with the door open and a sitter present, they can't get up and leave." E#7 verbally agreed with E#6.

5. An interview was conducted with E#1 on 2/1/17 at approximately 3:45 PM. E#1 verbally agreed E#3 lacked knowledge that a Geri Chair is a type of restraint and lacked knowledge of the use of companionship as an intervention." E#1 further stated having heard E#6 and E#7 when answering questions related to restraint and seclusion. E#1 stated "They did not have an understanding of the difference between restraint and seclusion. All staff have to complete a computer based learning on restraint and seclusion annually along with having to demonstrate restraint use. We are going to have to revisit (look at) what's in the program and make sure it's covering everything more clearly than what it is right now."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient in which the staff utilized a Geri chair, the Hospital failed to ensure the use of a Geri chair was only used when less restrictive interventions had been determined to be ineffective to protect the patient from harm. This has the potential to affect all inpatients and Emergency Department (ED) patients serviced daily by the Hospital, 53 and 88, respectively.

Findings include:

1. The Hospital policy titled "Falls/Yellow/Alert/High Risk For Falls Policy Number 9000-065" (Effective Date: June 2, 2016) was reviewed on 2/2/17 at approximately 11:30 AM. The policy stated "Special Instructions: ** For patients who are confused or non-compliant, additional considerations will be given for the need for closer observation and monitoring (I.e. arranging a family member to sit with the patient, arranging a staff member to sit with the patient, placement in a specialized bed or adjustment of patient care assignment)."


2. Pt #1's record was reviewed on 2/1/17 at approximately 10:50 AM. Pt #1 was admitted on [DATE] with the Chief Complaint of Abdominal Pain and was admitted to "Outbed (Outbed status was utilized by the Hospital for short term patients to provide short term care/services)" status with Constipation for enemas until clear. Pt #1 remained in "Outbed" status until 11/30/16 at 7:50 PM, at which time Pt #1 was converted to "Observation" status for Constipation and was discharged to a nursing home on 12/2/16. The record lacked documentation of the use of a Geri chair restraint.

3. A phone interview was conducted with Registered Nurse (RN) (E#3) on 2/1/17 at approximately 3:40 PM with the Director of Clinical Practice (E#1) present. E#3 stated Pt #1 "was in the Geri Chair around 4:30 ish (about 4:30 PM)... was crawling out of bed and taking off (Pt #1) clothes, staff replacing them and (Pt #1) would rip them off again. The Geri Chair was for safety. We were in there constantly. (Pt #1) was up in the Geri chair for quite awhile, but I don't remember exactly how long.

4. An interview was conducted with E#1 on 2/1/17 at approximately 3:45 PM. E#1 verbally agreed E#3 lacked knowledge that a Geri Chair is a type of restraint and lacked knowledge of the use of companionship as an intervention. E#1 stated "Our fall risk program incorporates a companionship process to have someone sit with patients who are at high risk for falls where all other interventions aren't effective."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined for 1 of 1 (Pt #6 ) patient requiring non-violent restraint usage for medical reasons, the Hospital failed to ensure patients were appropriately monitored per its policy. This has the potential to affect all patients requiring non-violent restraint usage.

Findings include:

1. The policy titles "Restraints for Non-Violent Behaviors" (effective 6/10/16) was reviewed on 2/1/2017 at approximately 1:00 PM. The policy required "page 3. #5 D. Patients are assessed and needs attended to minimally upon restraint initiation and every 2 hours. A list of interventions to be provided every 2 hours was included in the policy.

2. The record of Pt #6 was reviewed on 2/1/17 at approximately 1:00 PM. Pt #6 was admitted on [DATE] with the diagnosis of Sigmoid Diverticulitis with Perforation. Pt #6's record stated Pt #6 was placed in medical restraints on 1/27/2016 at 3:00 PM and continued to be in restraints on 1/31/17. The Daily Assessment Inquiry lacked documentation of 2 (two) hour assessment being completed on 1/27/17 at 6:00 PM, on 1/28/17 at 6:00 PM, and on 1/29/17 at 6:00 PM.

3. An interview was conducted on 2//1/17 at approximately 1:30 PM with the Director of Clinical Projects (E #1). E #1 stated "the expectation is a patient in restraints is assess every two hours at a minimum. That does not appear to have been done here."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient in which the staff utilized a Geri chair (a chair with a locking lap top table), the Hospital failed to ensure a physician order for use of a Geri chair was obtained. This has the potential to affect all inpatients and Emergency Department (ED) patients serviced daily by the Hospital, 53 and 88, respectively.

Findings include:

1. The policy titled "Restraints for Non-Violent Behaviors (effective date 6/10/2016) was reviewed on 2/1/2017 at approximately 10:00 AM. The policy stated on page 3, "4. A. The order must be obtained either prior to, during, or immediately following restraint application."

2. Pt #1's record was reviewed on 2/1/17 at approximately 10:50 AM. Pt #1 was admitted on [DATE] with the Chief Complaint of Abdominal Pain and was admitted to "Outbed (Outbed status was utilized by the Hospital for short term patients to provide short term care/services)" status with Constipation for enemas until clear. Pt #1 remained in "Outbed" status until 11/30/16 at 7:50 PM, at which time Pt #1 was converted to "Observation" status for Constipation and was discharged to a nursing home on 12/2/16. The record lacked documentation of the use of a Geri chair restraint.

3. A phone interview was conducted with Registered Nurse (RN) (E#3) on 2/1/17 at approximately 3:40 PM with the Director of Clinical Practice (E#1) present. E#3 stated Pt #1 "was in the Geri Chair around 4:30 ish (about 4:30 PM)... was crawling out of bed and taking off (Pt #1) clothes, staff replacing them and (Pt #1) would rip them off again. The Geri Chair was for safety. We were in there constantly. (Pt #1) was up in the Geri chair for quite awhile, but I don't remember exactly how long. I didn't realize the Geri Chair was a restraint until (3 South, Nurse Manager-E#8) told me later on."

4. An interview was conducted with E#1 on 2/1/17 at approximately 3:45 PM. E#1 verbally agreed E#3 lacked knowledge that a Geri Chair is a type of restraint and should have had an order.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0173
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview it was determined for 1 of 1 (Pt # 6) patient placed in a medical, non-violent restraint, the Hospital failed to ensure restraint renewal orders were complete. This has the potential to affect all patients which would require the use of non-violent restraints while at/in the Hospital.

1. The policy titled "Restraints for Non-Violent Behaviors (effective date 6/10/2016) was reviewed on 2/1/2017 at approximately 10:00 AM. The policy stated on page 3, "4. A. The order must be obtained either prior to, during, or immediately following restraint application. The order must include...type of restraint, reason for restraint, and duration."

2. The record for Pt #6 was reviewed on 1/31/17 at approximately 1:00 PM. Pt #6 was admitted on [DATE] with a diagnosis Sigmoid Diverticulitis with Perforation. Pt #6 was placed in medical, non-violent restraints on 1/27/17 at 3:00 PM and continued in medical, non-violent restraints as of 1/31/17. Physician orders for renewal of restraints were written on 1/28/17, on 1/29/17, and on 1/30/17 to "continue restraints" at 0700 AM each day. The renewal orders lacked the type of restraint, the reason for the restraint, and the duration of the restraint.

3. An interview was conducted on 2//1/2016 at approximately 3:30 PM with the Director of Clinical Projects (E #1). E #1 reviewed Pt #6's record and stated "a new restraint order should be written every day. Staff should not be writing continue restraints as an order." and agreed the renewal orders lacked the type of restraint, the reason for the restraint, and the duration of the restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0176
Based on document review and interview, it was determined for 2 of 3 (Advance Practice Nurses- APNs- APN#2 and APN#3) Allied Health Professionals and for 6 of 6 (MD#1, MD#2, MD#3, MD#4, MD#5, and MD#6) physicians whom have the ability to order the use of violent and/or non-violent restraints, the Hospital failed to ensure APNs and MDs ordering restraint and/or seclusion had a working knowledge of the Hospital's policy. This has the potential to affect all inpatients and Emergency Department patients serviced by the Hospital with an average daily census of 53 and 88, respectively.

Findings include:

1. The Hospital policies titled "Restraints and/or Seclusion for Violent Behavior", Policy Number 9000-035A and "Restraints for Non-Violent Behaviors", Policy Number 9000-035B, (both effective June 10, 2016) were reviewed on 1/31/17 at approximately 11:55 AM. The policies both stated orders for "restraint and/or seclusion" and for "restraints" "require an order from a physician or Allied Health Professional (APN or PA [Physician Assistant] credentialed through the Medical Staff Office) with competency in monitoring, assessment, and care of the restrained patient."

2. The physician (MD#1, MD#2, MD#3, MD#4, MD#5, and MD#6) files and the Allied Health Professional (APN #2 and APN#3) files were reviewed on 2/2/17 at approximately 8:50 AM with the Director of Clinical Projects (E#1). The files lacked documentation of competence in ordering restraints, in accordance with the Hospital's policy.
MD#1- initial appointment 7/19/10 and reappointed 1/1/16
MD#2- Initial appointment 8/1/16
MD#3- Initial appointment 10/31/16
MD#4- Initial appointment 7/18/05 and reappointment 1/1/17
MD#5- Initial appointment 3/19/79 and reappointment 1/1/17
MD#6- Initial appointment 8/1/16
APN#2- Initial appointment 7/13/16
APN#3- Initial appointment 3/20/15 and reappointment 1/1/16

3. An interview was conducted with the Director of Clinical Projects (E#1) on 2/2/17 at approximately 8:50 PM. E#1 stated "We couldn't find anywhere where we have had them (the APNs and physicians) review or sign that they are aware of our policy."