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.

UNIVERSITY OF KENTUCKY HOSPITAL 800 ROSE STREET LEXINGTON, KY 40536 July 6, 2012
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the use of restraints were implemented in accordance with safe and appropriate restraint techniques for one (1) of ten (10) sampled patients (Patient # 1).

The findings include:

Review of the facility's policy titled "Restraints and Seclusion" Policy A08-120, dated 01/10, revealed that when restraints were initiated, the Registered Nurse would complete a restraint flow sheet.

Review of the clinical record revealed the facility admitted Patient # 1 on 06/17/12, with diagnoses which included Deep Vein Thrombosis of lower leg and increased International Normalized Ratio (INR). Patient #1 was admitted as an inpatient from the Emergency Department on 06/18/12 at 2:31 PM. Further record review revealed Patient #1 became combative, pulling intravenous catheter (IV) out and cardiac leads off on 06/19/12 at 3:00 AM. The Resident Physician was notified and an order for restraints and Haldol IV were obtained. Restraints were applied on 06/19/12 at 3:00 AM and were taken off on 06/19/12 at 6:17 AM and Haldol was given four (4) times during the time that the restraints were on.

Review of the clinical record, including the Electronic Medical Record, revealed no restraint flow sheet was initiated or completed.

Interview with the Director of Accreditation, on 07/05/12 at 3:05 PM, revealed no restraint flow sheet was utilized as per the facility's policy.

Interview with the Electronic Medical Records Specialist, on 07/05/12 at 3:05 PM, revealed no restraint flow sheet in Patient #1's records.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and review of the facility's policy, it was determined the facility failed to identify, investigate and resolve grievances, according to their policy, for one (1) of ten (10) sampled patients (Patient #2). When the patient reported he/she had been dropped while in the radiology department, there was no documented evidence the incident was investigated. In addition, after a written complaint was received, the hospital did not inform the complainant of the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process.

The findings include:

Review of hospital policy titled "Patient Complaints and Grievances", effective December 2008, revealed any written complaints, including those received by e-mail, were considered a grievance. Continued review revealed the hospital would "respond to the substance of each grievance while identifying, investigating and resolving" any systemic problems indicated by the grievance.

Review of the clinical record revealed the hospital admitted Patient #2 on 03/17/12 with diagnoses which included Bacteremia (an infection in the blood stream).

Review of nursing documentation, dated 03/22/12, revealed the patient had been to the radiology department for testing. The nurse documented the patient reported having been dropped on an underinflated bed. Continued review revealed no documented evidence the complaint was reported to the supervisor.

Interview with Registered Nurse (RN) #5, on 07/06/12 at 1:10 PM, revealed she recalled the spouse of Patient #2 reported the patient was dropped in the radiology department. She stated she thought an incident report was completed but she did not know by whom.

Interview with Unit Manager (UM) #1 for the 100 Tower, on 07/06/12 at 1:35 PM, revealed UM #2 for the 200 Tower, where Patient #2 was located, was on vacation. She stated she believed UM #2 had looked into the complaint and made some notes, but UM #1 did not know any details.

Interview with the Accreditation Director, on 07/06/12 at 3:40 PM, revealed a former employee had investigated the incident. She stated the allegation could not be confirmed. Continued interview revealed no incident report or investigation report related to the alleged incident could be found.

Review of additional information provided by the hospital after the end of the survey revealed the Radiology Clinical Technical Manager provided a written account of the incident, dated 07/09/12. Continued review revealed she had become aware of the claim by Patient #2 "in early May", several weeks after the patient was discharged from the hospital.

Review of an e-mail, received by the hospital on [DATE], revealed the patient's spouse described multiple concerns related to the care of Patient #2 while an inpatient at the hospital. The concerns included a lack of care related to providing fresh water, assistance with personal hygiene, disrespect by direct care staff, poorly managed pain, and unanswered requests by the spouse for medical consults from different disciplines. In addition, the complainant reported the patient was dropped onto the bed in the radiology department, resulting in unresolved back pain.

Review of the Office of Service Excellence notes revealed the hospital left voice messages for the patient, on 04/02/12, to acknowledge receipt of the complaint. Continued review revealed an acknowledgement letter was sent to the patient on 04/04/12.

Review of internal hospital documents revealed the concerns expressed by the complainant were forwarded by the Customer Relations Specialist (CRS) to the Unit Manager where the patient's room was located, the attending physician and a physician resident named in the complaint. Continued review revealed the patient and/or spouse had not responded to the acknowledgement e-mail and therefore the CRS did not know how they wanted the grievance addressed.

Review of the physician resident's response indicated the patient's problems while at the hospital were related to being overweight, and not within in the scope of the resident's involvement in the case. Review of the Unit Manager's response revealed she thought an incident report had been completed related to the patient being dropped in the radiology department and indicated she had addressed issues with staff related to the patient not receiving proper nursing care. Review of the attending physician's response revealed he did not feel the patient's case reflected any substantive deviation from acceptable medical practice. He stated the resident "hit the bed hard" during transfer to the bed in the radiology department, and attributed the incident to the patient's weight. No documented evidence of specific investigative actions on the part of the hospital were apparent.

Continued review of internal documents and a request by the State Agency for investigation results related to the incident in radiology revealed no documented evidence an incident report was filed or an investigation initiated when it was reported to hospital staff.

Review of a letter to Patient #2 and spouse, dated 04/18/12, revealed the hospital had "taken steps to address communication and other concerns". Continued review revealed no detail was given related to how the grievance was investigated or what the results of the investigation were.

Interview with the Manager for the Office of Service Excellence, on 07/06/12 at 4:40 PM, revealed the complainant did not respond to e-mails by the hospital and did not indicate how they wanted the hospital to address the concerns. He clarified it was not clear to the hospital if the complainant was providing an "FYI" (for your information) or desired a full investigation. He stated if serious allegations were made, e.g. a fall, he would expect an investigation be initiated, regardless of the complainant's intent when making the complaint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on interview, record review and review of the facility's policy it was determined the facility failed to ensure the use of restraints was in accordance with the order of the Physician for one (1) of ten (10) sampled patients (Patient # 1).

The findings include:

Review of the facility's policy titled "Restraints and Seclusion" Policy A08-120, dated 01/10, revealed the Physician must describe the type of restraint to be applied.

Review of the clinical record revealed the facility admitted Patient # 1 on 06/17/12, with diagnoses which included Deep Vein Thrombosis of lower leg and increased International Normalized Ratio (INR). Patient #1 was admitted as an inpatient from the Emergency Department on 06/18/12 at 2:31 PM. Further record review revealed Patient #1 became combative, pulling intravenous catheter (IV) out and cardiac leads off on 06/19/12 at 3:00 AM. The Resident Physician was notified and an order for restraints and Haldol IV obtained. Restraints were applied on 06/19/12 at 3:00 AM and were taken off on 06/19/12 at 6:17 AM and Haldol was given four (4) times during the time that the restraints were on.

Review of the clinical record, including the Electronic Medical Record, revealed the Physician ordered, on 06/19/12 at 3:43 AM, soft upper right and left wrist restraints. Clinical record review revealed that "3 point" (two upper extremities and one lower extremity or two lower and one upper extremity) restraints were applied on 06/19/12 at 3:00 AM to Patient #1.

Interview with the Director of Accreditation, on 07/05/12 at 3:05 PM, revealed the nursing staff were to follow the Physician's orders.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure orders for the use of restrainst or seclusion were not written as a standing order or on an as needed basis (PRN) for one (1) of ten (10) sampled patients (Patient # 1).

The findings include:

Review of the facility's policy titled "Restraints and Seclusion" Policy A08-120, dated 01/10, revealed that restraint orders were based on an individual order never a standing or PRN (as needed) order.

Review of the clinical record revealed the facility admitted Patient # 1 on 06/17/12, with diagnoses which included Deep Vein Thrombosis of lower leg and increased International Normalized Ratio (INR). Patient #1 was admitted as an inpatient from the Emergency Department on 06/18/12 at 2:31 PM. Further record review revealed Patient #1 became combative, pulling intravenous catheter (IV) out and cardiac leads off on 06/19/12 at 3:00 AM. The Resident Physician was notified and an order for restraints and Haldol IV obtained. Restraints were applied on 06/19/12 at 3:00 AM and were taken off on 06/19/12 at 6:17 AM and Haldol was given four (4) times during the time that the restraints were on.

Review of the clinical record, including the Electronic Medical Record, revealed an order for "PRN Haldol/restraints", dated 06/19/12 at 5:15 AM. Review of the clinical record further revealed nursing documentation on 06/19/12 at 6:50 AM, verbal order per MD to put patient back in restraints if he/she started pulling out IV and leads.

Interview with the Director of Accreditation, on 07/05/12 at 3:05 PM, revealed the PRN order for restraints and the nursing documentation to be a PRN order for restraints was not the facility's policy which stated to never have a standing or PRN order for restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0170
Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the Attending Physician was consulted as soon as possible after an order was obtained for a restraint for one (1) of ten (10) sampled patients (Patient # 1).

The findings include:

Review of the facility's policy titled "Restraints and Seclusion" Policy A08-120, dated 01/10, revealed the Attending Physician must be consulted as soon as possible if he/she did not order the restraint.

Review of the clinical record revealed the facility admitted Patient # 1 on 06/17/12, with diagnoses which included Deep Vein Thrombosis of lower leg and increased International Normalized Ratio (INR). Patient #1 was admitted as an inpatient from the Emergency Department on 06/18/12 at 2:31 PM. Further record review revealed Patient #1 became combative, pulling intravenous catheter (IV) out and cardiac leads off on 06/19/12 at 3:00 AM. The Resident Physician was notified and an order for restraints and Haldol IV obtained. Restraints were applied on 06/19/12 at 3:00 AM and were taken off on 06/19/12 at 6:17 AM and Haldol was given four (4) times during the time that the restraints were on.

Review of the clinical record, including the Electronic Medical Record, revealed the ordering Physician was a Resident Physician that ordered the restraint for Patient #1. Further review revealed no documented evidence that the Attending Physician was notified as soon as possible after the ordered restraint.

Interview with the Electronic Medical Records Specialist, on 07/05/12 at 3:15 PM, revealed the competed medical record was printed and there was no evidence the Attending Physician was notified of the restraint for Patient #1.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure that the condition of the patient who was restrained was monitored according to the facility's policy for one (1) of ten (10) sampled patients (Patient # 1).

The findings include:

Review of the facility's policy titled "Restraints and Seclusion" Policy A08-120, dated 01/10,
revealed, under "Clinical Management" that the Registered Nurse or other qualified staff would monitor the violent or self-destructive patient every fifteen (15) minutes.

Review of the clinical record revealed the facility admitted Patient #1 on 06/17/12, with diagnoses which included Deep Vein Thrombosis of lower leg and increased International Normalized Ratio (INR). Patient #1 was admitted as an inpatient from the Emergency Department on 06/18/12 at 2:31 PM. Further record review revealed Patient #1 became combative, pulling intravenous catheter (IV) out and cardiac leads off on 06/19/12 at 3:00 AM. The Resident Physician was notified and an order for restraints and Haldol IV obtained. Restraints were applied on 06/19/12 at 3:00 AM and were taken off on 06/19/12 at 6:17 AM and Haldol was given four (4) times during the time that the restraints were on.

Review of the clinical record, including the Electronic Medical Record, revealed no documented evidence of every fifteen (15) minute monitoring of Patient #1 as per the facility's policy.

Interview with Director of Accreditation, on 07/05/12 at 3:05 PM, confirmed there was no monitoring of Patient #1 per the facility's policy.

Interview with the Electronic Medical Records Specialist, on 07/05/12 at 3:15 PM, revealed the whole medical record for the date in question was printed and there was no documentation of every fifteen (15) minute assessments/monitoring.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure when restraints were used for the management of violent or self-destructive behavior, a staff memeber saw the patient face-to-face within one (1) hour after the initiation of the intervention for one (1) of ten (10) sampled patients (Patient # 1).

The findings include:

Review of the facility's policy titled "Restraints and Seclusion" Policy A08-120, dated 01/10, revealed a face-to-face evaluation of a patient exhibiting violent or self-destructive behavior must occur within one hour of the initiation of the restraint.

Review of the clinical record revealed the facility admitted Patient # 1 on 06/17/12, with diagnoses which included Deep Vein Thrombosis of lower leg and increased International Normalized Ratio (INR). Patient #1 was admitted as an inpatient from the Emergency Department on 06/18/12 at 2:31 PM. Further record review revealed Patient #1 became combative, pulling intravenous catheter (IV) out and cardiac leads off on 06/19/12 at 3:00 AM. The Resident Physician was notified and an order for restraints and Haldol IV obtained. Restraints were applied on 06/19/12 at 3:00 AM and were taken off on 06/19/12 at 6:17 AM and Haldol was given four (4) times during the time that the restraints were on.

Review of the clinical record, including the Electronic Medical Record, revealed no documented evidence of the one (1) hour face-to-face evaluation, post restraint application.

Interview with Director of Accreditation, on 07/05/12 at 3:05 PM, revealed there was no documented one (1) hour in person evaluation for Patient #1.