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.

MERCY HOSPITAL SPRINGFIELD 1235 E CHEROKEE SPRINGFIELD, MO 65804 June 10, 2011
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to ensure patient privacy was provided to two (Patients #57 and #85) of two patients reviewed with grievances regarding privacy issues. The facility failed to provide patient privacy by using the first three letters of the patients' last names on a dry-erase white board in public view for all patients and/or visitors in the Neonatal Intensive Care Unit. The unit census was 28. The facility census was 508.

Findings Included:

1. Review of a facility policy entitled, "Commitment to Respect and Care," revised 07/02, showed the following:

-We honor the confidentiality of the patient;
-We share information about the patient only with persons involved in the patient's care;
-We release patient information only with the consent of the patient/surrogate;
-We protect the patient's personal privacy;
-We assure that patients have appropriate attire to protect their modesty;
-We ask visitors to leave the patient's room while treatment/care is given.

2. Review of a grievance dated 05/05/11 showed Patient #85's family member filed a written complaint regarding the following:

-Patient #85 was admitted to the facility on [DATE] for a surgical procedure;
-They arrived at 10:00 AM for a surgery scheduled at 12:00 PM;
-Soon after arrival, the patient and spouse were taken to a small examination room where another patient, and two family members were also waiting;
-There was a partially closed curtain between patients (no other sound proofing partition);
-Two nurses were asking both patients personal information that all in the room could hear;
-Patient #85 was asked to undress and put a gown on, with the visitors in the room (of the opposite sex);
-Patient #85's spouse complained about the above.

During a concurrent observation, interview and computer review of information asked patients while waiting for surgery on 06/07/11 at 2:25 PM, the following was discovered:

-The surgical waiting rooms were small, approximately 10 feet by 10 feet, with two chairs, computers, vital sign equipment, and a one cloth curtain dividing the two chairs;
-Registered Nurse (RN) Staff T stated patients were placed in these rooms, vital signs are taken, the patient puts a gown on, allergies were verified, consent for surgery verified, last food/fluid verified, all medications reviewed and confirmed when last taken, tobacco use, dentures, hearing aid, jewelry, piercings, teaching is performed, and emergency contact;
-Staff T stated the surgery area had no private rooms;
-Staff T confirmed the procedure for pre-surgical interview/preparation remained unchanged since this incident.

Staff failed to ensure this patient's privacy and failed to put interventions in place to prevent recurrence for approximately one month.

3. Review of facility policy entitled, "Use and Disclosure of Protected Health Information (PHI) for Facility Patient Directory Purpose," revised 06/10 showed the following:

- If the patient has given authorization to be in the directory, SJHS may disclose to individuals, who ask for the patient by name, that the patient was treated and released;
- SJHS co-workers are not to release the date, time, or destination of the patient.

4. Review of Patient #57's signed PHI Communication Resource Tool, dated 12/10/10, showed the patient did not want to be a confidential or non-published patient for the directory (which mean: If you are in the hospital seeking treatment and a spouse or other family member calls to inquire if you are still there, can we say yes or no)?

Review of Patient #57's Emergency Department record, dated 12/10/10, showed the patient was admitted that date seeking an evaluation/treatment for alcohol/drug abuse.

Review of a grievance dated 01/27/11 showed the patient complained that a fell ow co-worker of hers/his and that co-worker's spouse were told of patient's destination in the hospital. Patient #57 felt very violated by their visit and knowledge of her/his need for treatment.

During an interview on 06/08/11 at 11:30 AM, Privacy Officer Staff SS stated Patient #57 did not understand the use of the PHI Communication Tool. The tool allowed visitors to know patients' location, with the exception of those on the Behavioral Health Unit (contradictory to the policy verbage).

Staff failed to follow their own policy, failed to ensure patients understood the PHI Communication tool, and failed to maintain privacy location for patients with the exception of spouse or family.





5. Observation on 06/07/11 at 3:03 PM in the Neonatal Intensive Care Unit showed a large white board with a column for patients' name. Each column contained three letters. The unit census was 28.

6. During an interview on 06/07/11 at 3:03 PM, Staff Y, Shift Coordinator, stated staff listed each patient by the first three letters of their last name. If the patient has a two or three letter name then that patient's entire last name is on the board. Persons visiting other neonates can freely walk in front of the board and read the names of others on the board.

7. During an interview on 06/07/11 at approximately 3:05 PM Staff V, Quality Improvement Analyst, stated staff put the three letters of the patient's last name on the board. He/she stated if the patient's name contained two or three letters, their last name would be on the board. He/she concurred that the board was in public view of the general public.

8. During an interview on 06/08/11 at 4:30 PM Staff F, Nurse Manger, stated the facility did not have a policy regarding the use of patients' initials or names in public view.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review, the facility's staff failed to ensure each patient and/or patient's representative had an established Advance Directive or offered the opportunity to establish an Advance Directive for 14 (Patient #13, #8, #10, #12, # 18, #19, #51, #52, #54, #55, #31, #32, #38, and #90) of 22 patients' records reviewed for Advance Directives. The facility failed to document in a prominent part of the patient's medical record whether or not the patient had executed an advance directive for 14 (Patient #13, #8, #10, #12, #51, #52, #54, #55, #31, #32, #38, 19, 18, and #90) of 22 patients' medical records reviewed for Advance Directives. The facility failed to document in the patient's medical record whether or not the patient would like to complete an advance directive, or like assistance with one for one (Patient #20) of 22 patients' medical records reviewed for advance directives. The facility also failed to obtain a copy of an advance directive for one (Patient #33) of one patient's medical record reviewed with an advance directive placed in the medical record. This practice had the potential to affect all patients. The facility census was 508.

Findings included:

1. Record review of the facility's Procedure No: 805, titled, "PATIENT'S RIGHT TO SELF-DETERMINATION IN HEALTH CARE DECISIONS POLICY" revised on 06/04/01, showed the following direction:

POLICY - We encourage individuals to exercise their right to retain control of medical treatment preferences through advance directives which state choices regarding medical treatment/procedures, or which name someone to make choices, if the individual becomes incapacitated.
A. In support of the above, St. John's health System will:
- Provide written information regarding the individual's right under state law (whether statutory or recognized by the courts) to self-determination in healthcare decisions and St. John's Health System policies regarding implementation of these rights.

This information will be provided to all adult individuals and emancipated minors in the following situations:
At the time of the individual's admission as an inpatient to St. John's Health System hospitals;

- At the time of admission for services, ask the individual whether or not he/she has executed an advance directive and document the presence or absence of an advance directive in the individual's medical record.

- In the event it becomes appropriate for decisions to be made on the basis of an individual's advance directive, but a copy of the directive is not in the medical record, it will be the responsibility of the physician/care team to discuss and note the content of the absent directive in the medical record.
- Information and assistance will be provided to the individual who has not made an advance directive but wishes to prepare one.

2. Record review of the facility's Procedure No: 801, titled, "COMMITMENT TO RESPECT AND CARE" revised 07/02, showed the following direction:
-We involve the patient in decisions about care and treatment;
-We inform patients of their right to complete an advance directive and provide assistance to those who wish to do so;
-We respect the adult patient's wishes, even if the patient cannot speak for him/herself;
-We identify and work with surrogates who best know the incapacitated patient and can convey the patient's wishes;
-We honor a patient's advance directive'
-We involve children and incapacitated persons, to the extent of their capabilities, indecisions about their care and treatment;

3. During an interview on 06/06/11 at 2:20 PM, Patient #13 stated he/she had not talked with anyone regarding an advance directive.

Record review of patient #13's medical record showed the 83 y/o (year old) patient did not have an advance directive in the medical record and no documentation as to whether the patient had ever executed an advance directive.

4. During an interview on 06/06/11 at 2:40 PM, Patient #8 stated he/she had not talked with anyone regarding an advance directive.

Record review of patient #8's medical record showed the 76 y/o patient did not have an advance directive in the medical record and no documentation as to whether the patient had ever executed an advance directive.

5. During an interview on 06/06/11 at 2:45 PM, Patient #10 stated that he/she had not discussed an advance directive with anyone.

Record review of patient #10's medical record showed the 70 y/o patient did not have an advance directive in the medical record and no documentation as to whether the patient had ever executed an advance directive.

6. Record review of Patient #90's medical record showed the 46 y/o patient was admitted on [DATE] with multiple diagnoses. The documentation in the medical record stated the advance directive had been completed but Staff CC, RN, Assistant Director of Nursing could not provide the advance directive document.

7. Record review of Patient #12's medical record showed the 64 y/o patient did not have an advance directive in the medical record and no documentation as to whether the patient had ever executed an advance directive. The patient was in the Neurological unit and was too medically unstable for an interview.

8. During an interview on 06/08/11 at 2:10 PM, Staff RR, Registered Nurse (RN), Charge Nurse, stated that the most acute patient of the 22 patients on the Medical Intensive Care Unit (MICU) was Patient #51, a 52 y/o patient admitted on [DATE].

Record review of patient #51's medical record showed the patient did not have an advance directive in the medical record and no documentation as to whether the patient had ever executed an advance directive.

9. Record review of Patient #52's medical record showed the patient was a 79 y/o admitted on [DATE] to the MICU for respiratory distress. The medical record showed the patient did not have an advance directive in the medical record and no documentation as to whether the patient had ever executed an advance directive.

10. Observation on 06/08/11 at 2:30 PM, in the Neurological Trauma ICU (NTICU) showed Patient #54 in bandages covering both arms and legs. The patient's family members were at bedside.

During an interview on 06/08/11 at 2:30 PM, Staff QQ, RN, Charge Nurse, stated patient #54 had been in an automobile accident and fractured both arms and legs.

Record review of patient #54's medical record showed the 65 y/o patient was admitted on [DATE]. The medical record contained no advance directive and no documentation as to whether the patient had ever executed an advance directive. The patient was too medically unstable (critically ill) for interview.

11. Observation on 06/08/11 at 2:40 PM, in the NTICU showed Patient #55 bandaged from head to toe.
During an interview on 06/08/11 at 2:40 PM, Staff QQ, RN, stated Patient #55 was the most acute (having severe symptoms and a short course) of all eight patients in the NTICU. Staff QQ stated the patient's organs were shutting down (progressively failing to function) and he/she was not expected to live.

Record review of patient #55's medical record showed the 47 y/o patient was admitted on [DATE] and did not have an advance directive in the medical record and no documentation as to whether the patient had ever executed an advance directive. The patient was too medically unstable for interview.




12. Observation on 06/07/11 at 2:47 PM, in the 4d Unit showed Patient #31 sitting at bedside in chair with Intravenous (IV) fluids flowing in arm from a pump.

Review of patient #31's medical record showed the patient was admitted to the facility on [DATE] with diagnoses of status post sigmoidectomy (a resection of the sigmoid colon) complicated with anastomotic leakage (a dreaded leakage characterized by an inflammation of the thin tissue that lines the inner wall of the abdomen and covers most of the abdomen organs, fever or drainage from wound or drain, presence of abscess or fever) and a fistula (an abnormal connection between an organ, vessel, or intestine and another structure) with increased drainage from the wound.

Record review of patient #31's medical record showed he/she had no advance directive in the medical record and no documentation as to whether he/she had ever executed an advance directive.

During an interview on 06/07/11 at 2:49 PM, staff confirmed the patient did not have an advance directive. He/she stated the facility's computer program (EPIC) did not have a mechanism to indicate when a patient did not want an advance directive. He/she stated if a patient wanted more information on advance directive, nursing staff clicked on "would like more information," printed the advance directive information from the computer and provided information to patient. Staff also stated if a patient came to the facility with an advance directive, nursing staff asked patient if all information was still correct, but the computer system did not allow for staff to note patient's response.

13. Observation on 06/07/11 at 3:45 PM, in the 4eICU (4 East Intensive Care Unit) showed Patient #32 lying awake in bed.

Record review of patient #32's medical record showed the patient was admitted on [DATE] with a new diagnosis of lung cancer. He/she had no advance directive in the medical record and no documentation as to whether he/she had ever executed an advance directive.

During an interview on 06/07/11 at 3:45 PM, Staff FFF, 4eICU RN stated staff informed patients that the facility have copies of the advance directive if they want to formulate one while on the Unit. Patient #32 confirmed he/she did not have an advance directive in the record nor had she/he ever formulated one.

14. Record review of Patient #38's medical record showed the patient was admitted to the facility on [DATE] with diagnosis of congestive heart failure (CHF). The patient had a heart catheterization (an insertion of a tube into the chamber or vessel of the heart) and a stint placed during admission. Patient #38 had no advance directive in the medical record and no documentation as to whether the patient had ever executed an advance directive.

During an interview on 06/08/11 at 9:51 AM, both Staff FF (Director of Catheterization Lab) and Staff GG (Assistant Director of Catheterization Lab) stated patient #38 came to the emergency room (ER) and physician admitted the patient to another Unit prior to his/her admission to the Catheterization Lab Unit. Both Staff FF and GG concurred that the Unit did not have a mechanism in place to ensure patients received information on advance directives




15. Review of Patient #19's History and Physical (H&P), dated 06/05/11 showed the patient was admitted to the surgical intensive care unit (SICU) on that date with a diagnosis of a craniotomy (surgical removal of a portion of the brain). The patient was intubated (a tube in the throat to assist in breathing via a ventilator) and could nod appropriately.

Review of Patient #19's medical record showed staff failed to document if the patient had an advance directive.

During an interview on 06/07/11 at 9:14 AM, Registered Nurse (RN) Staff G stated the facility did not have a system to follow-up on the advance directive information once the patient's admission assessment was completed.

16. Review of Patient #20's medical record showed the patient was admitted on [DATE] with a diagnosis of a thrombosed right knee requiring an above the knee amputation on 06/04/11. Staff documented the patient did not have an advance directive, but failed to document if Patient #20 would like one, or needed assistance with one.

17. Review of Patient #18's medical record showed the patient was admitted on [DATE] with a diagnosis of a small bowel obstruction. Staff failed to document if the patient had an Advance Directive.

18. Review of Patient #33's medical record showed the patient was admitted on [DATE] with a diagnosis of cellulitis (inflammation at the cellular level). Staff documented the patient had an advance directive; however, failed to retrieve it and put a copy on the medical record.

During an interview on 06/08/11 at approximately 9:00 AM, RN Staff DDD stated that the only way to obtain a copy of the advance directive was for nurses to continue to ask daily and re-communicate the need in shift report.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews, record review and policy review, the facility failed to inform 13 patients and/or their representatives (Patients #13, #8, #9, #1, #2, #14, #17, #20, #27, #31, #38, #56 and #29) of 66 current sampled patients of their rights in advance of providing or discontinuing care. The facility also failed to provide information to 28 of 28 patients' representatives in the Neonatal Intensive Care Unit of their rights in advance of providing or discontinuing care. This had the potential to affect all patients.
The facility's census was 508 patients.

Findings Included:

1. Review of the facility's policy and procedure # 801, titled "Commitment to Respect and Care," dated 12/87 and last revised on 07/02 showed in part:
-The five core Mercy values guide our decisions and actions (Dignity, Justice, Service, Excellence, and Stewardship) and define our commitment to respect and care for patients and their families at all times.
-Essential Elements to Initiate and Maintain a Relationship of Trust and Respect:
-We welcome patients and their families to St John's.
We serve patients and their families as their needs dictate and our capabilities allow without regard to race, religion, gender, handicap, age, national origin, or ability to pay.
We expect patients and families to treat caregivers and one another with respect.
We provide a safe environment to the best of our ability. We do this through ongoing education of patients and staff and through vigilance for unsafe situations and processes.
-We involve the patient in decisions about care and treatment.
We provide full information to patients/surrogates to assist in decisions they must make. This information includes reasonable treatment options, risk and benefits, and financial implementations.
We recognize that adult patients/emancipated minors with decision making capacity may make an informed decision not only to accept but also to refuse treatment.
We help patients/surrogates understand that they are responsible for the results of not participating in the recommended plan of care.
We inform patients of their right to complete an advance directive and provide assistance to those who wish to do so.
We disclose unanticipated outcomes and continue to provide patients/surrogates full information to assist in any follow-up decisions that need to be made.
-We respect the adult patient's wishes, even if the patient cannot speak for him/herself.
We identify and work with surrogates who best know the anticipated patient and can convey the patient's wishes.
We honor a patient's advance directive.
We involve children and incapacitated persons, to the extent of their capabilities, in decisions about their care and treatment.
-We provide the best possible treatment for pain and discomfort.
We assess the patient's perception of pain/discomfort.
We work with the patient and care team to assure the best possible response to the patient's pain and discomfort; this includes referrals to other Health System resources.
-We honor the confidentiality of the patient
We provide privacy for discussions with the patient/family about the patient's care.
We ask patients for personal and family information that is necessary for good patient care.
We share information about the patient only with persons involved in the patient's care.
We only access record of patients for whom we have direct responsibility for treatment or monitoring quality of care.
We release patient information only with consent of the patient/surrogate.
-We listen to patients/families and respond promptly.
We encourage patients and their families to share their concerns with us at any time.
We involve other Health System resources as needed to resolve patient/family concerns.
We work to resolve patient/family concerns in a timely fashion.
-We protect the patient's personal privacy.
We assure patients have appropriate attire to protect their modesty.
We assure that the patient is properly covered when receiving treatment/care.
We ask visitors to leave the patient's room while treatment/care is given.
We are sensitive to a patient's cultural differences regarding modesty.

The policy and procedure failed to show how the facility would inform patients and/or their legal representatives of their rights and responsibilities.

2. During an interview on 06/06/11 at 2:20 PM, Patient #13 stated he/she did not remember anyone talking to him/her about patient's rights nor did he/she remembered receiving any written information.

Record review of patient #13's medical record showed staff failed to document whether parent and/or representative received information regarding patient's rights.

3. During an interview on 06/06/11 at 2:40 PM, Patient #8 stated he/she doesn't remember if anyone gave him/her information regarding patient's rights or if he/she received any written information.

Record review of patient #8's medical record showed staff failed to document whether parent and/or representative received information regarding patient's rights.

4. During an interview on 06/06/11 at 2:55 PM, Patient #9 stated he/she did not receive information on patient's rights nor did anyone talk to him/her about patients ' rights.

Record review of patient #9's medical record showed staff failed to document whether parent and/or representative received information regarding patient's rights.

5. During an interview on 06/06/11 at 3:10 PM, Staff D, Registered Nurse (RN), Charge Nurse, stated if a patient transferred to the hospital from another facility, they may not always receive patients' rights information with their admission documents.

6. Review of Patient #14's medical record showed the patient was admitted to the facility on [DATE] with diagnoses of right-sided cardiovascular accident (stroke) like symptoms, Methicillin Susceptible Staphylococcus Aureus (MSSA - a non-methicillin resistant strain infection) and scalp abscess.

Staff documented in the patient's medical record that he/she received an explanation of his/her rights on 05/31/11 at 5:12 PM. During an interview on 06/07/11 at 10:35 AM, Patient #14 stated he/she could not say whether he/she received a copy of his/her rights and responsibilities upon admission because he/she arrived at the hospital very ill. He/she stated he/she did not have a copy of his/her rights and responsibilities.

7. Review of Patient #17's medical record showed the patient was admitted to the facility on [DATE] with a symptom of swelling in the left leg.

Staff did not document in the patient's medical record that he/she received information regarding his/her rights and responsibilities. During an interview on 06/07/11 at 10:50 AM, Patient #17 stated he/she did not receive information regarding his/her rights upon admission and he/she did not have a copy of his/her rights and responsibilities.

8. Review of Patient #31's medical record showed the patient was admitted to the facility on [DATE] with diagnoses of status post sigmoidectomy (a resection of the sigmoid colon) complicated with anastomotic leakage (a dreaded leakage characterized by an inflammation of the thin tissue that lines the inner wall of the abdomen and covers most of the abdomen organs, fever or drainage from wound or drain, presence of abscess or fever) and a fistula (an abnormal connection between an organ, vessel, or intestine and another structure) with increased drainage from the wound.

Staff documented in the patient's medical record that he/she received an explanation of his/her rights on 06/01/11 at 3:51 PM. Record review showed the patient signed the "General Consent" form, but the form did not have acknowledgement of patient's rights on it. During an interview on 06/07/11 at 3:08 PM, Patient #31 stated he/she could not say whether he/she received a copy of his/her rights and responsibilities upon admission. He/she stated he/she did not have a copy of his/her rights and responsibilities. Patient stated he/she had concerns regarding the facility transferring him/her to another facility for rehabilitation and he/she did not know the location of the facility nor did he/she want to go to another facility; he/she preferred going home. He/she stated he/she would like more information on the rehabilitation facility the facility planned to transfer him/her to and he/she did not know what his/her rights were concerning the situation.

9. Review of Patient #38's medical record showed the patient was admitted to the facility on [DATE] with a diagnosis of congestive heart failure.

Staff did not document in the patient's medical record that he/she received information regarding his/her rights and responsibilities. During an interview on 06/08/11 at 9:51 AM, Patient #38 stated he/she did not receive a copy of his/her rights and responsibilities upon admission.

During an interview on 06/08/11 at 9:57 AM, both Staff FF (Director of Catheterization Lab) and Staff GG (Assistant Director of Catheterization Lab) stated patient #38 came to the facility ' s emergency room (ER) and the physician admitted the patient to another Unit prior to his/her admission to the Catheterization Lab Unit. Both Staff FF and GG concurred that the Unit did not have a mechanism in place to ensure patients received information on patients' rights and responsibilities.

10. Review of Patient #56's medical record showed the patient was admitted to the facility on [DATE] with diagnoses of seizure activity, fractured skull and subdural hemorrhage (a collection of blood on the surface of the brain).

Staff did not document in the patient's medical record whether his/her parent and/or representative received an explanation of the patient's rights and responsibilities. During an interview on 06/08/11 at 1:55 PM, Patient #56's guardian stated he/she did not receive a copy of patient's rights and responsibilities upon admission nor since admission.

During an interview on 06/08/11 at 2:21 PM, Staff BBB (Staff Registered Nurse - Pediatrics/Adolescent Intensive Care Unit) stated staff on the Unit usually provided patients' rights and responsibilities to patients and/or guardians at the time of admission to the Unit. He/she concurred that the record did not show that patient #56's guardian received information on patients' rights and responsibilities.




11. Review of Patient #1's medical record showed the patient was admitted to the facility on [DATE] for surgical removal of the gall bladder.

Staff failed to document in the patient's medical record that he/she received information regarding his/her rights and responsibilities.

12. Review of Patient #2's medical record showed the patient was admitted to the facility on [DATE] with a diagnosis of cancer.

Staff failed to document in the patient's medical record that he/she received information regarding his/her rights and responsibilities.

During an interview on 06/06/11 at 3:18 PM, Registered Nurse, Staff A confirmed the record did not contain documented evidence that patient #2 received a copy of his/her rights. Staff A stated the facility recently revised an overall consent/rights form (03/01/11) and evidently staff failed to incorporated the rights portion into this form.

13. Review of Patient #20's medical record showed the patient was admitted to the facility on [DATE] with a diagnosis of a thromboses (a blood clot caused separation of the knee) right knee resulting in amputation.

Staff failed to document in the patient's medical record that he/she received information regarding his/her rights and responsibilities.

14. Review of Patient #27's medical record on 06/07/11 at 2:07 PM showed the patient was admitted to the facility on [DATE] at 11:28 AM with a diagnosis of right total hip revision.

Staff failed to document in the patient's medical record that he/she received information regarding his/her rights and responsibilities.





15. Review of Patient #29's medical record showed staff failed to document whether parent and/or representative received information regarding patient's rights.

During an interview on 06/07/11 at 2:55 PM Staff Y, Shift Coordinator, stated the three ring binder of information given to each representative on admission of their neonate to the intensive care unit did not contain patient's right information.

During an interview on 06/07/11 at 3:17 PM Staff CCC, RN (Registered Nurse) and transport nurse stated the packet given to each parent and/or representative of the neonates in the Neonatal Intensive Care Unit did not have patient' rights information in it.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, and policy review the facility failed to ensure patients with suicidal and assault precautions were provided care in a safe setting for seven (Patients #50, #61, #62, #64, #65, #83, #87) of 10 patients on Unit A and 16 (Patients #49, #68, #69, #70, #71, #72, #73, #75, #76, #78, #79, #80, #81, #82, #88, #89) of 17 patients on Unit B of the Marian Center. The facility failed to follow their policy for room/body checks for all 27 patients on suicidal and assault precautions on Units A and B. The facility census was 508

Findings Included:

1. Record review of the facility's policy titled, "Precautions," revised date: 12/2010 showed the following direction:
-Suicide Precautions may be indicated when a patient has any or a combination of those listed below.
-Recent suicide attempt;
-Suicidal ideation;
-Suicidal plan/intent and means to carry out;
-Family history of suicide as a way of coping;
-Impulse control problems;
-History of poor management of stressful situations;
-Poor judgment and insight;
-Hopelessness;
-Cognitive impairment;
-Chronic, painful disease processes of which the patient feels no relief.
-Losses;
Procedure:
-Obtain a physician's order for Suicide Precautions (SP) as needed.
-Remove all potentially dangerous items and store in secured area; send home with family if possible.
-Patient may wear regular clothing unless otherwise indicated/deemed unsafe by nurse and or physician.
-Check patient no less than every 15 minutes, or as indicated by physician's order; document safety checks at time of observation on implementation record.
-Check patient's room and belongings a minimum of every eight hours to assure safety.
-Assess patient a minimum of every eight hours for specific thought content/behavior related to suicide. Offer support and reassurance, encouraging verbalization and identification of feelings while assessing suicide risk. Obtain "no self harm" contract verbally as appropriate.
-Patient on involuntary detention may be in any room as deemed appropriate by the nurse and/or physician unless otherwise indicated but as not allowed off the unit except for medical procedures that cannot be performed on the unit, and only when accompanied by unit personnel.
-The attending or on-call physician will review the need to continue suicide precautions on a daily basis and will discontinue when indicated by patient's mental status and behavior.
-Assault Precautions may be indicated when a patient has any or a combination of those listed below.
-Recent assault;
-Previous assault;
-History of or recent property destruction;
-Family history of assault as a way of coping.
-Impulse control problems;
-History of poor management of stressful situations;
-Poor judgment and insight;
-Threatening and/or intimidating behaviors;
-Cognitive impairment;
-Procedure:
-Obtain a physician's order for assault precautions.
-Remove any potentially dangerous items from patient and store according to, "Restricted Items Policy."
-Patient is not allowed to wear footwear that will potentially harm others such as cowboy boots and hiking boots.
-Check patient no less than every 15 minutes and document safety checks at time of observation on implementation record.
-Search patient, patient's room and belongings a minimum of every eight hours for restricted items.
-Assess a minimum of every eight hours for specific thought content/behavior related to assault.
Encourage verbalization and identification of feelings while assessing assault risk. Obtain "no assault" contract verbally.

2. Record review of the facility's policy titled, "Restricted Patient Belongings (Items not allowed in patient's possessions)," revised date 04/2011 showed the following direction:
-To ensure the safety of all patients, visitors, and the environment on the inpatient units the restricted items are those things that can be used to cut, lacerate, scrape, and puncture, suffocate/asphyxiate (to deprive someone of oxygen), strangle, hang, overdose/poison, harm others, destroy property, create a fire hazard, increase hospital liability and control environment.
-Other items not allowed in the patient's possession are listed below.
-keys;
-Knives of any kind;
-Metal with sharp points and edges;
-Metal silverware;
-Tools;
-Disposable/bladed razors;
-Breakable containers such as glass flower vases, make-up containers, and perfume containers;
-Suffocation/Asphyxiation/Hanging/Strangling;
-Scarves;
-Bandanas-handkerchiefs;
-Window blind cords;
-Drawstrings from clothing/bags, shoes/boot laces, bib overalls, etc;
-Straps from purses/luggage, etc;
-Personal appliances (blow dryers, curling irons, etc);
-Plastic bags, including St. John's bags;
-Aerosol cans/products;
-Belts;
-Extra linen/gowns are to be removed as they are a hanging risk.
-Harm Others;
-Equipment/sports equipment;
-Musical instruments (allow on B Unit only with supervision and a physician's order);
-Physical assistive devices when being actively used as a weapon (canes, crutches, etc.) - walkers and wheelchairs on A Unit when needed;
-Heavy boots/footwear;
-Guns/weapon of any kind.

3. Record review of facility's policy titled, "Safety Checks," showed the following direction:
-Patients are checked at a minimum every 15 minutes.
-A nurse, mental health technician, or designated staff member may complete safety checks.
-The patient must be viewed visually by the staff member responsible for the checks.
-The patient must be checked for physical (breathing, not in physical distress), emotional (calm versus angry, yelling etc.), and behavioral (activity, attitude, etc.).
-Notify nurse immediately of any physical, emotional, or behavioral distress.
-Use appropriate codes from legend to indicate patient activity.
-Sign initials under appropriate shift heading.

4. Record review of the facility's policy titled, "Marian Center Inpatient - A Unit, Unit Based Scope," and "Marian Center Inpatient - B Unit, Unit Based Scope," dated 2010 showed the following:
-Both A and B Unit care for patients with Axis I psychiatric disorders.
-Both A and B Unit serve young adults of [AGE] through senior adults.
-Both A and B Unit serve patients with an imminent risk for acute medical status deterioration caused by the presence of an active psychiatric and/or substance abuse condition.
-Both A and B Unit serve patients in jeopardy for safety such that the patient is not safe in a less intensive level of care.
-Both A and B Unit serve patients that are an immediate threat of harm to self/others.
-Both A and B Unit serve patients with severe functional impairment to the point that the patient can no longer care for him/herself and/or has minimal to no support/resources to do so.

5. Record review of the facility's undated document titled, "Admission Criteria and Unit Placement Guidelines," showed criteria for placement on the psychiatric intensive care unit as follows:
-Hallucinations, delusions, severe confusion, disorganization, paranoia, psychosis, impaired judgment and reality testing such that patient cannot function in the milieu or in groups with other patients due to over stimulation; patients unable to be redirected to appropriate behavior.
-Acute mania, severely intrusive, pacing, easily over-stimulated.
-Violent patients with the potential need for S/R (seclusion/restraint). Recent history (72 hours) of violence and impulsive behavior; threatening and unable to be redirected including aggressive, assaultive and/or homicidal behaviors;
-Severe anxiety, severe ritualistic behavior interfering with ability to participate in therapeutic groups and milieu.
-Suicidal/self-harm risk including habitual self mutilation, actively seeking objects to harm self, unable to contract and/or unreliable in reporting thoughts to staff.

6. Record review of the facility's undated document titled, "Admission Criteria and Unit Placement Guidelines," showed criteria for placement on the general adult unit as follows:
-Patients with mild to moderate confusion, hallucinations, delusions that are manageable and can participate in activities to a certain degree.
-Suicidal patients not actively trying to find means on unit to harm self.
-Moderate anxiety/ritualistic behaviors that can be redirected.
-Patients who can be redirected if exhibiting behaviors of harm to others.

7. Record review of the facility's document titled, "Preparing for your visit at St. John's," revised 03/2010 showed:
The facility wants to work with you to ensure that you receive high quality healthcare. Therefore at all times we recognize that you have the right to receive care in a safe setting.

8. Observation on 06/08/11 from 9:20 AM to 10:10 AM of the Marian Center Unit A showed an 11 bed unit with a census of ten patients. The patients' rooms (104-109) showed observations of the following:
-Unsecured furniture of a three drawer nightstand of heavy wood construction (exception room 104), desk of heavy wood construction, and a small chair.
-Exposed plumbing on the commode that was approximately 18 inches from the floor and approximately three inches from the wall.
-Three hinges exposed within the patient's side of the room after closing the door to the room.
-A light fixture above the sink (exception room 104 no sink under the light.) The light fixture was approximately 24 inches long and five inches wide at the point of attachment to the wall. Both top and bottom sides of the light sloped to a flat front of approximately one and a half to two inches in width.

Heavy unsecured furniture or furnishings offer potentially deadly projectiles if thrown and could easily be maneuvered and positioned under a protruding device or looped cord for choking or strangulation. Exposed plumbing allowed for a ligature attachment point. The three exposed hinges posed looping hazards/ligature attachment points, the light fixture could allow for a device to be looped around and secured for strangulation.

9. Record review of the document titled, "Precautions Report," dated 06/08/11 showed Unit A had seven patients with suicide precautions using rooms 104-109.

10. Observations on 06/08/11 from 10:10 AM to 11:00 AM and 2:15 PM to 2:29 PM of the Marian Center Unit B showed a 28 bed unit with a census of 17. The patients' rooms 100-103, 109-112, and 114-117 showed observations of the following.
-Thermostat (temperature control for the room) protruded from the wall approximately one and one-half inches.
--Unsecured furniture of two three drawer nightstands of heavy wood construction, two large chairs, two moveable beds.
-Exposed plumbing on the commode that was approximately 18 inches from the floor and approximately three inches from the wall. An exception was room 100, which had a sprayer that could be extended from the main commode pipe (approximately 10 inches long.)
-Three hinges exposed within the patient ' s side of the room after closing the door to the room.
-A light fixture above the sink (exception room 104 no sink under the light.) The light fixture was approximately 24 inches long and five inches wide at point of attachment to the wall. Both top and bottom sides of the light sloped to a flat front of approximately one and a half to two inches in width.
-A faucet with separate hot and cold long handles (approximately four inches long) and a high neck faucet (approximately 10 inches tall) on the hand sink in each room.

Heavy unsecured furniture or furnishings offer potentially deadly projectiles if thrown and could easily be maneuvered and positioned under a protruding device or looped cord for choking or strangulation.
Exposed plumbing allowed for a ligature attachment point. The three exposed hinges posed looping hazards/ligature attachment points. The light fixture, thermostat, and configuration of the long handles and high necked faucets could allow for material or a device to be looped around/over the object to be used for choking or strangulation.

11. Observations on 06/08/11 from 10:10 AM to 11:00 AM and 2:15 PM to 2:29 PM of the Marian Center Unit B showed a 28 bed unit with a census of 17. The private rooms showed the following:
-Room 104 had unsecured furniture of a regular bed and a hospital/electric bed, one large chair, and a desk. Other areas of concern previously identified and explained were exposed plumbing, a long handled-high necked faucet, and a light fixture.
-Room 107, 108, and 113 all had unsecured furniture of one bed, one three drawer table, and a large chair (the bed in 113 was a hospital/electric bed. Other areas of concern previously identified and explained were exposed plumbing, long handled-high necked faucet, three exposed hinges in the patient's room, protruding thermostat, and light fixture above the sink.

During interviews on 06/08/11 from 10:10 AM to 11:00 AM and 2:15 PM to 2:29 PM Staff J, Nursing Director of Neurology step down and Neuro. - Trauma Intensive Care Unit, stated he/she observed and concurred with the findings found in each room.

12. Record review of the document titled, "Precautions Report," dated 06/08/11 showed Unit B had fifteen patients with suicidal precautions and one patient with assault precautions using rooms 100-117.

Observation on 06/08/11 at 10:30 AM showed the Unit B small day room with the following:
-Built in cabinets and each had a handle approximately three inches in length, for a total of 30 handles.
-Each handle secured to the cabinet with two Phillips head screws.
-The cabinet handles could allow for material or a device to loop through the handle and used for choking or strangulation.
-The Phillips head screws could be removed and used by patents for self harm.
-Exposed cords from electronics and between electronics were noted.
-A cable cord from the wall to the VCR was approximately four feet long.
-Two Stereo wires from the stereo to the speakers in a cabinet were each approximately four feet long.
-One power cord from the above cabinet hanging down and not plugged in; it was approximately four feet long.
-One cable from the television to the VCR was approximately three feet long.
-A power cord from the VCR to the wall was approximately three feet long with two loops approximately one foot long (for a cord approximately five feet long).
-Unsecured furniture of a couch, loveseat, two small chairs, two large chairs, a table, seven small chairs around the table, an exercise bike, and a piano.
-Three hinges inside the room when the door shut.
-Two protruding thermostat boxes.

During an interview on 06/08/11 at 10:30 PM Staff J, Nursing Director of Neurology step down and Neuro - Trauma Intensive Care Unit and Staff JJ, Administrative Director of Marian Center, stated that the observations of the small day room were as noted above. Staff JJ also stated there were times when patients with suicidal ideation would be alone in the small day room.

Observation on 06/08/11at 10:53 AM showed a monitor in the nurses ' station of the camera in the small day room. The monitor did not show the entire room.

During an interview on 06/08/11 Staff LL, Assistant Director of the Unit B, Marian Center, stated the facility did not have a designated staff responsible for monitoring the cameras.

13. Record review of the facility document, titled,"15- minutes Patient Observation Record," showed the following:
- A 24 hour period of pre-printed times, of every 15 minutes.
-The precautions on the side were circled if ordered for the patient.
-Suicide precautions and Assault precautions required a room/body check between 7:00 AM and 3 PM and between 6:00 PM and 11:00 PM, which would be initialed by the staff that completed the check.

14. Observation on 06/08/11 at 2:18 PM showed on Unit B, room B135, a handicap shower with a hand-held shower nozzle approximately six feet long and metal.

Observation on 06/09/11 at 9:05 AM showed on Unit B, room B135 a shower room that contained a locked cabinet with a round hole cut in it. The round hole contained another shower nozzle inside it like the currently used metal one, but white in color. Staff could easily remove the shower nozzle device from the hole.

During an interview on 06/09/11 at 9:05 AM Staff LL, stated patients who used the shower in room B135 required assistance from staff and staff stayed with the patients while they showered. Staff LL stated the shower room could be used by other patients, but that was not the usual process.

15. Observation on 06/09/11 at 9:20 AM showed on Unit B, room B121, a tub room with the following looping hazards and/or ligature attachment points:
-A protruding faucet approximately 15-16 inches above the floor of the bathtub.
-A box made of heavy wood construction that was mounted flush to the wall. The box was approximately 18 inches tall, 16 inches wide, and six inches deep directly above the faucet.
-The box was slanted at the top and sloped down away from the wall. The door to the box was slightly smaller, allowing for any material to stop and not slid off.
-The door to the box was unlocked. The open door showed four (two higher and two lower) metal pipes protruding approximately two inches from the wall. The two lower metal protruding pipes had knobs on them.

During an interview on 06/09/11 at 9:30 AM, Staff J and Staff TT, Administrative Director of Quality, stated the faucet, the box above the faucet, and the protruding pipe inside the box could be a looping hazard and/or ligature attachment points.

16. During an interview on 06/09/11 at 9:30 AM, Staff LL stated the process should be to lock the door above the faucet after controlling the temperature.

During an interview on 06/09/11 at 11:00 AM, Staff J stated the facility did not have a policy regarding the protruding thermostats.

During an interview on 06/09/11 at 1:50 PM Staff TT, Administrative Director of Quality, stated the facility did not have a policy which made a particular staff responsible for monitoring videos when patients were by themselves in the small day room with the door shut.

17. During an interview on 06/09/11 at 2:15 PM Staff VV, Senior Vice-President - Chief Operating Officer, stated that at that time there was nothing he/she was aware of that would cause the facility to be unsafe for patients in the Marian Center.

During an interview on 06/09/11 at 2:15 PM Staff WW, Physician, Vice-President for Clinical Excellence stated that in the past few years staff made changes such as changes in the shower curtain rods, shower knobs, and faucets on Unit A due to some fire safety issues. He/she stated staff did not change the faucets on Unit B because patients on that Unit were considered to be at a lower risk than patients on Unit A.

18. During an interview on 06/09/11 at 3:20 PM Staff ZZ, General Shop Manager, stated that new faucets for Unit B had been looked at and a couple of estimates provided.

During an interview on 06/09/11 at 3:20 PM Staff XX, Regional Director of Facilities, stated that there had not been any directive for new faucets for Unit B to be purchased and installed.




19. Observations on 06/09/11 at between 9:00 AM and 10:00 AM of the Marian Center Unit A showed the following:
-Two unsecured tables in the patients' hallway, both measuring six feet by eight feet.
-Three large unsecured chairs, all measuring forty-three inches tall and twenty and one-half inch wide.
-One wall phone (#1) outside of the nurses' station with a detachable phone cord. The cord measured one-hundred and four inches when stretched.
-One wall phone (#2) outside of the nurses' station on the front hall with a long phone cord. The cord also measured one-hundred and four inches when stretched.
-One desk phone (#3) outside of the nurses' station with a long phone cord.
-One wall phone with a long spiral cord encased in an unlocked metal box outside of the building on the "Courtyard." The spiral cord measured one hundred and fifty-six inches. The metal box measured fourteen inches by eleven inches.
-The Dayroom/Conference room had an exposed power cord from the VCR to the wall. The cord measured approximately five to six feet long with two loops approximately one foot long.
-A cable cord from the wall to the VCR measured approximately five to six feet long.

During an interview on 06/09/11 at 9:25 AM, Staff JJ stated staff used the phone on the Courtyard to call other staff to regain entrance onto the Unit.

20. Observations on 06/09/11 at between 9:00 AM and 10:00 AM of the Marian Center Unit A showed the following:
-Unit A had a "Shower Ante-Room" outside of the shower area. The room contained a large utility cart that had clean linens and gowns on it. The cart contained the following number of items:
-Twenty-two heavy blankets
-Fifteen cotton sheets
-Fourteen regular sheets
-Twenty-six pillowcases
-Twenty towels
-Twenty-five washcloths
-Twelve large (approximately twenty-four inches by twenty-four inches)
-Ten patients' gowns with strings
-Two patients' gowns with snaps

During an interview on 06/09/11 at 9:27 AM, Staff JJ stated some patients use the bathroom unsupervised and all patients on the Unit had access to the Shower Ante-Room.




21. Review of an event report involving Patient #86, dated 10/25/10, showed the following:

-Patient #86 was on suicide precautions with 15-minute monitoring, and the most current assessment revealed the patient felt very depressed and anxious. The patient rated her/his depression a "20" on a scale of 1-10 (with 10 being worst). Patient had verbalized thoughts of wanting to harm self and did not know if he/she could keep self safe. The patient continued on 15-minute monitoring.
-Staff found the patient lying in bed with a pillow over his/her face. When the pillow was removed, the Mental Health Tech (MHT) discovered a phone cord wrapped around the patient's neck.
-Staff cut the cord off the patient's neck.
-Staff placed the patient on one-to-one observation, after the incident.
-Staff removed the phone cords off the phones and patients had to request them from the nurses when they wanted to make calls. Patients had to return the phone cords to the nurses' station at the end of their phone calls.

Observation of the unit where patient #86 resided, on 06/09/11 at approximately 9:00 AM, showed phones, with cords, available for patient use.

Staff failed to protect this, and all suicidal patients, even though assessment revealed possible intent and possible harm to self.

22. Observation on 06/09/11 at 9:00 AM, of the Marian Center B Unit, showed two desk type phones, with removable phone cords of approximately ten feet long, accessible to all patients (near the nurses' station).

The B Unit currently housed twelve patients that had either suicidal or homicidal thoughts/precautions.

Three of these patients had previously attempted suicide and/or homicide, and five of these patients had a plan to achieve a suicidal or homicidal act.

During an interview on 06/09/11 at 9:35 AM, RN Staff LL stated that there weren't always staff at the nurses' station to monitor the use of the phones. Staff LL stated the phones were available, with cords, 24-hours a day, seven days a week.

Review of Patient #84's History and Physical, dated 06/08/11, showed the patient was admitted on that date with diagnoses of depression and suicidal thoughts.

23. During an interview on 06/09/11 at 9:25 AM, MHT Staff UU stated the 15-minute monitoring of patients was completed consistently starting at room 100 (B Unit) and continued in order of room number until all patients were located.

24. Observation (in room #108 of the B Unit) on 06/09/11 at approximately 9:40 AM, showed an electric hospital bed, with a cord of approximate 48-inches in length, four siderails with openings at approximately 36 inches high, and a footboard and headboard with two openings each (handles) at approximately 36-inches high, all of which could present a ligature hazard. This room door was unlocked and accessible to multiple suicidal patients.

25. Observation and interview on 06/10/11 at 10:00 AM, on the Marian Center B Unit, showed Staff AAA demonstrated how contraband rounds would be done (in room #111, which housed Patient #84). Staff AAA stated contraband rounds had already been completed by the mental health techs (MHTs) earlier that morning on all rooms (documentation of rounds was shown).

At 10:02 AM Staff AAA found a 1-5/8 inch metal, (phillips head, sheet rock) screw (considered contraband and harmful in nature) in the bathroom, on the floor, next to the toilet.

Review of room 111's contraband check documentation showed the contraband check had been completed prior to 10:00 AM on 06/10/11.







26. Observation on 06/09/11 at 9:00 AM, on Unit A of the Marian Center in room A112 showed an unsecured cord lying around and under the ice machine in the common dining room. The cord was approximately 6 feet long and located on a cabinet approximately 36 inches off of the floor providing a possible ligature hazard for patients' on suicidal precautions. The common television/video player attached approximately 6 feet off of the floor had four unsecured cords, each approximately 6 feet long that were unsecured and could provide a possible ligature hazard for patients' on suicidal precautions.

27. Observation on 06/09/11 at 9:10 AM, in patient Room A105 on Unit A of the Marian Center showed a protruding toilet handle approximately 5 and ? inches long and 36 inches above the floor and provided a possible ligature hazard. The room had a three hinged door that was not suicide proof and could provide a ligature hold with the door was closed. The facility failed to have a policy and procedure for patient room doors that specified if patient room doors were to be kept open or closed. Observation on Unit A showed patient rooms doors both open and closed throughout the unit. The patient in room A105 was diagnosed with depression and was currently on suicidal precautions with a plan to cut his jugular vein.

28. During an interview on 06/09/11 at 9:45 AM, Staff HHH, Behavior Health Technician, responsible for 15 minute checks on Unit B, stated she conducts her 15 minute checks on patients in the same manner every time and does not vary her pattern of observations. Without variance in rounding of patients on suicidal precautions the patients can determine the pattern of checks and observations and may have up to 15 minutes to affect a suicide or suicide attempt.

29. During an interview on 06/10/11 at 10:15 AM, Staff XX, Regional Director of Facilities (Engineering), stated there have been no breakaway studies (test to determine the amount of body weight an object can withstand until it breaks away or falls) for the strength of the lights or thermostats in the Marian Center.

"The Office of the Ombudsman for Mental Health and Developmental Disabilities" dated 02/2002, stated the following in regard to Suicide Prevention Alert:
- Review/revise policies and procedures for client observation. " For patients with high suicide risk, make sure there is adequate around-the-clock observation, " John Oldham, MD.
- monitor consistency of the implementation of observation procedures;
- enhance staff orientation/education regarding suicide risk factors;
- identify and remove or replace non-breakaway hardware;
- weight test all breakaway hardware, so that it works as designed for the lightest weight client.

Fifty-six suicide attempts were reported as Serious Injuries to the Office of the Ombudsman for Mental Health and Mental Retardation over the same time period. Fifty-two percent of the attempts were medication overdoses, and 23% were attempts to hang or strangle oneself. Eighty-two percent of the attempts occurred in a facility or treatment program as defined above.

In 1998, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a " Sentinel Event Alert - Inpatient Suicides: Recommendations for Prevention. " Their review of 65 inpatient suicides found that 61 occurred in a psychiatric or general hospital. Of the 27 that occurred in a general hospital, 14 occurred in a psychiatric unit, 12 in medical/surgical units, and one in the emergency room . In 75% of the cases, the method of suicide was a hanging in a bathroom, bedroom, or closet.
VIOLATION: PATIENT RIGHTS: SECLUSION OR RESTRAINT Tag No: A0214
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to document in the patients' medical record the date and time of telephone notification to the Centers for Medicare & Medicaid Services (CMS) of patient deaths associated with the use of restraints for eleven (#38, #39, #40, #41, #42, #43, #44, #45, #46, #47, and #48) of eleven death records reviewed for restraints and failed to report within 24 hours to CMS for one (Patient #45) of eleven death records reviewed for timely reporting. The facility census was 508.

Findings included:

1. Record review of the facility's policy/procedure no. 233, titled "Restraint Policy" revised 02/11 showed the following direction:

SECTION IV: REPORTING OF PATIENT DEATHS (Non-Violent/Violent Self Destructive)
POLICY
The following patient deaths must be reported to CMS-Region 7:
-Any patient death that occurs while a patient is in restraints or seclusion
-Any death occurs within 24 hours after removal from restraint or seclusion.
-Each death known to the hospital that occurs within 1 week after restraint or seclusion, where it is reasonable to assume that use of the restraint or placement in seclusion directly or indirectly contributed to a patient's death.
Each death referenced in this paragraph must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient's death. The date/time that CMS is notified of the patient death and use of restraints will be documented in the patient's medical record.

2. Record review of the facility's "Expiration/Restraint Log" dated 2010-2011 showed Patient #38 expired (died ) on 02/09/10 at 4:30 PM while in restraints on 6A Medical Intensive Care Unit (MICU). The patient's medical record documented the date of notification to CMS by facsimile (fax) as 02/10/10 but the facility failed to document the time of notification and the notification by telephone, which is required.

During an interview on 06/08/11 at 9:10 AM, Staff F, Registered Nurse (RN), Quality Manager, stated there was no time documented for the death reporting of Patient #38 and the documentation did not include the date or time of telephone notification.

3. Record review of the facility's "Expiration/Restraint Log" dated 2010-2011 showed Patient #39 expired on [DATE] at 2:47 PM within 24 hours of restraint removal on 6A MICU. The patient's medical record did not have the time/date documented when CMS was notified by telephone. The documentation in the medical record stated that CMS was notified by fax on 02/21/11 at 1:30 PM.

4. Record review of the facility's "Expiration/Restraint Log" dated 2010-2011 showed Patient #40 expired on [DATE] at 6:46 AM within 24 hours of restraint removal on 6A MICU. The patient's medical record did not have the time/date documented when CMS was notified by telephone. The documentation in the medical record stated that CMS was notified by fax on 05/11/11 at 11:15 AM.

5. Record review of the facility's "Expiration/Restraint Log" dated 2010-2011 showed Patient #41 expired on [DATE] at 6:04 AM while in restraints on 6A MICU. The patient's medical record did not contain any notice of reporting the death to CMS.

6. Record review of the facility's "Expiration/Restraint Log" dated 2010-2011 showed Patient #42 expired on [DATE] at 1:19 PM within 24 hours of restraint removal on 6A MICU. The patient's medical record did not contain any notice of reporting the death to CMS.

During an interview on 06/08/11 at 9:20 AM, Staff F, RN, stated there was no documentation in Patient's #41 and #42 medical records of any reporting to CMS of the deaths.

7. Record review of the facility's "Expiration/Restraint Log" dated 2010-2011 showed Patient #43 expired on [DATE] AT 9:22 AM within 24 hours of restraint removal on 6A MICU. The patient's medical record did not have the time/date documented when CMS was notified by telephone. The documentation in the medical record stated that CMS was notified by fax on 01/18/11 at 10:43 AM.

8. Record review of the facility's "Expiration/Restraint Log" dated 2010-2011 showed Patient #45 expired on [DATE] at 7:59 AM within 24 hours of restraint removal on 4E Coronary (heart) Care Unit. The patient's medical record did not have the time/date documented when CMS was notified by telephone. The documentation in the medical record stated that CMS was notified by fax on 03/29/11 at 7:29 AM, more than 24 hours after the required notification allowed by policy and federal regulation.

During an interview on 06/08/11 at 9:45 AM, Staff F, RN, stated the date and time was documented later than 24 hours as required and there was no documentation in Patient #45 medical record of telephone reporting.

9. Record review of the facility's "Expiration/Restraint Log" dated 2010-2011 showed Patient #46 expired on [DATE] at 2:28 PM within 24 hours of restraint removal on 3E Surgical ICU (intensive care unit). The patient's medical record did not have the time/date documented when CMS was notified by telephone. The documentation in the medical record stated that CMS was notified by fax on 04/19/11 at 1:15 PM.

10. Record review of the facility's "Expiration/Restraint Log" dated 2010-2011 showed Patient #47 expired on [DATE] at 4:56 PM within 24 hours of restraint removal on 6A MICU. The patient's medical record did not have the time/date documented when CMS was notified by telephone. The documentation in the medical record stated that CMS was notified by fax on 05/17 at 9:35 AM.

11. Record review of the facility's "Expiration/Restraint Log" dated 2010-2011 showed Patient #48 expired on [DATE] at 1:15 AM within 24 hours of restraint removal on 6A MICU. The patient's medical record did not have the time/date documented when CMS was notified by telephone. The documentation in the medical record stated that CMS was notified by fax on 05/31/11 at 1:07 PM.

12. During an interview on 05/08/11 at 2:00 PM, Staff PP, RN, Risk Manager, responsible for the reporting of patients death affiliated with restraints to CMS, stated he/she did not know why the two medical records [Patients' #41 and #42] did not have a record of CMS notification or why CMS was notified late on the death of Patient #45. Staff PP stated the system [electronic medical record system] did not have a monitoring plan to follow up on death reporting to CMS. Staff PP also stated he/she was unaware that the time/date of telephone reporting to CMS was required to be documented in the medical record rather than the fax reporting.