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 HOSPITALS PORTAGE MEDICAL CENTER 6847 N CHESTNUT RAVENNA, OH 44266 Dec. 5, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on medical record review, tour of the Emergency Department (ED), patient and staff interviews, and policy review, the facility failed to inform ED patients of their rights, including how to file a complaint, failed to ensure care plans were updated to include restraint usage, failed to ensure physician orders were obtained for restraint usage and the restraints applied were the restraints ordered, and failed to ensure restraint usage was monitored per facility policy. The cumulative effect of these systemic practices resulted in the facility's inability to ensure that the patients rights would be met. This affected seven patients of a total of thirteen medical records reviewed. The facility had a census of 80.

Findings include:

The facility failed to inform ED patients of their rights, including how to file a complaint. Please see A 117.

The facility failed to ensure care plans were updated to include restraint usage. Please see A 166.

The facility failed to ensure physician orders were obtained for restraint usage and the restraints used matched those ordered. Please see A 168.

The facility failed to ensure restraint usage was monitored per facility policy. Please see A 175.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on medical record review, tour of the Emergency Department (ED), and patient and staff interviews; the facility to failed to inform ED patients of their rights, including how to file a complaint, for three of three ED patient medical records reviewed (Patients 1, 2, and 3) and one of two ED patients interviewed (Patient Y). The current census at the time of the survey was 80.

Findings include:

1) The ED records for Patients 1, 2 and 3 were reviewed on 12/02/13. The records lacked any evidence the patient or a representative of the patient were informed of their rights and how to file a complaint.

2) Staff E (registration clerk) was interviewed on 12/02/13 during tour of the ED beginning at approximately 10:30 AM. Staff E stated a quick registration is initially completed and then once a patient is brought back to the ED the registration process is completed. Once the patient is brought back to the ED a general consent is obtained, which includes "Notice of Privacy Practices." Staff E was asked if every patient receives a copy of the "Notice of Privacy Practices" and initially indicated yes. Staff E stated patients presenting to the ED for the first time per year receive a copy of the notice, however, they do not receive the notice again within the year unless it is specifically requested by the patient.

3) Patient Y was interviewed at 10:55 AM regarding his/her care. Patient Y was asked specifically if he/she recalled receiving the "Notice of Privacy Practices" as indicated on his/her consent form and stated "no." Patient Y was asked if he/she had received any paperwork thus far and stated "no." Patient Y was asked if he/she recalled being informed of his/her rights, including how to contact the Ohio Department of Health, and stated "no."

4) At 11:52 AM on 12/02/13 Staff E was asked to confirm the last documented visit Patient 2 had to the ED, the patient had not received any paperwork thus far, including "Notice of Privacy Practices." After viewing the electronic record, Staff E stated Patient 2's last visit to the ED was on 02/28/11, almost three years ago. Staff E confirmed Patient 2 should have been given the notice during this visit at the time of registration.

5) Staff C (ED director) and Staff D (ED nursing manager) were also present during the tour of the ED and during the interview with Staff E at 11:52 AM on 12/02/13. Staff C and Staff D were also interviewed at 11:52 AM 12/02/13 to provide any evidence the facility informs patients or a representative of the patient of his/her rights, including how to file a complaint with the facility and/or the Ohio Department of Health. Neither Staff C nor Staff D were able to do so.

6) A second tour of the ED was conducted on 12/03/13 at approximately 1:35 PM. Again Staff C and Staff D were asked to provide evidence patients were informed of their rights, including how to file a complaint with the facility and/or the Ohio Department of Health. Staff D indicated there was some information posted within each ED room and proceeded to point this out. Upon closer examination it was determined the posting was a telephone number for assistance with narcotic drug abuse. Both Staff C and Staff D confirmed this information was not related to patient rights, including how to file a complaint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interviews the facility failed to ensure care plans were updated to include restraint usage for three of three medical records reviewed with restraint usage (Patients 9, 11, and 7). A total of 13 medical records were reviewed and the census at the time of the survey was 80.

Findings include:

1) The medical record for Patient 9 was reviewed beginning on 12/03/13 with Staff G and Staff B present. He/she was admitted on [DATE] with a diagnosis of mental status change. Patient 9 arrived through the Emergency Department on 12/02/13 and an order was obtained for "soft wrist restraint; soft ankle restraint" at 11:15 PM for "support and promote physical healing; avoid treatment interruptions and enable active interventions for the patient." At the time of the record review Patient 9 was still in bilateral wrist and ankle restraints and a new order was obtained on 12/03/13 at 6:00 AM.

At time of discovery on 12/04/13 at 11:04 AM the care plan lacked documentation of restraint usage and interventions. This was confirmed by Staff G and Staff B at the time of discovery, at which time both staff further confirmed it should have been addressed on the nursing care plan.

2) The medical record for Patient 11 was reviewed beginning on 12/03/13 with Staff G and Staff B present. He/she was admitted on [DATE] with a diagnosis of pneumonia. A telephone order for "soft wrist restraint" was obtained on 10/26/13 at 10:45 PM for "support and promote physical healing; avoid treatment interruptions and enable active interventions for the patient." Patient 11 remained in soft bilateral wrist restraints until 6:46 PM on 10/28/13, at which time they were discontinued.

On 12/03/13 at 3:00 PM Staff G and Staff B confirmed the nursing care plan lacked documentation of restraint usage and interventions but should have.

3) The medical record for Patient 7 was reviewed on 12/02/13. He/she was admitted on [DATE] with a diagnosis of altered mental status. An order for " soft wrist restraint" was obtained on 09/22/13 at 3:15 PM for "support and promote physical healing; avoid treatment interruptions and enable active interventions for the patient." Patient 7 remained in restraints until 09/25/13 at 2:42 PM, at which time they were discontinued.

On 12/02/13 at 4:00 PM, Staff G confirmed the nursing care plan lacked any documentation of restraint usage and interventions but should have.

4) Facility policy Interdisciplinary Care Plan with Clinical Practice Guidelines was reviewed on 12/04/13. Per said policy, "the patient's plan of care identifies all of the current problems that are immediate and the highest priority for the patient, which will remain until resolved." It further stated "each discipline identifying and adding a clinical practice guideline to the plan of care will be required to address their discipline-specific problem, carry out appropriate interventions, and provide documentation of the patient's progress."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, the facility failed to ensure physician orders were obtained for restraint usage for two of three patient medical records reviewed with restraint usage (Patients 11 and 7) and the restraints applied correlated with the restraints ordered for one of three patient medical records reviewed (Patient 7). A total of 13 medical records were reviewed and the census at the time of the survey was 80.

Findings include:

1) The medical record for Patient 11 was reviewed beginning on 12/03/13 with Staff G and Staff B present. He/she was admitted on [DATE] with a diagnosis of pneumonia. A telephone order for "soft wrist restraint" was obtained and restraints were applied on 10/26/13 at 10:45 PM. The medical record lacked evidence of a documented physician assessment of Patient 11 or progress note for the initiation of the restraints.

A renewal order for "soft wrist restraint" was then obtained on 10/27/13 at 2:52 AM and Patient 11 remained in soft bilateral wrist restraints until 6:46 PM on 10/28/13. Again the medical record lacked evidence of a documented physician assessment of Patient 11 or progress note for the continued use of restraints.

The medical record also lacked evidence of a physician's order for the use of restraints on 10/28/13.

Staff G and Staff B confirmed these findings on 12/03/13 at approximately 3:00 PM.

2) The medical record for Patient 7 was reviewed on 12/02/13. He/she was admitted on [DATE] with a diagnosis of altered mental status. An order for "soft wrist restraint" was obtained on 09/22/13 at 3:15 PM for "support and promote physical healing; avoid treatment interruptions and enable active interventions for the patient." At 3:15 PM, the restraint flowsheet documented the soft wrist restraints were applied. On 09/22/13 at 4:00 PM, an order for "vest, soft wrist, and soft ankle" was obtained. The restraint checklist lacked documentation of the vest or ankle restraints applied. At 4:52 PM the restraint flowsheet noted the restraints were discontinued. At 5:30 PM, the restraint flowsheet noted soft wrist restraints were applied. The medical record lacked a new restraint order until 10:30 PM when an order for "vest, soft wrist, soft ankle restraint" was obtained. The restraint flowsheet noted at 10:37 PM, the patient was found at end of bed confused, the physician was called and an order was received. The vest, soft wrist and ankle restraints were applied. At 2:32 PM on 09/23/13, an order for "vest, soft wrist restraint" was obtained. At 3:08 PM, an order for "soft wrist restraint" was obtained. The restraint flowsheet did not note the lack of a vest restraint until 6:00 PM, but soft wrist and ankle restraints were still noted in use. The ankle restraints were not documented as being removed until 12:00 AM on 09/24/13 when soft wrist only was documented on the restraint flowsheet. Also at 12:00 AM on 09/24/13 an order was obtained for "soft wrist restraints". On 09/24/13 at 5:38 PM, an order was obtained for "vest restraint". The restraint flowsheet at 5:40 PM noted soft wrist and vest restraint in place until discontinuing restraints on 09/25/13 at 2:42 PM.

Again the medical record lacked evidence of a documented physician assessment of Patient 7 or progress note for the continued use of restraints.

On 12/02/13 at 4:00 PM, Staff G confirmed the restraint flowsheet documentation of restraints used and the physician's orders did not match and the medical record lacked any documentation of physician assessment of restraint usage.

3) Facility policy "Restraints" was reviewed on 12/03/13. Per said policy, "a physician's order is required for continuing a restraint order and is based on examination by the physician and documented clinical justification for the continued need for restraint."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview; the facility failed to ensure restraint usage was monitored per facility policy for one of three medical records reviewed with restraint usage (Patient 7). A total of thirteen medical records were reviewed. The facility had a census of 80.

Findings include:

1) The medical record for Patient 7 was reviewed on 12/02/13. He/she was admitted on [DATE] with a diagnosis of altered mental status. An order for "soft wrist restraint" was obtained on 09/22/13 at 3:15 PM for "support and promote physical healing; avoid treatment interruptions and enable active interventions for the patient." At 3:15 PM, the restraint flowsheet documented the soft wrist restraints were applied. The patient remained in restraints until 09/25/13 at 2:42 PM at which time the restraints were discontinued.

The medical record lacked documentation of safety checks every two hours on 09/22/13 from 5:30 PM until 8:00 PM; on 09/23/13 from 6:00 AM until 8:30 AM, from 12:30 PM until 3:40 PM, and from 3:40 PM until 6:00 PM; and on 09/24/13 from 4:05 AM until 6:25 AM and from 6:25 AM until 4:12 PM. The medical record lacked documentation that the restraints were discontinued during these times.

On 12/02/13 at 4:00 PM, Staff G confirmed the restraint flowsheet documentation lacked any documentation of safety checks at least every two hours during the above times.

2) Facility policy "Restraints" was reviewed on 12/03/13. Per said policy, "staff will monitor the patient every two hours to determine the physical and emotional well being of the patient including pain levels; the need for toileting/hygiene; the need for nutrition/hydration; safety monitoring including checking skin integrity, providing range of motion, checking circulation and sensation of restrained extremities; the need for continued restraint use or less restrictive method; and vital signs as ordered by the physician."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on medical record review, staff interviews, and review of policy; the facility failed to ensure nursing staff had orders prior to initiating wound care and that staff followed hand hygiene while performing wound care (A395) and failed to ensure the nursing care plan was updated to reflect and address all of a patient's needs (A396). The cumulative effect of these systemic practices resulted in the facility's inability to ensure that the patients needs would be met. This affected a 4 patients reviewed with wounds with a totalof 13 medical records reviewed. The current facility census was 80.

Findings include:

The facility failed to ensure nursing staff had orders prior to initiating wound care and that staff followed best practice for hand hygiene while performing wound care. Please see A 395.

The facility failed to ensure the nursing care plan was updated to reflect and address all of a patient's needs. Please see A 396.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interviews, and review of policy; the facility failed to ensure nursing staff had orders prior to initiating wound care for three of four patient medical records reviewed with identified wounds (Patients 12, 13, and 8) and that staff followed best practice for hand hygiene while performing wound care for one of two wound care observations made (Patient 12). A total of 13 medical records were reviewed and the current census at the time of the survey was 80.

Findings include:

1) The medical record for Patient 8 was reviewed on 12/03/13. The patient was admitted on [DATE]. The admitting note by the physician on 09/19/13 at 7:17 PM stated the patient had decubitus ulcers on back and chest region as well as the coccyx. The emergency room nursing assessment stated the patient had four ulcers on admission. The medical record noted a stage three ulcer to the left posterior thorax region and a stage four ulcer to the coccyx on admission. The medical record lacked documentation of any orders for wound care, any wound care provided or any assessment/measurement of any wounds. This was verified by Staff G on 12/04/13 at 10:00 AM.

2) The medical record for Patient 13 was reviewed on 12/05/13. The patient was admitted on [DATE]. The emergency room nursing assessment on 12/03/13 at 11:54 AM listed pressure ulcers present on admission to the coccyx, bilateral heels and calf. On 12/03/13 at 1:58 PM, the nursing interventions flowsheet list pressure ulcers to the right coccyx, left calf, and bilateral heels cleansed with normal saline and a foam dressing applied. The right coccyx ulcer was listed as unstageable due to black necrotic tissue and measured four centimeters by two and a half centimeters. The left calf ulcer was listed as a stage three pressure ulcer and measured two centimeters by two centimeters, with no depth listed. The bilateral heel ulcers were listed as stage one and reddened. The medical record lacked documentation by any physician regarding any skin breakdown or evaluation of the wounds. The medical record lacked documentation of a wound care consult or order for a wound care consult. The medical record lacked documentation of wound care orders until 12/05/13 at 9:24 AM when an order for wound care using specific products every three days and as needed to the bilateral coccyx and left calf ulcers. This was verified on 12/05/13 at 2:25 PM by Staff A.

At 10:30 AM on 12/05/13, Staff A and B were interviewed. They stated the facility had protocols for skin care that were approved by the medical staff and the governing body. They stated the nurses implement the protocol when skin breakdown is identified, but an order was not generated. An order is only written if a physician wanted a non-protocol wound care. Staff A and B verified there should be an order written on each patient indicating at least that the protocol should be followed or the specific dressing to be used and frequency of dressing changes for each wound.









4) Observation of wound care for Patient 12 was performed on 12/05/13 beginning at 9:04 AM. Staff I (clinical nurse specialist) performed the wound care while Staff J (intensive care unit nurse) assisted. Staff A and Staff B were also present during the observation.

After gathering the necessary supplies Staff I stated he/she had previously cleaned their hands and proceeded to put on a pair of clean gloves. Patient 12 ,who was non-verbal except for moaning, was assisted to his/her left side by Staff J. Patient 12 was observed to have a ABD pad over his/her coccyx area and reddened rash over his/her right hip.

Staff I removed the ABD dressing and dispose of it in the trash. With the same dirty gloves on, Staff I then picked up a clean ABD pad, saturated it with normal saline solution and began to wipe over the wounds on Patient 12's coccyx area and right hip. Staff I then disposed of the soiled ABD pad and proceeded to obtain measurements of the wounds while wearing the same dirty gloves.

Staff I then proceeded to open a package of Aquacel foam (adhesive wound dressing) and attempt to fit it to Patient 12's right hip wound. After applying, Staff I proceeded to open another Aquacel foam package and attempted to fit it to Patient 12's coccyx wound. After determining he/she needed a different size of the foam dressing, Staff I stepped toward the door to Patient 12's room and proceeded to open it using the door handle.

After requesting additional supplies from staff outside of the room, Staff I then closed the door and returned to Patient 12's bedside. Staff I failed to change his/her gloves and perform hand hygiene after coming in contact with the "dirty" door handle. Staff I repeated this at least two additional times while waiting on supplies and ran his/her gloved hand across Patient 12's coccyx wound prior to putting on the new, clean Aqaucel foam dressing.

Staff I was observed to wear the same pair of gloves from start to finish of Patient 12's wound care.

These findings were discussed with Staff B at 10:10 AM on 12/05/13. At that time Staff B stated Staff I did not follow best practice or facility expectations for hand hygiene. Staff B further stated such hand hygiene is "nursing 101." Staff B was then asked if the facility had a policy regarding hand hygiene during wound care and stated no.

5) The medical record for Patient 12 was then reviewed on 12/05/13 with Staff G and Staff B present. Both Staff G and B confirmed 0n 12/05/13 at 3:10 PM there was no order for the wound care observed earlier, stating staff followed the facility "protocol" for wound care.

On 12/05/13 at 3:10 PM both Staff G and Staff B were asked for documentation of the physician's assessment of Patient 12's wound, as the care was supposed to be based on interdisciplinary assessment. After reviewing the record, neither Staff G nor Staff B could find any evidence a physician had assessed Patient 12's wounds as of 12/05/13. The ED admitting physician note completed on 12/04/13 at 9:43 AM indicated "there are no obvious skin lesions or breakdown noted on my exam." And the consultation note completed on 12/04/13 at 12:11 PM, after Patient 12 was admitted to the intensive care unit, lacked any mention of a skin assessment except to say "there is a significant amount of redundant tissue" from prior weight loss.

Facility policy "Actual Pressure Ulcer Skin Care Protocol" was reviewed again on 12/05/13. Under the heading of "level" at the beginning of the policy was the following documented statement "Interdependent [*Requires a physician order]." The policy went on to specify those procedures requiring said physician's order, including the cleansing of wounds with normal saline, application of hydrocolloid, hydrogel and non-adherent dressings, packing materials, and skin preps.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on medical record review, staff interviews, and review of policy; the facility failed to ensure the nursing care plan was updated to reflect and address all of a patient's needs. This affected one of four patient medical records reviewed with a wound or surgical incision (Patient 6). A total of 13 medical records were reviewed. The current facility census was 80.

Findings include:

1) The medical record for Patient 6 was reviewed on 12/05/13 with Staff G and Staff B. A 12/04/13 nursing assessment note indicated a "left hip drain" was present with "dressing intact." Review of the surgical consent form and procedure report revealed on 12/04/13 Patient 6 had "drainage of left abscess" and returned to the nursing unit with a "pigtail drainage catheter" in place.

Staff G and Staff B confirmed on 12/05/13 at 3:10 PM the medical record lacked evidence the nursing care plan had been updated since the drainage device was placed.

Facility policy Interdisciplinary Care Plan with Clinical Practice Guidelines was reviewed on 12/04/13. Per said policy, "the patient's plan of care identifies all of the current problems that are immediate and the highest priority for the patient, which will remain until resolved." It further stated "each discipline identifying and adding a clinical practice guideline to the plan of care will be required to address their discipline-specific problem, carry out appropriate interventions, and provide documentation of the patient's progress."