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 ARDMORE, INC 1011 FOURTEENTH AVENUE, NORTHWEST ARDMORE, OK 73401 July 30, 2015
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on review of hospital documents and interview with hospital staff, the hospital failed to ensure a current nursing care plan for 7 of 9 (# 3, 4, 5, 6, 7, 8 and 9) medical records reviewed.

Findings:

The surveyors reviewed medical records on 07/29/2015 between 9:30 a.m. and 12:30 a.m. with Staff N.

Staff N stated the nursing staff is responsible for updating the nursing care plans, for their assigned patients, in the electronic medical record, during every shift. Staff N also stated the nursing staff work 12- hour shifts beginning at 7:00 a.m. (AM) or 7:00 p.m. (PM).

The nursing care plans were not updated every shift in the following records on the following dates:

#3- 8/19/2014, 08/20/2014, 8/21/2014 and 8/22/2014
#4- 11/30/2014, 11/31/2014, 12/01/2014, 12/02/2014, 12/03/2014 and 12/04/2014
#5- 12/11/2014 and 12/12/2014
#6- 12/20/2014
#7- 06/11/2015
#8- 06/28/2015, 06/29/2015, 06/30/2015 and 06/31/2015
#9- 07/16/2015

Staff N confirmed the care plan findings during medical record review.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of hospital documents and interviews with staff, the hospital failed to ensure patients were free from all forms of abuse. This occurred in 2 of 2 (#21, #23) grievances that alleged abuse.

Findings:

1. A policy titled, "Reporting Patient Abuse or Neglect Caused by a Co-Worker," effective date 06/01/2015, documented, "... Charge Nurse/Department Manager Conducts interviews with patient/family/co-workers. Notify primary physician to assess patient if signs of abuse present. Notify Vice President/Administrator on Call to initiate investigatory leave..."

2. Review of Grievance #21 documented the patient's representative (rep) filed a grievance with the hospital alleging physical, mental and sexual abuse. Review of the investigation summary did not contain evidence the patient's rep and other patients had been interviewed.

On 07/29/2015 at 11:00 a.m., Staff N, the interim manager of where Grievance #21 had occurred was interviewed. Staff N stated at the time of the grievance she had been recently appointed as the interim manager. Staff N also stated she did not know she was supposed interview the patient, patients rep, or any other patient on the unit as part of the investigation.

3. Review of Grievance #23 documented the patient filed a grievance stating, " she felt abused". Review of the investigation summary did not contain evidence the hospital followed their abuse policy. The investigation report did not contain evidence the hospital conducted any interviews with the patient, family member or co-workers. The investigation summary only documented, "...Unable to verify complaint. Patient was unhappy during her stay and was very demanding of the staff. She would get upset with a staff member and then apologize later in the shift..."
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure restraint use in the emergency department( ED) was incorporated into the hospital's quality assessment and performance improvement (QAPI) program.

Findings:
A policy titled, "Hospital Wide-Restraint Policy", review date 03/17/2014, documented, "...Our commitment to become restraint free is demonstrated by the identification of opportunities for change in regard to restraint use through the performance improvement process...."

The hospital's QAPI plan for fiscal year (FY) 2015 was reviewed. The plan documented a goal to decrease the annual restraint usage by 25%.

On 07/28/2015 between 9:55 a.m. and 10:20 a.m., Staff M, identified as the chair person for the hospital restraint committee, was interviewed.

Staff M stated restraint audits are conducted on the medical-surgical units, intensive care units (ICU), behavioral health unit and the ED.

Staff M stated the restraint data for the behavioral health unit and ED were reported directly to QAPI.

The surveyors requested and reviewed the hospital ' s QAPI meeting minutes for the past 12 months.

Review of the minutes did not contain documentation restraint usage in the ED were monitored, reviewed and analyzed through QAPI. This was confirmed by Staff R.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure restraints were applied in accordance with physician orders. This occurred in three of six (# 2, 13 and 14) patients in restraints.

Findings:

1. On 07/30/2015 at 4:35 p.m., Staff R stated orders for restraints are written per calendar day (daily) while the patient is restrained.

A policy titled, " Hospital Wide-restraint Policy, review date, 03/17/2014, documented, "...If restraints are removed or discontinued prior to the expiration of the original order, a new order must be obtained prior to reapplying the restraints and all requirements will be repeated. An exception to this is when restraints are removed and (sic) a temporary basis for range of motion, toileting, feeding, hydration needs, vital signs, repositioning and assessment checks such as circulation..."

2. Record #2- The medical record did not contain orders for specific restraints. The physician orders were for four siderails in the up position. Nursing staff documented the patient was in four point restraints. There were no physician orders for the four point restraints.

3. Record #13- The medical record documented the patient was placed in soft wrist restraints on 06/30/2015. The restraint flowsheet documented a "supervised release" on 07/01/2015 at 4:00 a.m. Review of the medical documented the restraints were removed due to the patient agitation and swelling in the patients wrists.

Restraints were reapplied on 07/01/2015 at 5:17 a.m. There were no physician orders for the reapplication of the restraints. This was confirmed by Staff R on the afternoon of 07/30/2015.

4. Record #14- The medical record documented the patient was placed in bilateral soft wrist restraints on 06/29/2015. The left wrist restraint was removed on 06/30/2015 at 2:00 a.m. The left wrist restraints was reapplied at 06/30/2015 at 3:00 a.m. There were no physician orders for the reapplication on the restraints.