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.

ASCENSION ST JOHN MEDICAL CENTER 1923 SOUTH UTICA AVENUE TULSA, OK 74104 July 8, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and staff interview, it was determined the hospital failed to ensure restraints were:

a. not used for staff convenience. See Tag A-0154;

b. used only when less restrictive interventions were ineffective. See Tag A-0164;

c. the least restrictive method used to accomplish the intended purpose. See Tag A-0165;

d. included in the patient plan of care. See Tag A-0166;

e. assessed for appropriate and safe application. See Tag A-0167;

f. not provided via a restraint protocol that contradicted state and federal guidelines. See Tag A-0168; and

g. the hospital failed to include the use of restraints in the QAPI program. See Tag A-0154.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the least restrictive restraint method was used for three (#1, 6 and #9) of three records reviewed for the use of restraints. Findings:

A hospital policy, titled, Restraint and Seclusion, documented,
"... Restraint or Seclusion Use:... will be the least restrictive device to accomplish this purpose..."

On 07/08/13, three (#1, 6, and #9) clinical records were reviewed for the use of restraints. None of the records had clear documentation of less restrictive interventions attempted before the use of restraints.

Patient #6 was restrained for five days. There was no documentation the patient was assessed for symptoms that indicated the restraint continued to be necessary. There was no documentation removal of the restraints was attempted.

Staff C confirmed this finding.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to include restraints in the plan of care for three (#1, 6 and #9) of three records reviewed for the use of restraints. Findings:

On 07/08/13, the hospital's policy and procedure for the use of restraints was reviewed. The policy required staff to include the use of restraints in the patient's plan of care.

The three clinical records reviewed had no documentation the use of restraints was incorporated into the plan of care.

Staff B and Staff C could not find restraints addressed in the plan of care when they reviewed the electronic medical record.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure restraints were not used for staff convenience. The hospital also failed to include the use of restraints in the QAPI program. Findings:

A hospital policy, titled, Patient Rights and Responsibilities, documented, "... Patients have the right to:... Be free from restraints that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff..."

Another hospital policy, titled, Restraint and Seclusion, documented, "... Restraint or Seclusion Use:... Never used for punishment or staff convenience... "

On 07/08/13, restraint logs from all patient units were reviewed. The logs for non-intensive care units documented the staff applied patient restraints for reasons that included: "confused", "impulsive", "won't stay in bed", "getting out of bed", "high risk for falls", "fall risk", and "patient safety."

Some logs did not document a reason for the application of a restraint.

Staff C stated she did not review the logs for the appropriate use of restraints. She stated that perhaps the unit managers reviewed them but no formal report was required to be submitted to her about the use of restraints.

She stated the use of restraints was not evaluated through the quality assessment / performance improvment process.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to ensure less restrictive interventions were attempted before physical restraints were used for three (#1, 6 and #9) of three records reviewed for the use of restraints. Findings:

A hospital policy, titled, Restraint and Seclusion, documented,
"... Restraint or Seclusion Use:... Used only in emergency situations and when alternative methods are insufficient to protect the patient from harming himself/herself or others..."

On 07/08/13, three clinical records (#1, 6 and #9) were reviewed for documentation of the use of restraints. None of the records documented staff attempted to use less restrictive interventions before physical restraints were applied.

Staff B confirmed this finding.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure restraints were assessed for appropriate and safe application for three (#1, 6, and #9) of three records reviewed for the use of restraints. Findings:

On 07/08/13, the hospital policy for restraints did not include a requirement for staff to assess and document that restraints were properly and safely applied.

None of the three records reviewed had documentation that indicated this was done by staff when restraints were applied or reapplied.

Staff B could not find supporting documentation in the clinical record.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure a restraint protocol used in the critical care and progressive care units did not contradict state and federal guidelines. Findings:

A hospital protocol, titled, Restraint Protocol for Critical Care Patients and 8 West Progressive Care Unit, documented, "... Use the following criteria for application and removal. Restraint use is based on the assessed needs of the patient when one or more of the following application criteria is present...

decreased level of consciousness / can be aroused but unable to maintain wakefulness
exhibits confusion and/or disorientation
unable to remember instructions
no understanding of therapies, equipment, risks
pulls at tubes, lines, dressing, etc...."

The protocol allowed for seven days of continuous restraint before a physician was required to reassess the patient's need for on-going restraint.

The clinical record for patient #6 documented the patient was restrained in recovery after surgery and continued to be restrained in one of the critical care units. The patient was restrained for five days until she was taken off life support.

The clinical record documented the patient was restrained for a "decreased level of consciousness". There was no documentation of patient behaviors that supported why a decreased level of consciousness would contribute to a need for restraint.

Staff E and Staff F were asked why patients in the intensive care/progressive care units might be restrained. They stated it was usually because the patients were intubated.

They were asked if intubated patients were sedated. They stated, "Usually." When they were asked why a sedated patient would need to be restrained, there was no response.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to ensure a physician assessed restrained patients for three of three records reviewed. Findings:

A hospital policy, titled, "Restraint and Seclusion," documented, "... Medical and Surgical:... The patient will be evaluated by the physician and the order authenticated within 24 hours of restraint initiation... renewal order or new order... will be based upon patient examination completed by the physician... Critical Care/8 West Progressive Care Unit Protocol:... The patient will be evaluated by the physician... Continued use of restraint will require a renewal order... based on physicians evaluation..."

On 07/08/13, three clinical records were reviewed for patients who had been restrained. The records had no documentation the physician had evaluated the patients after restraints had been utilized and/or had not evaluated the need for the continuation of restraints.

Staff B stated the hospital had problems with physician compliance with this requirement.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
Based on clinical record review, policy and procedure review, document review and staff interview, it was determined the hospital failed to ensure clinical records documented the behaviors that warranted the use of restraints for three of three records reviewed for patients in restraints. Findings:

On 07/08/13, staff E was asked if the hospital had a protocol or standing orders for the use of restraints in the critical care units. He stated there was none.

A hospital policy, titled, "Restraint and Seclusion," documented,
"... Document the following... Patient's behavior/actions that require restraint or seclusion..."

The policy also referenced a restraint protocol for critical care units and the 8 West progressive care unit.

The hospital protocol, titled, "Restraint Protocol For Critical Care Patients and 8 West Progressive Care Unit," documented, "... It is the standard of care for patients admitted to the intensive care units or the 8 West progressive care unit, based on assessed needs, to have soft restraints applied to maintain safety of the patient's tubes, wounds and dressings. Use the following criteria for application...
decreased level of consciousness... Can be aroused but unable to maintain wakefulness... exhibits confusion and/or disorientation... Unable to remember instructions... No understanding of therapies, equipment, risks..."

The clinical record for patient #6 (an ICU patient who was recorded by the hospital as a death in restraints) documented the patient had wrist restraints applied for the following behaviors: "[decreased] level of consciousness" and "unable to maintain wakefulness." The record documented the patient was restrained while "unable to lift head" and "resting." There was no documentation of behaviors that indicated the patient needed restraints.

Staff D was asked if the behaviors documented by staff supported the use of wrist restraints. No reply was given.

In the other two clinical records reviewed for the use of restraints, there was no documentation of the specific behaviors exhibited by the patient that supported the use of restraints.

Individual nursing unit restraint logs documented the following behaviors exhibited by patients who were restrained:

11 East Medical Unit: "confused, impulsive"... "won't stay in bed"... "compromising treatment"...

11 West Telemetry Unit: The restraint log had no documentation of why restraints were used.

12 East Medical/Surgical Unit: "high risk for falls"... "getting out of bed"... "fall risk"...

12 West Medical Unit: "patient safety"...

14 West Oncology Unit: There was no documentation of why restraints were applied.

NeuroTrauma Surgical ICU: There was no documentation of why restraints were applied.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0186
Based on clinical record review, policy and procedure review, and staff interview, it was determined the hospital failed to ensure clinical records documented interventions that were tried and failed prior to the use of restraints for three of three records reviewed for patients in restraints. Findings:

A hospital policy, titled, "Restraint and Seclusion," documented,
"... Document the following... Alternative methods of restraint or seclusion that were ineffective and the patient's response if appropriate..."

There was no documentation of interventions attempted before the application of restraints for three clinical records reviewed.

On 07/08/13, staff B confirmed this finding.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0187
Based on clinical record review, policy and procedure review, document review and staff interview, it was determined the hospital failed to ensure clinical records documented the behaviors that warranted the use of restraints for three of three records reviewed for patients in restraints. Findings:

On 07/08/13, staff E was asked if the hospital had a protocol or standing orders for the use of restraints in the critical care units. He stated there was none.

A hospital policy, titled, "Restraint and Seclusion," documented,
"... Document the following... Patient's behavior/actions that require restraint or seclusion..."

The policy also referenced a restraint protocol for critical care units and the 8 West progressive care unit.

The hospital protocol, titled, "Restraint Protocol For Critical Care Patients and 8 West Progressive Care Unit," documented, "... It is the standard of care for patients admitted to the intensive care units or the 8 West progressive care unit, based on assessed needs, to have soft restraints applied to maintain safety of the patient's tubes, wounds and dressings. Use the following criteria for application...
decreased level of consciousness... Can be aroused but unable to maintain wakefulness... exhibits confusion and/or disorientation... Unable to remember instructions... No understanding of therapies, equipment, risks..."

The clinical record for patient #6 (an ICU patient who was recorded by the hospital as a death in restraints) documented the patient had wrist restraints applied for the following behaviors: "[decreased] level of consciousness" and "unable to maintain wakefulness." The record documented the patient was restrained while "unable to lift head" and "resting." There was no documentation of behaviors that indicated the patient needed restraints.

Staff D was asked if the behaviors documented by staff supported the use of wrist restraints. No reply was given.

In the other two clinical records reviewed for the use of restraints, there was no documentation of the specific behaviors exhibited by the patient that supported the use of restraints.

Individual nursing unit restraint logs documented the following behaviors exhibited by patients who were restrained:

11 East Medical Unit: "confused, impulsive"... "won't stay in bed"... "compromising treatment"...

11 West Telemetry Unit: The restraint log had no documentation of why restraints were used.

12 East Medical/Surgical Unit: "high risk for falls"... "getting out of bed"... "fall risk"...

12 West Medical Unit: "patient safety"...

14 West Oncology Unit: There was no documentation of why restraints were applied.

NeuroTrauma Surgical ICU: There was no documentation of why restraints were applied.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to ensure the clinical record included documentation of the patient's response to restraints and a rationale for continued use for three of three records reviewed for the use of restraints. Findings:

A hospital policy, titled, "Restraint and Seclusion," had no documentation that required staff to assess and record a patient's response to the application of restraints.

Three of three records reviewed for patients who were restrained had no documentation of this requirement.

On 07/08/13, staff D stated she was not aware of this requirement.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of hospital documents and medical records and interviews with hospital staff, it was determined, the hospital's quality assessment and performance improvement program (QAPI) failed to review, analyze and track restraints and seclusions in the hospital. Three of three patient records reviewed (Patients #1,2,3), the patients were restrained and suffered an adverse patient event resulting in death. All patients chosen were off the monthly death in restraint logs from January 2013 through present and also each individual unit's monthly restraint logs for the same time period. There was no evidence presented of review of restraint use or review of the deaths while restrained. The patient advocate stated that all she looked at was to see if the death in restraint forms were filled out. Reviews of the forms revealed they were incomplete and not completely filled out. Patient #2, the patient in the complaint was not included in the hospital's death in restraint logs. The hospital was unaware CMS had been notified of this patient's death while restrained.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on clinical record review and staff interview, the hospital failed to ensure clinical records were complete and accessible for surveyor review.

See Tag A-0438.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on clinical record review and staff interview, the hospital failed to ensure clinical records were complete and accessible for surveyor review. Findings:

On 07/08/13, the surveyors selected twenty clinical records relevant to the application and use of restraints. The manager of medical records cued the records onto computers for the surveyors' use.

The surveyors were unable to locate information in the clinical records regarding the use of restraints.

Three clinical record superusers were asked to assist the surveyors with navigation through the records. They had difficulty navigating the closed records, stating the closed records did not have the same appearance as the open records they were used to working with.

After searching the records for a period of about an hour and a half, the superusers located some information about restraints in the clinical records. However, the restraint documentation was incomplete and fragmented so that it required movement between multiple screens to find relevant information.

The restraint documentation was primarily "check" boxes or pre-determined responses that were not detailed and patient-specific. The staff did not utilize the fields for narrative documentation. Not all the required documentation related to restraints was found in the records.

After a period of two hours, and with a narrow focus on just restraint related information, the surveyors had reviewed only three charts.

The manager of medical records was asked if a printed document would be more expeditious that trying to navigate the computerized record. She stated it would not.