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.

DELTA MEDICAL CENTER 3000 GETWELL RD MEMPHIS, TN 38118 Sept. 24, 2015
VIOLATION: GOVERNING BODY Tag No: A0043
Intakes: TN 267

Based on facility policy, medical record review and interview, the Governing Body failed to assume responsibility and provide oversight of the hospital to ensure all patient rights were promoted.

The findings included:

1. The Governing Body failed to ensure the Chief Executive Officer (CEO) was accountable for the quality of care provided to the patients in the hospital.
Refer to A057.

2. The Governing Body failed to be responsible and ensure all patients' right to voice grievances, receive care in a safe setting and be free of restraints were promoted.
Refer to A119, 144 and 168.

3. The Governing Body failed to ensure policies were implemented to ensure all patient grievances were addressed, fall interventions were implemented and patients were free of restraints.
Refer to A115, 119, 144 and 168.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy, document review, medical record review and interview, the Governing Body failed to ensure the Chief Executive Officer (CEO) was accountable to the governing body for the quality of care provided to patients related to restraints and falls for 3 of 3 (Patients #1, 2 and 3) sampled patients.

The findings included:

1. Review of the facility's "Governing Board Bylaws" revealed, "...FACILITY MANAGEMENT...The CEO is responsible for the overall management of the facility...The CEO's duties include, but are not limited to the following...creating a culture of safety and quality throughout the organization and maintaining that culture..."

2. Medical record review for Patient #1 revealed an admission to the hospital on [DATE] with the diagnosis of Bipolar and Schizophrenia.

Review of the 9/3/15 Patient Care Notes revealed at 5:51 PM the patient exhibited combative behaviors and was placed in a restraint. There was no documentation of a physician's order to restrain the patient at 5:51 PM.

Review of the 9/7/15 Patient Care Notes revealed at 1:20 PM the patient exhibited threatening behaviors and was placed in a restraint. There was no documentation of a physician's order to restrain the patient at 1:20 PM.
Refer to A168.

3. Medical record review for Patient #2 revealed the patient (MDS) dated [DATE] at 6:16 PM. The 8/18/15 ED Triage note revealed at 6:40 PM "...pt [patient] here to detox from alcohol..." and the patient was admitted to the hospital.

Document review revealed on 8/21/15 Patient #2 filed a complaint grievance with the Interim Risk Manager (RM). The grievance included complaints regarding the patient falling in the emergency room resulting in a wound to the lip and chipped tooth, food not delivered appropriately, night staff hollering and playing loud music, personal hygiene problems and being told not to notify the supervisor regarding problems.

There was no documentation the facility appropriately investigated the allegations, implemented appropriate corrective actions and notified the complainant of the investigation and actions.

Review of the emergency room (ER) record revealed Patient #2 (MDS) dated [DATE], had an elevated blood alcohol level and was documented to be intoxicated. The patient reported a fall while in the ER on 8/18/15 resulting in a wound to the lip and chipped tooth.

There was no documentation the patient was assessed for fall all risk factors and interventions implemented to prevent falls with injury in accordance with the facility policy.
Refer to A 119 and 144.

4. Medical record review for Patient #3 revealed an admission to the hospital from 7/31/15 - 8/11/15 with diagnoses of Schizoaffective Disorder, Pancreatitis, Chronic Abdominal Pain, Agitation, Psychosis, Suicidal Ideation.

Review of the 8/3/15 physician's order revealed an order to place the patient in restraints at 9:00 AM.
Review of the 8/3/15 Patient Care Notes revealed at 11:17 AM the patient "...had to be placed in the restraint chair..."
Review of the Patient Observation Record revealed the patient was in the restraint chair at 9:15 AM, 9:30 AM, 9:45 AM, 10:00 AM and 10:15 AM.

There was no documentation to clarify the time the patient was actually in the restraint chair.
Refer to A 168.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on facility policy, document review, medical record review and interview, the facility failed to ensure all patients' rights were protected and promoted.

The findings included:

1. The facility failed to follow policies and procedures to ensure all patient grievances were addressed and in accordance with facility policy.
Refer to A119.

2. The facility failed to ensure all patients received care in a safe setting to prevent falls and in accordance with the facility policies and procedures.
Refer to A144.

3. The facility failed to ensure the patients' right to be free from restraints and in accordance with the facility policy.
Refer to A168.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy, document review, medical record review and interview, the facility failed to ensure the patient complaint grievance process included a thorough investigation, corrective resolution actions and a response to the complainant for 1 of 1 (Patient #2) sampled patients with a complaint grievance.

The findings included:

1. Review of the "Patient and/or Patient Representative (Complainant) Grievance" policy revealed, "...PURPOSE: To define [name of hospital] policy concerning patient/patient representative (complaint) grievance and to establish a mechanism for responding to such a grievance...Policy Statement: Each patient at [name of hospital] has the right to expect considerate, respectful, and informed care. When these expectations are not met, the patient and/or patient representative is entitled to register this discrepancy and to receive information and/or evidence of action(s) taken to insure quality care...
DEFINITION: A grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS [Centers for Medicare and Medicaid] Hospital Conditions of Participation... PROCEDURE...A copy of the grievance is to be forwarded to the Patient Advocate within one (1) business day...After a thorough investigation by the Department Manager, the facts and actions are to be documented and forwarded to the Patient Advocate...Grievances will be reviewed and a response provided within a specific time frame...Response will be sent Certified Mail and will include: The name of the hospital, contact person, the steps taken to investigate the complaint, the results and date of completion...Grievances are reviewed through the Ethics Committee per a decision of the governing board, Board of Trustees, in November, 2009."

2. Medical record review for Patient #2 revealed the patient (MDS) dated [DATE] at 6:16 PM and was later admitted , "...pt [patient] here to detox from alcohol..."
Review of the 8/18/15 ED physician's note revealed the Physician Assistant (PA) documented at 7:05 PM, "PHYSICAL EXAM...Head exam normal...Eye exam normal...ENT exam normal, Pharynx exam normal, Uvula exam normal, Tonsil exam normal...Intoxicated..." There was no documentation the patient had an injury to the lip or tooth prior to coming to the ED.

Review of the 8/19/15 ED physician's note revealed at 4:00 AM the physician documented, "...Went to check on patient after patient became verbally abusive towards nurses and staff. Patient yelling loudly that he has urinated on self and is demanding a shower...also states that he fell near his bed while trying to find the urinal and bit his lip and cracked his tooth...small lip abrasion and mild swelling on the bottom lip..."
At 4:30 AM the physician documented, "...Spoke to ER tech...who...had seen patient multiple times prior to midnight 8/18 with a lip bruise..." There was no documentation the patient had the lip abrasion or chipped tooth prior to coming to the ED on 8/19/15 at 6:16 PM.

3. Review of the Grievance report form revealed Patient #2 filed a grievance on 8/21/15. The form was completed by the Interim Risk Manager (RM), whom was also temporarily serving as Patient Advocate.

The grievance included the following:
While he was in the Emergency Department on 8/18/15, "...he needed to urinate and was hollering down the hallway but no one would answer him. He decided to try to get off the stretcher and the mattress slipped causing him to lose [loose] his balance...he fell against the counter and busting his lip and hitting his tooth. Patient stated the ED nurse accused him of coming in with the busted lip. During the fall patient stated he urinated a little on himself...stayed in those wet clothes for 6 hours...wanted to take a shower...but staff brought him some body wipes..."

The patient indicated, "...originally he was on [name of a dual diagnosis detox unit] and staff woke him up in the middle of the night to transport him to [name of a mental health unit]. They took his belongings and patient complained that the night staff was very loud, hollering down the hall and playing loud music...felt the staff from nights were not very helpful, were disrespectful, and not accommodating...asked for a sandwich when he did not receive diet items ordered...did not receive the sandwich...his dirty clothes had not been washed...asked for clean socks that he did not receive until today..."

The patient indicated he was in a group session "...this am and the facilitator [name] called his name, rolled her eyes and told him to quit calling the house supervisor...Patient does not want to be on [name of this unit]..."

The Interim RM documented the following in the grievance:
Apologized for the disrespectful nature of his care.
The patient could call the house supervisor at any time or the RM and gave them the phone extension numbers.
Had the patient transferred to the Dual Diagnosis Unit he requested.
Informed the Mental Health Unit Manager of the complaints regarding dirty clothes, loudness of the staff and disrespectful behavior of the staff. The RM documented the Manager "...will talk with her staff..."
The RM documented, "...I talked with the ED manager regarding the ED complaints. [Name of the ED manager] indicated the patient was very enumerated [inebriated] and disruptive when he came in...will follow up and speak with her staff regarding the other complaints..."

The grievance form revealed the sections titled "Steps taken to Investigate grievance" and Results of grievance process" were blank and had not been completed.

4. During an interview on 9/14/15 at 2:00 PM in the conference room, the Interim Risk Manager stated there was no additional investigation or response for Patient #2's grievance.

During an interview on 9/14/14 at 2:30 PM in the conference room the Unit Manager stated there was no additional investigation or response for Patient #2's grievance.

During an interview on 9/14/15 at 3:00 PM in the conference room the Chief Nursing Officer (CNO) verified there was no additional information for Patient #2's grievance.

There was no documentation the patient's grievance was thoroughly investigated, had appropriate corrective actions taken to correct or evidence of a written response to the patient with actions taken in accordance with the facility's policy.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy, document review, medical record review and interview, the facility failed to ensure all patients received care in a safe setting that included a fall risk assessment with interventions to prevent falls and injuries for 1 of 3 (Patient #2) sampled patients.

The findings included:

1. Review of the "Fall Precaution Assessment" policy revealed, "...PURPOSE...To identify those patients at risk for falls...To identify those environmental factors that may contribute to falls...To improve patient outcomes related to falls...To provide the nurse with guidelines to identify and assess...patients who are at risk for falls...To assure that appropriate interventions/precautions are employed/instituted ..."
The fall policy revealed, "...Patients admitted to [name of hospital]...will receive a fall risk assessment..."

2. Medical record review for Patient #2 revealed the patient (MDS) dated [DATE] at 6:16 PM.
The 8/18/15 ED Triage note revealed at 6:40 PM "...pt [patient] here to detox from alcohol..."

The 8/18/15 ED "NURSING ASSESSMENT: PSYCH/SOCIAL" note at 5:56 PM revealed the patient was "...intoxicated, unsteady gait...patient confused and intoxicated...alcohol on breath...Safety: Side rails up, Cart/Stretcher in lowest position, Family at bedside, call light in reach, hospital id band on..." There was no documentation the patient was assessed for falls risk.

The 8/18/15 nursing note revealed at 7:00 PM an IV was started with a physician's order for 1 liter of Normal Saline bolus and "...Safety: Side rails up, Cart/Stretcher in lowest position, Family at bedside, call light in reach, hospital id band on..."

Review of the 8/18/15 ED physician's note revealed the Physician Assistant (PA) documented at 7:05 PM, "PHYSICAL EXAM...Head exam normal...Eye exam normal...ENT exam normal, Pharynx exam normal, Uvula exam normal, Tonsil exam normal...Intoxicated..." There was no documentation the patient had an injury to the lip or tooth prior to coming to the ED.

7:30 PM revealed, "...Safety: Side rails up, Cart/Stretcher in lowest position, Family at bedside, call light in reach, hospital id band on..."

8/19/15 3:40 AM revealed, "...Safety: Side rails up, Cart/Stretcher in lowest position, call light in reach, hospital id band on..." There was no documentation the family was at the bedside. There was no documentation the patient was assessed for falls risk or additional interventions implemented.

Review of the 8/19/15 physician's note revealed at 4:00 AM, "...patient became verbally abusive towards nurses and staff. Patient yelling loudly that he has urinated on self and is demanding a shower...also states that he fell near his bed while trying to find the urinal and bit his lip and cracked his tooth...small lip abrasion and mild swelling on the bottom lip..." There was no documentation a fall risk assessment was performed or additional fall interventions implemented.

Review of the 8/19/15 at 4:30 AM revealed the physician documented, "...Spoke to ER tech...who...had seen patient multiple times prior to midnight 8/18 with a lip bruise..."

There was no documentation the patient had the lip abrasion or chipped tooth prior to coming to the ED on 8/19/15 at 6:16 PM. There was no documentation an assessment was conducted to identify safety concerns to prevent falls.

The ED record revealed the patient was admitted to the Med Surg unit and left the ED on 8/19/15 at 5:25 AM.

3. During an interview on 9/15/15 at 11:15 AM in the conference room the Chief Nursing Officer (CNO) was asked if the ED followed the facility fall policy. The CNO stated she did not know if the ED had a fall policy or procedure and stated she would have the ED Assistant Director provide that information.

During an interview on 9/15/15 at 11:20 AM in the conference room the ED Assistant Director stated the ED "...follows the hospital policy [for falls]...We have our own computer assessment...I don't know what our policy is for falls." The ED Assistant Director stated each computer screen has a safety box at the bottom of the screen and if you click on it, several boxes will pop up with fall interventions. The computer system also has a "Nursing Assessment: Fall Risk" section.

There was no documentation a fall risk assessment was performed for Patient #2. There was no documentation the ED had a system in place to assess patients' fall risk with interventions based on risk.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy, medical record review and interview, the facility failed to ensure all restraints were implemented with a physician or Licensed Independent Practitioner (LIP) orders and in accordance with facility policy for 2 of 3 (Patients #1 and 3) sampled patients.

The findings included:

1. Review of the facility's "Restraints and Seclusion" policy revealed, "....PURPOSE...to support the limited use of restraints...these guidelines supports the use of least restrictive and most protective measures...while preserving the rights, dignity, and well-being of the patient...DEFINITIONS...A restraint is...Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...Order by Physician: The physician or licensed independent practitioner (LIP)...is responsible for ordering restraint...[in case of emergency restraint use]...the order from the attending physician will be obtained during the emergency, or immediately (within a few minutes) after the implementation of restraint...Protection of the Patient's Rights, Dignity, and Well-Being...Staff must keep in mind the dangers restraint...present to a patient's self-esteem, feelings of independence and pride...PROCEDURE...5. The Registered Nurse will utilize the 'Restraint/Seclusion Intervention' form. 6. The order must: a. Include the clinical justification for each episode of restraint/seclusion, and b. Be time-limited to include a start and end time and date, and c. Designate the type(s) of restraint/seclusion to be applied..."

2. Medical record review for Patient #1 revealed an admission to the hospital on [DATE] with the diagnosis of Bipolar and Schizophrenia.

Review of the 9/3/15 Patient Care Notes revealed at 5:51 PM, "...patient was combative, fighting staff and verbal abuse...special duty code was called. patient was placed in psy. chair per staff..." There was no documentation of a physician's order to place the patient in the restraint chair at 5:51 PM.

Review of the 9/7/15 Patient Care Notes revealed at 1:20 PM, "...he became very aggressive with staff, he began threatening another pt as well as throwing chairs around the dayroom...placed in the restraint chair...pt eventually calmed down..." There was no documentation of a physician's order to place the patient in the restraint chair at 1:20 PM.

Review of the 9/12/15 physician's Restraint Orders revealed a physician's order to restrain the patient at 3:50 PM related to the patient pushing and hitting another patient for stealing his body wash.

An additional 9/12/15 physician's order revealed to restrain the patient at 4:54 PM related to kicking the door and then attempting to throw a chair thru the door.

Review of the 9/12/15 Patient Care Notes revealed:
At 3:50 PM, "...Pt. became upset with female peer- pushed her down...then hit her in forehead with fist---'She stole my body wash'...Pt. placed in restraint chair for safety of others-1:1 initiated per protocol..." At 4:00 PM, "...Restraints removed..."

At 6:10 PM, "...Restraints released..." There was no documentation of a physician's order for this restraint released at 6:20 PM and no documentation of when the restraint was implemented.

At 6:16 PM, "...Pt. kicked plexi-glass out of door-then picked chair up attempting to put it thru front door...Intervention Restraints required for pt. safety and the safety of others..."

During an interview on 9/15/15 at 1:30 PM in the conference room the Unit Manager verified there were no physician's orders for all restraints documented on 9/3/15, 9/7/15 and 9/12/15 and it was not clear if the documentation was a late entry or a new restraint episode.

3. Medical record review for Patient #3 revealed an admission to the hospital from 7/31/15 - 8/11/15 with diagnoses of Schizoaffective Disorder, Pancreatitis, Chronic Abdominal Pain, Agitation, Psychosis, Suicidal Ideation.

Review of the 8/3/15 physician's order revealed an order to restrain the patient and "Begin time 0900 [9:00 AM]..."

Review of the 8/3/15 Patient Care notes revealed at 11:17 AM the RN documented, "...she had to be placed in the restraint chair for her own safety..."

Review of the 8/3/15 "Patient Observation Record" revealed the patient was in the restraint chair at "...9:15 A [AM]...9:30 A...9:45 A...10:00 A...10:15 A..."

There was no consistent documentation to verify when the patient was place in the restraint.

During an interview on 9/15/15 at 1:30 PM in the conference room the Unit Manager verified the medical record did not reflect a consistent time the patient was placed in restraints.
VIOLATION: QAPI Tag No: A0263
Based on facility policy, medical record review and interview, the Governing Body failed to ensure the facility QAPI program identified, developed and implemented an effective quality program.

The findings included:

1. The Governing Body failed to ensure the facility's QAPI program maintained an effective system to address all patient grievances.
Refer to A286.

2. The Governing Body failed to ensure the facility's QAPI program developed effective fall interventions that provided patient safety.
Refer to A286.

3. The Governing Body failed to ensure the facility's QAPI program demonstrated evidence the facility followed their policy and procedure for the use of restraints.
Refer to A168.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on facility policy, medical record review and interview, the facility failed to ensure the Quality Assessment Performance Improvement (QAPI) program identified safety indicators and developed and implemented preventative actions to address grievances, falls and restraints for all patients.

The findings included:

1. Review of the facility's "Restraints and Seclusion" policy revealed, "...Performance Improvement: The hospital will use performance improvement processes to identify opportunities to reduce risks associated with the use of restraint...The hospital will take action on its improvement priorities...The hospital will evaluate changes to confirm they resulted in improvements..."

2. During an interview on 9/15/15 at 2:10 PM the Chief Nursing Officer (CNO) was asked if the facility's QAPI program had identified problems with grievances, falls and restraints. The CNO stated there had been problems identified and there were no formal QAPI meeting minutes or action plans developed. The CNO was asked to provide any evidence available for interventions related to grievances, falls and restraints.

3. An interview was conducted on 5/16/15 at 9:00 AM in the conference room with the CNO, Chief Executive Officer (CEO) and the Executive Director of Behavioral Health present.

During the interview the CNO provided interventions for facility grievances as follows:
The need to improve the Risk Manager (RM) Program on 7/24/15 when the RM and Patient Advocate positions were vacated, as these positions are responsible for patient grievances.
The RM position is expected to be filled on 9/21/15.
The Patient Advocate Position was filled on 8/31/15 and are currently orientating.
Met with Senior Staff of Behavioral Health to discuss improvements in Customer Service and Hospitality.

During the interview the CNO provided interventions for Falls as follows:
Appointed a Performance Improvement team to conduct an analysis in July 2015 related to falls.
Remodeled the Senior Unit Day Room to facilitate continuous visualization.

During the interview the CNO provided interventions for Restraints as follows:
Appointed a Performance Improvement Team in August 2015.
Recruited and hired new staff that included Mental Health Technicians, CPI Instructor, and 4 new supervisor/Assistant Director Nursing positions.
Posted restraint education on the hospital intranet.

During an interview on 9/16/15 at 10:00 AM the CNO stated the facility was unable to provide a list of the staff that had taken the restraint education on the hospital intranet.

There was no documentation the facility QAPI program implemented effective interventions for grievances, falls and restraints.