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.

BRIDGEWELL HOSPITAL OF CINCINNATI 5500 VERULAM STREET CINCINNATI, OH Sept. 3, 2014
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observation, medical record review, facility admission packet and policy review; the facility failed to ensure patients were informed of the process to file a grievance including the right to file a complaint with the State Agency and the state hotline number. This affected 10 of 10 medical records reviewed. The facility census was 18.


Findings include:

An observation of the facility during the initial tour on 08/28/14 at 1:30 PM failed to reveal evidence the state hotline number was posted in the facility. Staff B confirmed the finding at the time of the observation.

Review of the medical records for eight active patients (Patient #1, #2, #3, #4, #5, #8, #9, and #10) and two discharged patients (Patient #6 and #7) failed to reveal evidence that the patient/responsible party was informed of the procedure to file a grievance with the facility, the right to file a grievance with the State Agency or provided the State hotline number.

Review of the facility patient admission packet included a facility Patient Bill Of Rights document dated 06/2011, which revealed the patient has a right to file a grievance. The admission packet failed to contain information of the process for filing a grievance, who to contact, notification of the right to file a complaint with the State Agency and the State Agency hotline number.

Review of the facility's Patient Rights Policy effective 04/21/11 and last reviewed 03/28/14 revealed patients and or their legal representative have the right to file a grievance per Hospital Complaint and Grievance Policy without fear of punishment or reprisal. Bridgewell Hospital has a Client's Rights Advocate available as per policy.

Review of the undated facility Complaint and Grievance Procedure revealed the process to file a complaint and included the phone number of the Client Rights Advocate. The procedure failed to contain information regarding the right to file a complaint with the State Agency and the State Agency hotline number.

An interview with Staff B on 08/29/14 at 11:20 AM confirmed the above findings.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical record, staff interview, review of video footage, and review of the facility's investigation; the facility failed to ensure all patients were free from actual or potential abuse and injury. This affected two of ten medical records reviewed (Patients #6 and #2) and had the potential to affect all 18 patients at this facility.

Findings include:

1. Review of the medical record for Patient #6 was conducted on 08/28/14 and 09/02/14. Patient #6 (a 78 year old) was admitted to the facility on [DATE] with diagnoses of organic mood disorder, diabetes, dementia with psychosis, and high blood pressure. Review of the medical record revealed a nursing shift report that documented the patient was sent to the local hospital on [DATE] as the result of a fractured right leg injury sustained during a fall at the facility. Review of the "External Consultation/Emergency Medical Information Form" dated 08/18/14, documented Patient #6 "was aggressive and went after staff member who blocked him with her hands. Patient lost footing and fell on floor hitting his buttocks. Complains of leg pain".

Review of surveillance footage by the survey team on 08/28/14 revealed Staff H, who was a patient care assistant (PCA), pushed Patient #6 to the floor. The footage revealed there were two other PCAs (Staff G and J) and one registered nurse (Staff F) present during the time of the patient abuse and injury. The video footage revealed Staff F didn't see Staff H push Patient #6, but Staff F came to the area of the incident shortly after it happened. The footage revealed Staff F walked back down the hallway toward Patient #6 after the fall and spoke to Staff H, G, and J. Staff F then walked away to return to the nurses station without assessing the patient. The footage showed Staff H, G, and J standing and watching the patient lie on the floor without providing any assistance to the patient except to place a rolled up blanket under his head. Approximately ten minutes after the fall, the second registered nurse, Staff L, came out of the nurses station with the vital signs machine and began assessing the patient. The footage revealed none of the staff members helped Patient #6 who laid on the floor for approximately ten minutes before vital signs were taken or comfort measures given.

An interview was conducted with Staff B on 08/28/14 at 4:00 PM which confirmed Staff H pushed Patient #6 early morning on 08/18/14, which resulted in Patient #6 sustaining a fractured right leg. Staff H was terminated on 08/28/14 after the video footage was reviewed. The other two PCAs (Staff G and J) and the RN (Staff F) who walked away from Patient 6 without assessing him were suspended for three days without pay and had to complete mandatory education regarding care of patients following a fall, communication and care of patients with dementia.

An investigation conducted with Staff B, the two PCAs (Staff G and J) , the RN (Staff F) , and the quality assurance director on 08/25/14 revealed "video recording of incident clearly showed the patient being pushed by a PCA".

During an interview on 08/28/14 at 4:00 PM, Staff B stated that education had been provided to the two PCAs (Staff G and J) and the RN (Staff F) who had been suspended following Patient #6's fall and fracture. Staff B confirmed that no education had been provided to any of the remaining staff as of 08/28/14. In addition, the facility did not implement a system to monitor for any inappropriate behaviors by staff or mistreatment of patients, except for the three staff members suspended.





2. On 08/28/14, Patient #2 (an 88 year old) reported rough treatment by a PCA (Staff E) which result in pain in his/her shoulder. The facility obtained an x-ray of the right shoulder on 08/28/14 which listed an anterior right shoulder dislocation. Patient #2 was subsequently sent out to the emergency room . The emergency room transfer paperwork listed the diagnosis as right shoulder sprain.

During an interview on 08/28/14 at 4:00 PM, Staff B stated the facility suspended Staff E pending investigation of the allegation. The facility's investigation was not final at the time of the survey exit.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, medical record review, facility policy review, staff interview, and patient interview; the facility failed to ensure patient assessments for restraining devices for three patients (Patient #3, Patient #4, and Patient #5) observed with restraining devices. The facility census was 18.

Findings include:

1. Review of the medical record for Patient #3 revealed an admission date of [DATE] with a diagnosis to include severe anxiety and increased pacing. Review of a nursing progress note date 08/21/14 revealed the patient was transferred to a wheelchair with a self release safety belt after the patient made frequent attempts to get of out of the chair despite multiple redirects.

Review of a physician order dated 08/21/14 documented up as tolerated with assist and in wheelchair with self release belt. Review of the record failed to contain an assessment prior to the use of the self release seat belt with a determination that the patient could release the device.

Review of a physician progress note dated 08/28/14 revealed the physician questioned if the patient was experiencing increased agitation from the restriction of ambulation. A physical therapy evaluation was ordered.

Review of the physical therapy evaluation dated 08/27/14, revealed the patient goal was to get out of the wheelchair and walk more.

Review of a nursing note dated 08/27/14 at 5:57 AM revealed the patient manifesting agitation this shift, standing up with the wheel chair, fidgeting, grabbing on to others, and difficult to redirect. Review of a nursing note dated 08/27/14 at 7:42 AM documented the patient out in wheel chair, "gets up and tries to walk with wheel chair on his/her back".

An observation of Patient #3 in the common area on the unit on 08/28/14 at 1:30 PM revealed the use of a self releasing seat belt and the patient attempting to stand. Staff were observed rubbing the patient's back and telling the patient to sit down. At 2:40 PM the patient was observed fidgeting and attempting to stand with the seat belt on. At 3:30 PM the patient was leaning over in the wheelchair attempting to stand and staff redirected patient to sit down.

An interview on 08/28/14 at 3:30 PM with Staff C revealed the patient was a fall risk and the seat belt helped prevent falls. Staff C revealed the patient was unable to remove the self releasing seatbelt and confirmed the chart failed to contain an assessment for the device and did not address the patient's ability to remove the seat belt.


2. Review of the medical record for Patient #4 revealed an admission date of [DATE]. Review of a physician order on 08/21/14 revealed the patient may use a geri chair for comfort and positioning.

An interview with Staff C at 1:30 PM on 08/28/14 revealed the patient was messing with the fire alarm so they put the patient in the geri chair in the common area.

An observation on 08/28/14 at 1:30 PM revealed the patient seated in a geri chair with a tray. At 2:30 PM the patient continued to remain in the common area in a geri chair with a tray. At 3:30 PM the patient was sleeping while reclining in the geri chair with the tray removed in the common area. An observation on 08/29/14 at 3:30 PM revealed the patient was in the hallway wheeling self in a wheelchair with a self releasing seat belt.

Patient #4 denied being able to release the seat belt when asked on 08/29/14 at 3:20 PM. Patient #4 was observed in a wheelchair with a self release seat belt. Staff C was present and confirmed the observation and patient statement at the time of the observation.

Review of the medical record failed to reveal a physician order for a self releasing seat belt or an individualized assessment prior to the use of the self release seat belt. There was no documentation that the patient could release the device.

An interview with Staff C on 08/29/14 at 3:40 PM revealed the patient was a fall risk and the seat belt was to help them from falling. Staff C confirmed Patient #4 did not have a physician order for the seat belt and there was no assessment Patient #4 had the ability to remove the device.

3. Review of the medical record for Patient #5 revealed an admission date of [DATE]. Review of a nursing note on 08/23/14 revealed the patient had an unsteady gait and was in a wheelchair with a body alarm. A nursing note on 08/26/14 revealed the patient was transferring from chair to the wheelchair with limited assist. A nursing note on 08/26/14 revealed the patient was attempting to self release the seat belt constantly and attempting to transfer out of the wheelchair.

Review of a physician order dated 08/28/14 revealed the patient to have a self release seat belt.

Review of the medical record failed to reveal evidence of an assessment prior to the use of the self release seat belt with a determination that the patient could release the device.

An observation of the patient on 08/28/14 at 1:30 PM revealed the patient in a common area in a wheelchair with a self releasing seat belt. The patient was fidgeting with the belt and attempting to stand. At 2:40 PM the patient was self propelling the wheelchair in the hallway and continued to wear the self releasing seat belt. At 3:30 PM the patient was observed seated in the wheelchair at the end of the hall with the seat belt on.

On 08/29/14 at 3:30 PM the patient was observed sitting in the wheelchair with the self releasing seatbelt leaning over and touching the floor. Staff C asked the patient to release the seat belt and the patient could not release the device.

At 3:40 PM Staff C stated the patient was a fall risk and the seat belt helped to prevent falls. Staff C confirmed the physician order was obtained after the use of the self releasing seat belt and the medical record failed to have an assessment of the patient that included the ability to remove the device.

4. Review of the unnumbered facility Restraint/Seclusion Policy effective 01/17/11 and last reviewed on 04/01/14 revealed physical restraints with devices was defined as any method of restricting a patient's freedom of physical activity or normal use of his or her body using an appliance or device manufactured for this purpose. Mechanical supports used for restraints rather than for support purposes shall be considered physical restraint devices. The application of a restraint requires a physician order, an assessment of physical problems, medical status, vital signs, review of current medications, a one hour face to face physician evaluation, prior interventions used before the restraint, continuous observation with documentation every 15 minutes to address physical needs, vital signs and readiness to remove the restraint. The rationale for each episode of restraint should be clearly documented in the record by the physician who examined the patient.

5. In an interview on 08/28/14 at 10:30 AM, Staff A stated the agency had no use of restraints or seclusion for the past two years.

6. In an interview on 08/29/14 at 10:15 AM, Staff D stated staff must have an physician order for a self release seat belt. The patient must be assessed to include determination that the patient can release the belt otherwise the seat belt is considered a restraint. Staff D submitted the facility Physical Restraint Evaluation form as the document to use with patient restraints.

7. An interview with Staff B on 08/29/14 at 3:45 PM confirmed the above findings and revealed the agency did not have a policy related to the use of self releasing seat belts. Staff B further confirmed the patient records failed to contain documentation for assessment, alternatives and interventions, frequency of use and informed consent required per the restraint/seclusion policy.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of medical records, staff interview, review of video footage, review of the facility's investigation, observation, policy review, patient interview, and personnel file review; it was determined that the facility failed to protect all patients from injury and abuse resulting from the actions of a patient care assistant (PCA) which resulted in an immediate jeopardy determination (A145). The facility failed to ensure proper usage of restraining devices (A154) and failed to ensure staff received training in orientation as well as annually on restraint usage (A208). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the safety of the patients. The facility had a census of 18 patients.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0208
Based on personnel file review, facility policy review and staff interview; the facility failed to ensure staff received restraint/seclusion training on orientation and annually. This affected seven of seven personnel files reviewed and had the potential to affect all patients in the facility. (Staff C, F, G, J, I, E and H) The facility census was 18.

Findings include:

1. Review of the personnel file for Staff C revealed a date of hire of 10/30/13. The file failed to include evidence of orientation on hire and training for restraint/seclusion.

2. Review of the personnel file for Staff F revealed a date of hire of 05/12/14. The file failed to include evidence of orientation on hire and training for restraint/seclusion.

3. Review of the personnel file for Staff G revealed a date of hire of 06/03/13. The file failed to include evidence of orientation on hire and training for restraint/seclusion.

4. Review of the personnel file for Staff J revealed a date of hire of 01/17/11. The file failed to include evidence of training for restraint/seclusion since 2012.

5. Review of the personnel file for Staff I revealed a date of hire of 04/24/13. The file failed to include evidence of orientation on hire and training for restraint/seclusion.

6. Review of the personnel file for Staff E revealed a date of hire of 02/14/11. The file failed to include evidence of training for restraint/seclusion since 2012.

7. Review of the personnel file for Staff H revealed a date of hire of 05/22/13. The file failed to include evidence of orientation on hire and training for restraint/seclusion.

8. An interview with Staff K on 09/03/14 at 10:30 AM confirmed the above findings.

9. Review of the unnumbered Restraint/Seclusion Policy effective 01/17/11 and last reviewed on 04/01/14 revealed direct care and nursing personnel shall be permitted to implement seclusion and restraint only if these employees have successfully completed training programs on minimizing the use of restraint or seclusion and to maximize safety when using seclusion and or restraint. All staff shall have appropriate training during employee orientation and are refreshed in these training techniques on an annual and as needed basis. The documentation of successful completion of each orientation or training program shall be maintained in each employee's personnel folder.

10. Review of the Competency Policy (undated) in the Human Resource Manual revealed on page 1 that orientation modules must be completed and signed by each employee and verification of completed modules are filed in each employee's personnel file.