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.

JEFFERSON HEALTH- NORTHEAST 10800 KNIGHTS ROAD PHILADELPHIA, PA 19114 Aug. 24, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on review of facility policies and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure patients in restraints were monitored by a physician, other licensed independent practitioner or trained staff, at an interval determined by hospital policy, for two of five restraint medical records reviewed (MR10 and MR12).

Findings include:

Review on August 24, 2018, of the facility policy, " ... Restraint Care," dated March 19, 2018, revealed, " ... D. Evaluation/Reassessment ... Nursing: ... Patients are monitored as follows: 1. Evaluation of need for continued restraints is done on an ongoing basis and documented every two (2) hours. Monitoring is accomplished by observation, interaction with the patient or related direct examination of the patient ... E. Documentation: The medical record contains the following: ... 5. The patient's needs, including circulation, skin care, hydration, nutrition and elimination will be addressed a minimum of every two hours for the duration of the restraint ... ."

Review on August 24, 2018, of MR10 revealed the patient was treated in the facility on February 19, 2018. Further review of MR10 revealed the patient was placed in bilateral wrist restraints on February 19, 2018 at 0600. Further review of MR10 revealed no documented evidence of the ongoing physical monitoring of the patient, as required by facility policy, while the patient was in restraints on February 19, 2018 at 2000 and 2200.

Review on August 24, 2018, of MR12 revealed the patient was treated in the facility on August 10, 2018. Further review of MR12 revealed the patient was ordered to be placed in bilateral wrist restraints on August 10, 2018 at 2000. Further review of MR12 revealed no documented evidence of the ongoing physical monitoring of the patient, as required by facility policy, while the patient was in restraints on August 10, 2018 at 2000 and 2200 and on August 11, 2018 at 0000 and 0200.

Interview with EMP11, on August 24, 2018, at approximately 2:00 P.M., confirmed that the patient in MR10 was placed in bilateral wrist restraints on February 19, 2018. Further interview with EMP11 confirmed that MR10 "did not" contain documented evidence of the ongoing physical monitoring of the patient, specifically, every two (2) hour checks, as required by facility policy, while the patient was in restraints during the hours specified above.

Interview with EMP11, on August 24, 2018, at approximately 2:00 P.M., confirmed that the patient in MR12 was placed in bilateral wrist restraints on February 19, 2018. Further interview with EMP11 confirmed that MR12 "did not" contain documented evidence of the ongoing physical monitoring of the patient, specifically, every two (2) hour checks, as required by facility policy, while the patient was in restraints during the hours specified above.
VIOLATION: SUPERVISION OF EMERGENCY SERVICES Tag No: A1111
Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to provide provision for the Supervision of Emergency Services.
Findings include:
Review on August 23, 2018, of facility document, "Medical Staff Bylaws, Policies and Rules and Regulations ..." dated March 19, 2018, revealed "... 4.B. List of Departments and Divisions ... Department of Emergency Medicine ...". Further review of Medical Staff Bylaws revealed no provision of the requirements for the Supervision of Emergency Services.
On August 23, 2018, request was made to EMP3 at 3:00PM, for documented evidence of the medical staff member designated as the Supervisor of Emergency Services. None was provided.
Interview on August 23, 2018, with EMP3 and EMP5 confirmed EMP5 was the Chief of Emergency Services for all three (3) of the Hospital's campuses. Further interview confirmed the facility had not designated a qualified medical staff member as the Supervisor of the Emergency Services separate from the Chief of Emergency Services for this campus. Further interview confirmed there was no distinction between the Supervisor and Director. Further interview confirmed there was no provision for a designated onsite Supervisor to be immediately available in the absence of the Chief/Director of Emergency Services.