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.

Based on observation, record review, and interview, the facility failed to ensure that the use of restraint was ordered by a physician. Failure to do so resulted in 3 of 11 patients (Patient #1, #2, and Patient #4) being restrained as evidenced by four (4) raised side rails were raised with no physician's order for the restraints.

Findings included:

Record review of "Restraints and Seclusion Policy" published 1/23/2015 with two (2) versions stated that a restraint is four short rails up. "Restraints must have a physician's order, appropriate clinical justification for the restraint, a start time, and a time limit."

Observation of 4th floor - west on 6/6/2019, 10:00-11:00 AM, showed: 3 of 10 patients (Patient #1, 3, and Patient #4) had all four (4) side rails up.

Record review of the physician orders for Patient #1, #3, and Patient #4 showed that there were no orders for restraints, i.e., all four (4) side rails to be up.

In an interview with Staff A on 6/6/2019 at 11:00, she stated that only three (3) side rails should have been up, not all four (4) of them. She also stated that four (4) side rails up is a restraint.
Based on interview and record review, the facility failed to ensure that post-hospital home health services and equipment were available prior to discharge home. This failure resulted in 1 of 1 patient (Patient #1) being discharged home without a medical bed. Arrangements for home health services had not been finalized.

Findings included:

Record review of Progress Note by Staff K (MD) dated 6/3/2019 at 1:08 PM showed: Discharge Patient #1 home with home health once PEG tube is placed.

Record review of Case Management Follow Up Note by Staff P dated 6/7/2019 at 11:24 AM showed: Writer contacted patient's daughter. Discussed hospital bed possibly not arriving until Monday [6/10]. Home health coordinator will follow up with the company. The facility offered to have the patient returned until the bed could be secured but the daughter stated the patient did not want to come back to the hospital. The daughter stated she was ill and could not deal with this situation well. The daughter stated the hospital knew the patient would have a PEG and Patient #1 should have had a bed over a week ago. Writer reiterated need for Patient #1 to have his head elevated during feedings. The daughter, an RN, stated she was aware of that need. Writer asked the daughter if she would be able to manage without a hospital bed. The daughter replied that she was not bringing her father back to the hospital.

Record review of Home Health Progress Note by Staff Q (RN) dated 6/7/2019 at 11:43 AM showed: Received a call from the home health agency reporting patient discharged last night and that patient's daughter called to find out when a nurse would make the first home health visit. Patient #1 was not expected to discharge yesterday [6/6] as all home health arrangements were not completed. The home health agency reported they will need to attempt to find a nurse to go out to see patient but they cannot guarantee this. Case Management at the facility found out that a bed could not be delivered to Patient #1 until Monday [6/10]. A representative of the company providing the bed then reported that a bed was not available for "several weeks." Patient #1's daughter had concerns about Patient #1's discharge plan and was upset that the home health agency was not informed that Patient #1 was discharging yesterday [6/6]. "Apologized for discharge plan."

Record review of Discharge Planning Assessment for Patient #1 by Staff P dated 5/28/2019 at 11:05 AM showed home health information - An RN, physical therapy, occupational therapy, speech therapy, and an aide. Current home treatments: oxygen therapy, nasal cannula 2 liters at bedtime. Devices - walker. Anticipated discharge needs - [none are listed]

In an interview with Staff A and Staff R on 6/20/2019 at 9:00 AM, they reported that Staff P (case manager) had worked on Patient#1's discharge plan. Staff P had not gotten everything arranged prior to discharge.