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.

INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL 2401 UNIVERSITY AVE MUNCIE, IN 47303 Oct. 8, 2020
VIOLATION: IC PROFESSIONAL RESPONSIBILITIES POLICIES Tag No: A0772
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, observation and interview, the facility failed to maintain its infection prevention and control program in accordance with nationally recognized infection control (IC) guidelines to minimize the risk of exposure to patients, healthcare personnel (HCP) and visitors for two (2) occurrences.

Findings include:

1. Review of the Centers for Disease Control and Prevention (CDC) guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 7-15-20) indicated the following: "Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about... how and when to perform hand hygiene...Educate patients, visitors and HCP about the importance of performing hand hygiene immediately before and after any contact with their facemask or cloth face covering...Encourage physical distancing...Screen everyone (patients, HCP, visitors entering the facility for symptoms consistent with COVID-19 or exposure to others with [DIAGNOSES REDACTED]-CoV-2 infection...Actively take their temperature and document absence of symptoms consistent with COVID-19..."

2. Review of the [Facility 01] Infection Prevention Plan (revised 1-16-20) indicated the following: "The framework of the Infection Prevention and Control Program is based on the Center for Disease Control and Prevention (CDC)... guidelines and standards."

3. On 10-7-20 at 1035 hours, the Accreditation and Regulatory Compliance Specialist A2 and the Infection Preventionist A3 were requested to provide facility documentation indicating any Infection Control (IC), Incident Command or other facility directives for posting signs in public areas indicating how and when to perform hand hygiene (including the importance of performing hand hygiene immediately before and after any contact with their facemask or cloth face covering), encouraging physical distancing (maintaining 6 feet between people), and for screening all persons entering the facility for symptoms consistent with COVID-19 by performing temperature checks of everyone and no documentation was provided prior to exit.

4. During an observation on 10-7-20 at 1645 hours of the main entrance to the facility, in the company of staff A2, A3 and the Associate Chief Nursing Officer of Practice A6, the two (2) reception and screening staff on duty were observed to be without a thermometer and no temperature checks were performed by either staff while screening visitors and no signs indicating how and when to perform hand hygiene or encouraging physical distancing were observed in the main entrance and waiting area at the time of the observation.

5. On 10-7-20 at 1650 hours, staff A2 and A6 confirmed the above.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on document review and interview, the facility failed to ensure a consent for treatment was obtained from each patient admitted to the facility for 1 of 10 MR (medical records) reviewed (Patient #6).

Findings include:

1. Review of the policy/procedure Legal Health Care Consent (Adult and Minor) - Informed Consent (revised 7-18) indicated the following: "It is the policy of IU Health to obtain a signed "General Consent for Treatment" form at the time of treatment ...The General Consent for Treatment form captures the consent of a patient or the patient's authorized representative, as permitted by law, and authorizes IU Health to perform routine health care services.

2. Review of the MR for Patient #6 lacked documentation indicating form IU-222 titled "Consent for Treatment and Payment Responsibility" was signed on 6-27-20 at 2204 hours when the patient arrived to the ED with a chief complaint of chest pain.

4. On 10-8-20 at 1535 hours, the Accreditation and Regulatory Compliance Specialist A2 confirmed the MR for Patient #6 lacked documentation indicating a Consent for Treatment was signed by the patient at the time of treatment and no other documentation was available.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on document review and interview, the facility failed to follow its restraint and seclusion policy and ensure documentation of safety monitoring was maintained for 1 of 10 medical records (MR) reviewed (Patient #1).

Findings include:

1. Review of the policy/procedure Use of Restraints and Seclusion (revised 9-19) indicated the following: "Monitoring - Non-Violent Restraint. Monitoring is used to provide for patient safety, patient comfort and to determine when restraints can be safely discontinued ...On-going RN assessment is documented a minimum of every two (2) hours."

2. Review of the MR for Patient #1 indicated on 6-10-20 at 2118 hours an order to initiate a non-violent (vest) restraint was obtained and 2 hour safety checks were documented from 6-10-20 at 2118 hours to 6-11-20 at 0615 hours and the MR for Patient #1 lacked documentation indicating 2 hour safety checks were performed on 6-11-20 from 0800 hours to 1900 hours or on 6-12-20 from 0800 hours until discharge at 2219 hours.

3. On 10-8-20 at 1150 hours, the Accreditation and Regulatory Compliance Specialist A2 confirmed the MR for Pt#1 lacked documentation indicating the 2 hour safety checks were performed as indicated and no other documentation was available.