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.

SALEM HOSPITAL 890 OAK STREET, SE SALEM, OR 97301 Jan. 24, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
Based on interview, documentation reviewed in the medical record of 2 of 2 patients who were physically restrained for management of violent or self-destructive behavior (Patients 2 and 3) and review of policies and procedures, it was determined the hospital failed to ensure documentation of a one hour face-to-face medical and behavioral evaluation of the patient as required.

Findings include:

1. Refer to the findings at Tag A 171, CFR 482.13(e)(8), Patient Rights: Restraint or Seclusion. That deficiency reflects the following:

The record of Patient 3 reflected the patient was placed in 4-point restraints for violent or self destructive behaviors from 10/10/2016 at 2038 to 10/11/2016 at 0354, a period of more than seven hours.

The record contained no physician or other LIP one hour face-to-face assessment of the patient's physical and psychological status.

2. Refer to the findings at Tag A 168, CFR 482.13(e)(5), Patient Rights: Restraint or Seclusion. That deficiency reflects the following:

The record of Patient 2 reflected the patient was placed in 4-point restraints for violent or self destructive behaviors from 10/02/2016 at 0305 to 10/02/2016 at 0527, a period of more than two hours.

The record contained no physician or other LIP one hour face-to-face assessment of the patient's physical and psychological status.

3. During an interview on 12/16/2016 at 1430 with the Accreditation Specialist, he/she confirmed the medical records for Patients 2 and 3 contained no physician or other LIP one hour face-to-face assessment of the patients' physical and psychological status after initiation of the restraint.

4. The policy and procedure titled "Restraint and/or Seclusion, Use of" with an effective date "April 5, 2016", was reviewed. It stipulated: "Violent Restraint and Seclusion...The licensed independent practitioner shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, documentation in 1 of 1 medical record reviewed of a patient about who the hospital received an allegation of patient abuse (Patient 5), and review of policies and procedures, it was determined the hospital failed to implement policies and procedures it had adopted addressing allegations of patient abuse.
* Allegations of patient abuse were not appropriately and thoroughly investigated and documented;
* Allegations of patient abuse were not reported to appropriate individuals; and
* Patients were not provided written response to allegations of abuse.

Findings include:

1. The policy and procedure titled "PMC Sexual Assault Prevention/Incident" dated as approved "February 2013," was reviewed. It stipulated that: "Any time a report or witnessed incident of sexual encounter/sexual assault has occurred, the procedures herein will be instituted...Reported Allegation of Abuse by a Patient.- If any patient reports an incident of sexual abuse that is alleged to have occurred either prior to admission or at any time after admission, staff will assure that Mandatory Reporting is iniatiated (sic). A Sexual Abuse Nurse Evaluator (SANE) will be notified for investigation to be initiated. The SANE summary of evaluation will be charted and reports to appropriate authorities will be filed. Additionally, staff will notify House Supervisor, Manager, and Medical Director at the time the allegation is made..." The "Risk Communication/Documentation" section of the policy stipulated: "...Notify NAC, Security, and Nurse Manager and the Medical Director of the incident...Document the incident in the medical record of all concerned patients...Complete a Patient Safety Assessment (PSA) online..."

2. The policy and procedure titled "Patient Abuse-Neglect-Harassment" dated as approved "September 2014," was reviewed. It stipulated that: "Salem Health will investigate all allegations thoroughly and in a timely manner, and provide written responses to all complainants...Reporting observed abuse or allegations...Reporting party submits a Patient Safety Alert...If witnessed, document all observations with date, time, and people present...If an un-witnessed event, document the complaint as given to you...Department Manager/Director notifies Risk Management...Department Manager/Director implements the Event Management Process...External reporting of abuse, neglect or harassment of patients will occur in accordance with applicable local, State or Federal law."

3. The electronic medical record of Patient 5 was reviewed with the Manager of Accreditation & Patient Safety and the Director of the Psychiatric Unit on 05/27/2015 at 1240. The record reflected the patient was admitted on [DATE] at 1506 with diagnoses including schizoaffective disorder.

A RN note dated 03/27/2015 at 0919 reflected "...Door was closed. [Patient] came out and went straight to the phone telling the person 'I was molested during the night.'"

A RN note dated 03/27/2015 at 1049 reflected "[Patient] overheard on the phone telling [him/her] that someone came into [his/her] room and stuck something into [his/her] penis to give [him/her] a STD."

A physician note dated 03/27/2015 at 1421 reflected "This morning awoke with reported dysuria, and came to the conclusion that [he/she] must have been sexually assaulted in [his/her] room and that staff were either complicit or allowed someone into the unit to do so. When I asked [him/her] if there was any other evidence that [he/she] saw or heard, [he/she] insisted [he/she] needs no evidence and [he/she] still intends to file a complaint...In regards to allegation of sexual assault, there is no evidence that any incident occurred, as on prior allegations."

The record reflected the patient was discharged on [DATE].

The record contained no further information reflecting an investigation had been conducted related to the patient's allegation of abuse. The record contained no documentation reflecting appropriate hospital individuals and authorities were notified including but not limited to a SANE, House Supervisor, NAC, security and risk management as required by hospital policy.

4. During an interview on 05/27/2015 at 1140 the Director of Psychiatric Services stated that a SANE was not notified and no SANE assessment was completed for the patient's allegation of abuse. The Director of Psychiatric Services stated that the only information about the patient's allegation of abuse was the documentation contained in the patient's medical record. He/she stated there was no other documentation reflecting an investigation was conducted.

5. An interview was conducted on 05/27/2015 at 1305 with the Accreditation Specialist and the Director of Psychiatric Services. The Accreditation Specialist stated that the hospital's normal process for managing an allegation of patient abuse included completion of an incident report. However, the Accreditation Specialist stated that no incident report was completed for the patient's allegation of abuse. The Accreditation Specialist further stated that no written notice was provided to the patient or the patient's representative in response to his/her complaint of abuse. The Director of Psychiatric Services acknowledged that notification of appropriate hospital individuals and authorities was not carried out in accordance with hospital policy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, documentation reviewed in the medical records of 2 of 4 patients who were physically restrained (Patients 2 and 7), and review of policies and procedures, it was determined the hospital failed to ensure physical restraints were applied in accordance with appropriate and timely physician orders.

Findings included:

1. The medical record of Patient 2 was reviewed and reflected the patient was admitted on [DATE] at 0051 for suicidal ideation.

A RN note dated 10/02/2016 at 0305 reflected "Pt continued pounding and kicking the door and the wall beside the door so physician was notified, then security assisted and pt was placed in 4 point restraints ..."

A RN note dated 10/02/2016 at 0527 reflected " ...Pt verb readiness for restraint removal ...restraints removed ..."

The record reflected the patient was discharged on [DATE] at 0529.

The record contained no physician or other LIP order for the 4-point restraints.

2. During an interview on 12/16/2016 at 1430 the Accreditation Specialist confirmed the medical record contained no physician order for the 4-point restraints.

3. The policy and procedure titled "Restraint and/or Seclusion, Use of" dated as effective "April 5, 2016," was reviewed. It stipulated that: "Initiation of Restraint or Seclusion: A registered nurse may initiate violent restraint or seclusion in advance of the LIP's order ...Upon the initiation of restraint or seclusion and immediate stabilization of the patient, the registered nurse shall consult with a responsible LIP about the patient's physical and psychological status and obtain an order (telephone or written) ..."

4. The electronic medical record of Patient 7 was reviewed on 05/27/2015 at 1410 with the Manager of Accreditation & Patient Safety and the Accreditation Specialist. The record reflected the patient was admitted on [DATE] at 0313 with diagnoses including hyponatremia, agitation and grand mal seizure.

The record reflected the patient was physically restrained with right and left wrist restraints on 02/01/2015, 02/02/2015 and 02/03/2015.

Examples included:
The "Default Flowsheet" dated 02/01/2015 at 1100 reflected "Restraint Type...Soft restraints in use...Right wrist; Left wrist..."
The "Default Flowsheet" dated 02/02/2015 at 1100 and 2000 reflected "Restraint Type...Soft restraints in use...Right wrist; Left wrist..."
The "Default Flowsheet" dated 02/03/2015 at 0200 and 0700 reflected "Restraint Type...Soft restraints in use...Right wrist; Left wrist..."

The record contained one physician order for restraints as follows: "Restraint - Non-Emergency." The order was was dated 02/01/2015 at 1319, more than two hours after the wrist restraints were in use. The order was discontinued on 02/04/2015 at 0144. There were no other physician orders for restraint in the record.

The record reflected the patient was discharged on [DATE] at 1333.

The record contained no documentation reflecting when or if the wrist restraints were removed after the order for the restraints was discontinued on 02/04/2015 at 0144.

These findings were confirmed with the Manager of Accreditation & Patient Safety and the Accreditation Specialist at the time of the record review.

5. The policy and procedure titled "Restraint and/or Seclusion, Use of" dated effective "March 2014" was reviewed. It stipulated that: "...Medical Restraint may be used for the following indications...The patient is pulling at tubes, lines or dressings...The patient's actions are endangering themselves...If the attending physician is not available...a registered nurse may initiate a restraint in advance of a physician's order...The restraint order must be obtained by the physician either during the restraint/seclusion application or immediately following the application..."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, documentation reviewed in the medical record of 1 of 2 patients who were physically restrained for management of violent or self destructive behavior (Patient 3), and review of policies and procedures, it was determined the hospital failed to ensure physician orders for restraint were renewed within four hours by a physician or other LIP as required.

Findings include:

1. The medical record for Patient 3 was reviewed. The record reflected the [AGE] year old patient was admitted on [DATE] at 1922 with a diagnosis of suicide attempt, medication overdose, and drug intoxication.

The medical record reflected an initial physician order for violent restraints was written on 10/10/2016 at 2024.

A RN note dated 10/10/2017 at 2038 reflected "Pt placed in 4 point restraints...."

A RN note dated 10/10/2016 at 2224 reflected, "Patient arrived [to ICU] in four point restraints..."

A RN note dated 10/10/2016 at 2319 reflected "Dr...in room to assess patient...Violent restraints will continue as long as the patient combative and unsafe towards self and staff."

The record reflected the restraints were discontinued on 10/11/2016 at 0354, a period of more than seven hours after the physician order for restraints was written on 10/10/2016 at 2024.

The record reflected the patient was discharged on [DATE] at 1600.

The record contained no physician or other LIP order for continuation of the restraints after the initial restraint order expired after four hours.

2. During an interview on 12/16/2016 at 1430 with the Accreditation Specialist, he/she confirmed the medical record contained no subsequent restraint order when the initial order expired after 4 hours.

3. The policy and procedure titled "Restraint and/or Seclusion, Use of" dated as effective "April 5, 2016," was reviewed. It stipulated that: "Violent RESTRAINT AND SECLUSION...The initial and all subsequent restraint orders shall expire in...4 hours for patients 18 years of age and older."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, review of documentation in 1 of 1 medical record of a patient who was physically restrained with wrist restraints and who had shackles applied (Patient 7), it was determined that the hospital failed to ensure that medical record entries were clear and complete in the following areas:
* Documentation related to application, management and use of shackles was unclear and incomplete; and
* Documentation related to when or if wrist restraints were discontinued was unclear and incomplete.

Findings include:

1. The electronic medical record of Patient 7 was reviewed on 05/27/2015 at 1410 with the Manager of Accreditation & Patient Safety and the Accreditation Specialist. The record reflected the patient was admitted on [DATE] at 0313 with diagnoses including hyponatremia, agitation and grand mal seizure.

The record reflected the patient was restrained with shackles on 02/01/2015, 02/02/2015, 02/03/2015 and 02/04/2015. Examples included:

The "Default Flowsheet" dated 02/01/2015 at 1100 reflected "Restraint Type...shackles from OSH wrist and ankles..."
The "Default Flowsheet" dated 02/02/2015 at 1100 and 2000 reflected "Restraint Type... shackles from OSH wrist and ankles..."
The "Default Flowsheet" dated 02/03/2015 at 0200 and 0700 reflected "Restraint Type ...Shackles."
The "Default Flowsheet" dated 02/04/2015 at 0800 and 1600 reflected "[topical dressing]...on ankles under shackles..."

The record also contained a "Forensic Patient Risk Assessment Form" dated 02/02/2015 at 1400 and it reflected the following: "Name of Agency Providing Security...OSH...Risk Level...Level 2- Two unarmed officers." The forensic risk assessment included no information about the use of shackles.

The record reflected the patient was discharged on [DATE] at 1333.

The record was unclear and incomplete related to what was meant by "shackles from OSH." In addition the record contained no evaluation or other information addressing the reason the patient had shackles, when the shackles were applied, who applied the shackles, when or if the shackles were discontinued/removed at any time, or who was responsible for their use, application and monitoring.

2. During an interview on 05/28/2015 at 1345 the Accreditation Specialist stated that the patient was civilly committed and was admitted from a forensic unit at another facility. The Accreditation Specialist stated that the shackles were applied before the patient came to the hospital by non-hospital employees from the other facility for security purposes. He/she further stated that the non-hospital employees from the other facility were responsible for the application and use of the shackles. The Accreditation Specialist acknowledged the record was incomplete, unclear and did not include any documentation about why the patient had shackles, when they were applied, who applied them, or who was responsible for their use, application and monitoring.

3. Refer to the deficiency cited at Tag 168, CFR 482.13(e)(5) Patient's Rights - Restraint or Seclusion. That deficiency reflects the hospital's failure to ensure the medical record of Patient 7 who had right and left wrist restraints, was clear and complete related to when or if the wrist restraints were removed from the patient after the physician order for restraints was discontinued.