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.
| COLUMBIA MEMORIAL HOSPITAL | 71 PROSPECT AVENUE HUDSON, NY 12534 | July 7, 2022 |
| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0173 | |
| Based on record review and interview, the facility failed to renew restraint orders at least every twenty-four hours for 1 of 1 patients (Index patient # 1) reviewed during the complaint investigation survey. Findings: -Review of the index patient's medical record conducted off site on 3-29-22 revealed that the patient was restrained intermittently in a vest restraint from 3-12-21 at 11:55 AM to 3-22-21 at 11:32 AM. -An initial physician order for restraint was written on 3-12-21 at 11:55 AM for safety. -The renewal order for 3-14-21 was timed 16:22, 5 hours past due. -The vest restraint was discontinued on 3-15-21 at 11:12 AM; a new physician order for vest restraint was written at 5:37 PM for fall risk. This order was renewed on 3-16-21 at 2:10 PM. -The patient then remained in the vest restraint from 3-16-21 at 2:10 PM until 3-22-21 at 11:32 AM without daily restraint renewal orders in place. -Review of facility policy entitled: "Restraints", conducted on 3-29-22, indicates that the restraint order should have been renewed every 24 hrs. per the facility's policy. -Interview with the facility Chief Operating Officer, on 7-7-22 at 10:15 AM confirmed the findings. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0175 | |
| Based on record review and interview, facility nursing staff failed to document reassessments and safety checks in the patient's medical record in accordance with facility policy for 1 of 1 patients (Index patient # 1) reviewed during the complaint investigation survey. Findings: -Review of the index patient's medical record conducted off site on 3-29-22, revealed that the patient was restrained intermittently in a vest restraint from 3-12-21 at 11:55 AM to 3-22-21 at 11:32 AM. Nursing documentation of reassessments and safety checks were lacking on the following dates/times: On 3-12-21-there was no documentation until 8 PM; the patient was placed in a vest restraint at 11:55 AM on 3-12-21. On 3-13-21 documentation at 5:28 AM and not again until 08:15 AM. On 3-13-21-there was documentation at 5:46 PM and not again until 9:16 PM and then not until midnight on 3-14-21. On 3-14-21 documentation at 6:00 PM and not again until 10:32 PM. On 3-15-21 documentation at 8:00 AM and not again until 5:47 PM. On 3-21-21 documentation at 4:00 AM and not again until 08:00 AM. -Review of facility policy entitled: Restraints, conducted on 3-29-22, indicates that for patients in restraints, nursing staff are required to reassess and document every 2 hours as well as conduct and document safety checks every 30 min which can be documented at the end of the shift. -Interview with the facility Chief Operating Officer, on 7-7-22 at 10:15 AM confirmed the findings. |
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