HospitalInspections.org

Based on records reviewed and interviews the Hospital failed to ensure documentation of Physician training regarding the use of restraint or seclusion.

Findings included:

The Hospital policy titled Restraint and Seclusion for Non-Behavioral Health Units, dated 2/17/2017 indicated training of staff included Physicians and Licensed Independent Practitioners (LIPs) who ordered restraint or seclusion were trained in the requirements of this policy and demonstrate a working knowledge of this policy through periodic assessment of compliance.

Physician Assistant (PAs #1 & #2) Credential Files indicated restraint training, however.

The Surveyor interviewed the Chief Medical Officer at 1:30 P.M. on 10/27/2020. The CMO said the Hospital did not have documentation of Physician training regarding the use of restraint or seclusion.

Based on records reviewed and interviews the Hospital failed to ensure for one patient (Patient #1) of ten sampled patients, identification of Quality Assessment and Performance Improvement (QAPI) opportunities following a Patient Care Grievance, conveyed to the Hospital regarding three Nursing Assistants (CNA #1, CNA #2 & CNA #3) and one Physician Assistant (PA #2).

Findings included:

The Hospital Report, dated 5/27/2020 indicated a Patient Care Grievance that included allegations that three Nursing Assistants and one Physician Assistant (PA #2) did not provide Patient #1 with compassionate, dignified and respectful care.

The Hospital Report, dated 5/27/2020, indicated the Grievance Committee met and no additional actions were suggested.

1.) The Hospital failed to ensure Quality Assessment and Performance Improvement activities were identified and implemented following patient care issues involving CNA #2 & CNA #3).

The Hospital policy titled Patient's Rights and Responsibilities, dated 5/22/2018, indicated the patient had the right to receive considerate, response and compassionate care in a safe setting regardless of the Patient's age, gender, raced, national origin, religion, sexual orientation gender identity or disabilities.

The Surveyor interviewed the Chief Nursing Office (CNO) at 12:00 P.M. on 10/27/2020. The CNO said that the Resource Nurse provided CNAs #2 & #3 with Appreciative Coaching (a shared experience between the Resource Nurse and the CNA to collaborate, improve patient care, discover and support actions for success). The CNO said the Hospital did not have notes regarding Appreciative Coaching provided to CNAs #2 & #3 (regarding the care and communication delivered to Patient #1 that was expressed in the Patient Care Grievance) as required by the Hospital. The CNO said that the Hospital did not analyze if CNA #2 and or CNA #3 required performance improvement activities (regarding their patient care skills or patient communication) or monitoring (to ensure Patient #1's Patient Rights to dignity were respected).

The Surveyor interviewed the Human Resources Director at 1:00 P.M. on 10/27/2020. The Human Resources Director said that Appreciative Coaching with Hospital employees should be documented in the Manager's records. The Human Resources Manager said the Hospital did not provide re-education to the staff on the unit or the house (Hospital).

The Job Description titled Resource Nurse (Nurse Educator/Projects), dated 6/2016, did not indicate Appreciative Coaching as a requirement or performance criteria.

2.) The Hospital failed to ensure communication for opportunities for improvement following a Patient Care Grievance conveyed to the Hospital, regarding resuscitation (end-of-live interventions) directives (wishes) provided by PA #2 to Patient #1's guardian.

The Hospital Report, dated 6/2/2020, indicated Physician Assistant (PA #2) did not provide Patient #1's guardian with compassionate care when discussing resuscitation directives regarding Patient #1.

The Surveyor interviewed the Chief Medical Officer at 1:30 P.M. on 10/27/2020. The Chief Medical Officer said that it was the Hospital obligation to ask all patients or patient guardians regarding resuscitation directives. The Chief Medical Officer said that he/she did not speak with PA #2 regarding the Patient Care Grievance received by the Hospital concerning PA #2's conversation about Patient #1's resuscitation directives.

3.) The Hospital failed to ensure opportunities for improvement following the Patient Care Grievance submitted to the Hospital regarding Patient #1 and staff concerns regarding the use of an iPad.

The Surveyor interviewed Registered Nurse #1 at 11:30 A.M. on 10/23/2020. Registered Nurse #1 said the Hospital and Staff had concerns with Patient #1's family using an iPad to monitor Patient #1 all the time as an alternative to visitation that was restricted during the surge of the COVID-19 viral pandemic. Registered Nurse #1 said that the Hospital had concerns for Patient #2's privacy (Patient #1's room mate) and that staff could not be available all the time, to ensure Patient #2's privacy if the iPad was on all-the-time. Registered Nurse #1 said the Hospital did not have a written policy or document to guide staff and families (by the time of the Survey).

The Surveyor interviewed Registered Nurse #2 at 12:30 P.M. on 10/23/2020. Registered Nurse #2 said that the Hospital did not have many private patient rooms and to protect patient privacy, the Hospital should be more specific and have clear guidelines for the use of the iPad (during COVID-19 visitation restrictions).

The Hospital Report, dated 5/27/2020, indicated that the iPad should not be used for twenty-four hour (patient) surveillance (observation).

The Hospital provided no documentation of dissemination to staff, patients nor patient families, the Hospital's expectations regarding clear and specific use of the iPad for patient and family visitation purposes during COVID-19 visitation restrictions, by the time of the Survey.

4.) The Hospital failed to have a Quality Assessment and Performance Improvement Plan and the contracted staff traveler agency, specific to the Hospital as a single and distinct entity, separate of the Steward Health Care System, Inc.

4A.) The document titled Steward Health Care System, Inc. Patient Safety & Performance Improvement Plan, Services Patient Care Assessment Plan, effective for the Calendar Year 2015-2020, dated 3/2015, indicated no documentation of New England Sinai's Quality Improvement Plan as a single and distinct entity, separate of the Steward Health Care System, Inc.

Board of Directors Meeting Minutes, dated 8/18/2020, indicated the Chief Medical Officer presented the New England Sinai Hospital Quality and Patient Safety Plan 2020-2021 and summarized the quality assessment and reporting standards of the plan.

The Surveyor interviewed the Chief Executive Officer (CEO) at 1:30 P.M. on 10/23/2020. The CEO said the Hospital used the Corporate (Steward Health Care System Patient Safety & Performance Improvement Plan.

The Hospital provided no document to indicate the Hospital had a Quality Assessment and Performance Improvement Plan as a single and distinct entity, separate of the Steward Health Care System, Inc. to ensure the Hospital's Governing Body was responsible and accountable for ensuring the Hospital's ongoing QAPI Program for quality improvement, patient safety, and that reduction of medical errors, were defined, implemented, and maintained.

4B.) The Hospital failed to ensure responsibility for the contracted staff traveler agency (Cambay Consulting LLC) following the Patient Care Grievance regarding CNA #1's patient care issues, through its QAPI Program.

The Contract titled Master Agreement for Staffing Services between Steward Health care System, LLC located in Dallas, Texas and Cambay Consulting LLC, dated 4/6/2020, indicated an agreement for temporary staffing services. The Master Agreement for Staffing Services indicated a signature representing the Human Resources Executive Vice President for Steward Health care Systems, LLC. The Master Agreement for Staffing Services indicated no documentation of agreement with the Hospital, therefore generating no clear responsibilities to the Hospital Governing Body for Quality Assessment & Performance Improvement activities of the contracted service.

The Surveyor interviewed the Quality and Risk Manager at 9:00 A.M. on 10/27/2020. The Quality and Risk Manager said that he/she did not know if the Hospital would continue to use the staff traveler agency following the Hospital's determination to terminate CNA #1's services.

The Surveyor interviewed the CEO at 10:30 A.M. & 4:15 P.M. on 10/27/2020. The CEO said that he/she did not review the staff traveler agency Contract and that it was the Corporation (Steward Health Care System, Inc.) Human Resource contract.

The CNO said that the Corporation arranged the staff traveler agency contract (during the surge of the COVID-19 pandemic).

The Surveyor interviewed the Human Resources Director at 1:00 P.M. on 10/27/2020. The Human Resources Director said the Corporation signed the contract (for additional staff during the COVID-19 pandemic patient surge).