HospitalInspections.org

Based on Patient Handbook review and interview, it was determined the facility failed to provide patients with the address of the State Agency. The failed practice did not provide patients with information needed to file a grievance with the State Agency and could affect any patient needing to file a grievance. Findings follow.

A. Review of the Patient Handbook and other materials provided by the facility that are given to the patient did not contain the address of the State Agency.

B. During an interview on 01/02/13 at 1005, the Director of Patient Care Services stated, "I don't think we provide them (patients) with that information."

Based on policy review and interview, it was determined the facility failed to include in their policies a provision for protection of the patient during an abuse allegation investigation. The failed practice did not ensure the safety of the patient while the investigation was being conducted and could affect any patient making an abuse accusation. Findings follow.

A. Review of the Associate Standards of Conduct policy stated only information involving the investigation itself and did not address patient protection.

B. Findings were confirmed by the Director of Patient Care Services on 01/02/13 at 1115.

Based on clinical record review, it was determined the facility failed to ensure restraint orders specified the type of restraint for three (#3, #9 and #10) of four (#3, #4, #9 and #10) patients in restraints. The failed practice did not ensure the type of restraint used was the least restrictive and did not provide staff with information needed to know what type of restraint to apply. The failed practice could affect any patient with orders for restraints. Findings follow.

A. Patient #3 had three restraint orders. All three did not specify the type of restraint to be used. Findings were confirmed by the Director of Patient Care Services on 01/03/13 at 1100.

B. Patient #9 had two restraint orders. Both did not specify the type of restraint to be used. Findings were confirmed by the Director of Patient Care Services on 01/03/13 at 1100.

C. Patient #10 had 172 restraint orders. Twenty five of those orders did not specify the type of restraint to be used. Findings were confirmed by the Director of Patient Care Services on 01/03/13 at 1315.

Based on review of policies and clinical records, it was determined the facility failed to ensure restraint orders were signed within appropriate time frames for one (#4) of four (#3, #4, #9 and #10) patients in restraints. The failed practice did not ensure the patient was being monitored by a qualified licensed practitioner and had the potential to affect any patient in restraints. Findings follow.

A. Review of the clinical record of Patient #4 revealed the patient had orders for restraints on eight days (12/26/12, 12/27/12, 12/28/12, 12/29/12, 12/30/12, 12/31/12, 01/01/13 and 01/02/13). None of the orders were signed by the physician.

B. Review of the medical records policy titled "Authentication of Verbal Orders" stated, "verbal orders must be authenticated within 48 hours".

C. Review of the nursing policy titled "Physician's Orders" stated telephone orders must be "signed within 24 hours by the physician". The facility's Medical Staff Bylaws did not specify a time frame for having verbal/telephone orders signed.

D. The Restraint policy stated, "The physician/LIP (Licensed Independent Practitioner) will complete the Doctor's Order section of the Restraint Order Form by signing, dating and timing the order."

E. Findings were confirmed by the Director of Patient Care Services on 01/03/13 at 1100.

Based on clinical record review, it was determined the facility failed to ensure a new restraint order was obtained each time a patient was released, then placed back in restraints. Failure to ensure current restraints orders were in place for each episode of patient restraint allowed Patient #10 to essentially be restrained without a physician's order. Findings follow.

A. Review of Patient #10's restraint orders and monitoring forms revealed the following:
1) Restraint order on 04/29/12 at 0700, was not placed in restraints until 04/29/12 at 2000.
2) Restraint order on 05/02/12 at 0700, was not placed in restraints until 05/02/12 at 2130.
3) Restraint order on 05/03/12 at 0700, was not placed in restraints until 05/03/12 at 2000.
4) Restraint order on 07/18/12 at 0700, was not placed in restraints until 07/18/12 at 2000.
5) Restraint order on 08/26/12 at 0700, was not placed in restraints until 08/26/12 at 1930.
6) Restraint order on 09/04/12 at 0700, was not placed in restraints until 09/04/12 at 1900.
7) Restraint order on 09/28/12 at 0700, was not placed in restraints until 09/28/12 at 1500.
8) Restraint order on 10/05/12 at 0730, was not placed in restraints until 10/05/12 at 1500.

B. Findings were confirmed on 01/03/13 at 1315 by the Director of Patient Care Services