HospitalInspections.org

Based on interview, record review, and policy review, the facility failed to follow their internal policy to notify patients or patient representatives, who had filed a grievance, of the expected number of days the hospital would require to resolve the grievance. This was found for 10 (#24, #55, #56, #57, #58, #59, #60, #61, #62 and #63) of 10 grievances reviewed for resolution dates and had the potential to affect any patient or patient representative who had filed a grievance. The facility census was 53.

Findings included:

Record review of the facility's policy titled, "Patient Complaint/Grievance Process" revised 12/08, showed that if resolution is not possible within seven days, a written response will be sent to the patient or patient representative that will indicate an anticipated resolution date.

Record review of 10 grievance response letters dated 03/23/11 through 08/24/11, were sent to the following patients or patient representatives:
-Patient #24
-Patient #55;
-Patient #56;
-Patient #57;
-Patient #58;
-Patient #59;
-Patient #60;
-Patient #61;
-Patient #62;
-Patient #63.
The letter stated, "We are looking into your concerns and will be responding to you in writing as quickly as possible", and showed no expected date of resolution.

During an interview on 09/30/11 at 11:00 AM, Staff B, Director of Quality Management, stated that he/she didn't realize the policy stated the original letter should indicate an anticipated resolution date, "I missed that".

Based on observation and interview the facility failed to ensure the patients on the 3 Center Unit and on 2 Center Unit had personal privacy by preventing disclosure that the patient was in the facility. The facility census was 53 with seven of those on 3 Center and 11 on 2 Center.

Findings included:

1. Observation on 09/30/11 at 9:20 AM at the 3 Center unit showed the following:
-A nurse's station adjacent to the elevator lobby.
-Visitors and staff exiting the main elevators had to walk past the nurses desk to access patient rooms on the unit.
-Staff stored the loose leaf patient medical record binders on a mobile wire rack with the binder spines facing out towards the corridor.
-The binder spine for each medical record had the last name of a patient with the corresponding room number printed in large black, one inch block lettering.
-From the visitor hallway located in front of the nurses station, the chart spines, labeled with patients full last names, were readable.

2. During an interview on 09/30/11 at 9:59 AM, Staff QQ, Director of Respiratory services stated that the wire rack was usually stored with the names facing to one side and not facing forward exposing the identity of the patients on 3 Center.


29047

3. Observation on 09/30/11 at 9:40 AM showed 2 Center nurses station had a rolling rack of 11 charts positioned approximately four feet behind the desk. From the visitors hallway, located in front of the nurses' station, the chart spines were labeled with patients full last names in black letters approximately ? to one inch in size, which were readable to anyone using the hallway.

Observation on 09/30/11 at 9:58 AM showed 2 Center staff had moved the rolling rack of 11 charts to the back wall of the nurses station, which was approximately eight feet behind the desk. From the visitor hallway, which was located in front of the nurses station, ten of the 11 chart spines labeled with patients full last names were readable.

4. During an interview on 09/30/11 at 10:02 AM, Staff M, Registered Nurse (RN) stated that the rolling cart, containing the charts with patient names should be turned around so that the labeled spines of the chart aren't visible to the public. Staff M then instructed a staff member to remove the current labels on the chart and replace them with patient stickers, which were unreadable from a short distance.

Based on observation, interview, and record review, the facility failed to ensure that patients were removed from restraints when the patient no longer posed a safety concern to him/herself for two (#21 and #24) of two patients who were restrained while sedated. This had the potential to affect any patient in the hospital who was sedated and restrained.

The facility census was 53.

1. Record review of the facility's policy titled "Use of Physical or Chemical Restraints" revised on 06/11, showed that:
-Restraints were not to be used as a means of convenience;
-All orally and nasally intubated (a means for artificial breathing) patients would be placed in physical restraints for safety;
-Restraints may only be used while an unsafe situation exists and that once the unsafe situation ends, the use of the restraint should be discontinued;
-A chemical restraint is a drug or medication that is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement.

2. Observation on 09/27/11 at 9:55 AM showed Patient #21 on a ventilator, sedated with Propofol (sedative), and with both wrists in restraints. The patient's eyes were closed and he/she did not respond to sound or touch.

During an interview on 09/27/11 at 10:05 AM, Staff X, Registered Nurse (RN), stated that all patients who are intubated with an Endotracheal Tube (ETT - a tube that passes through the mouth and into the lungs) are physically restrained as a standard of care.

Record review of Patient #21's current medical record showed that sedation was initiated on 09/25/11 at 1:45 PM. The patient was placed in wrist restraints on 09/26/11 at 8:00 AM, indicating that the patient did not require physical restraints while sedated for 18 hours after he/she was intubated. Documentation showed that when the patient was placed in restraints, he/she was quiet and cooperative and remained quiet and cooperative until 8:00 PM, when the patient became restless. During this time, the patient's Propofol dosage was increased from 19.7 mcg/kg/min to 40 mcg/kg/min. Further documentation showed that from 09/27/11 at 2:00 AM until 09/29/11 at 10:00 AM, the patient rested quietly and remained cooperative, in restraints, while the sedation dosage was increased to 45 mcg/kg/min. On 09/28/11, a restraint progress note indicated that the patient was restrained to maintain life safety, lines, and tubes per protocol, because of the ETT.

Observation on 09/29/11 at 10:40 AM showed Patient #21 was restrained and sedated and opened his/her eyes when asked, but the patient did not move.

During an interview on 09/29/11 at 10:45 AM, Staff V, RN, stated that the Propofol dose for Patient #21 (currently at 45 mcg/kg/min) was a higher dose than "we like to see". Staff V stated that Patent #21 was a "3" (respond to commands only) on the Modified Ramsey Scale (used to monitor sedation) but "we like to see them at a 2" (Cooperative, oriented, tranquil,
accepts mechanical ventilation). Staff V added that it was a standard of practice to sedate and restrain patients so they don't pull out their ETT.

During an observation on 09/29/11 at 11:10 AM, Staff V explained to Patient #21 that he/she was receiving a dose of Prednisone (steroid). Patient #21 did not open his/her eyes or respond, but was restrained.

During an interview on 09/29/11 at 11:15 AM, Staff TT, Physician, stated Patient #21 was sedated and restrained to prevent the patient from removing his/her ETT. The physician stated Patient #21 may have been able to be removed from restraints while on Propofol, but was left in them because the patient becomes more alert during the afternoon. While reviewing documentation of the patient's minimal activity level and increased sedation dosage, Staff TT stated, "we may have some documentation issues", indicating that current documentation may not support the need for or reason why the patient's were in restraints. Staff TT added that the hospital does not sedate and restrain all patients who are ventilated (means of artificial breathing) and that although he/she signs the order for the restraints, the nurse decides who needs restraints.

During an interview on 09/29/11 at 2:30 PM, Staff D, Chief Clinical Officer (CCO) stated that all patients with ETT's are restrained. Staff D added that he/she was unable to determined why Patient #21's Propofol was continually increased, and agreed that based on the documentation in the patient's record, the Propofol could have been decreased.

Observation on 09/30/11 at 9:25 AM showed that Patient #21 continued to be restrained and sedated and only moved his/her head to respond to "Good Morning".

3. Record review of an internal facility investigation dated 07/29/11, showed a patient representative of Patient #24 filed a grievance with the facility regarding multiple care issues, which included over sedation of the patient while the patient was restrained. During the facility investigation of the grievance, a nursing manager observed Patient #24 (who was on a ventilator) on 07/20/11, and found the patient in wrist restraints and sedated to the point that the patient could not respond to voice or touch. Documentation of the investigation showed that the manager immediately removed the patient from restraints and instructed the nursing staff to contact the physician to find a less sedating medication. The outcome of the investigation found the concerns voiced in the grievance were substantiated. Education to nursing staff regarding appropriate restraint use during sedation, sedation levels, and documentation occurred during August, 2011 staff meetings. Additionally, attending physicians were included in weekly team meetings, which includes round table discussions about patients sedation, medications, and restraints.

Based on observation, interview and policy review the facility failed use a safe restraint technique when it failed to secure wrist restraints with a quick release tie as determined by hospital policy in one (#30) of three patients. The facility also failed to follow their policy related to the assessment of and care provided to patient's in restraints for four (#18, #22, #24, and #27) of eight patient's who were restrained. This had the potential to cause injury or neglect to the patient and could affect all patient's placed in restraints.

The facility census was 53.

Findings included:

1. Review of a policy titled, "Use of Physical or Chemical Restraints," Policy Number H-PC 05-010, Effective Date 09/1993, Revised Date 06/2011 included:
-Purpose: To delineate the responsibilities and procedural steps to be followed by Clinical and Medical Staff for the use of restraints in compliance with Hospital policy, Joint Commission standards and the Medicare Conditions of Participation;
-Section II; Non-Emergency Use of Restraints; Physical; A) Nursing; #2(b): Apply the restraint gently and fasten securely to the bed frame. Fasten using a quick release tie. Restraint should never be fastened using a knot.

2. During an observation on 09/28/11 at 1:50 PM, Staff A, Registered Nurse, (RN) Supervisor, attempted to release Patient #30's soft wrist restraints on both wrists, but the restraints would not release due to being tied in a knot.

During an interview on 9/28/11 at 1:50 PM, Staff A, RN, confirmed all wrist restraints are to be tied with a quick release tie that releases in one pull. Staff A confirmed the patient's wrist restraints failed to be tied with a quick release knot.

Failure to use a quick release tie can delay or prevent the patient from being moved quickly in the event of an emergency and may result in patient injury or death.


29047

3. Record review of the facility's policy titled "Use of Physical or Chemical Restraints" revised on 06/11, showed that documentation on the Restraint Flow Sheet should include assessment of the patient and care perforned, every two hours.

4. Record review of the facility's "Restraint Flow Sheet" showed that the patient's current activity and assessment of the restrained extremity should be documented by the RN / Licensed Practical Nurse (LPN) every two hours and that the Certified Nurse Aide (CNA) should document care performed every two hours. Care performed included documentation that the patient was released from restraints, repositioned, that the call light was in reach, that personal hygiene was performed, and that toileting, oral care, nutritional needs, and hydration needs were all met.

5. Record review of Patient's #18's current medical record showed missing documentation on the patient's wrist Restraint Flow Sheet for:
-Assessment of the patient's activity and restrained extremities on 09/24/11 from 8:00 AM until 6:00 PM;
-Care performed on 09/24/11 from 12:00 PM until 6:00 PM;
-Care performed on 09/25/11 from 8:00 AM until 8:00 PM.

6. Record review on 09/27/11 at 2:44 PM of Patient's #22's current medical record, showed missing documentation on the patient's wrist Restraint Flow Sheet for:
-Care performed on 09/24/11 from 8:00 AM until 8:00 PM;
-Care performed on 09/25/11 from 8:00 AM until 8:00 PM;
-Care performed on 09/27/11 from 8:00 AM until 2:00 PM.

7. Record review of Patient #27's closed medical record showed missing documentation on the patient's wrist Restraint Flow Sheet for:
-Care performed on 07/10/11 from 8:00 AM until 8:00 PM;
-Assessment of the patient's activity, restrained extremities, and care provided on 07/20/11 from 8:00 AM until 8:00 PM;
-Assessment of the patient's activity and restrained extremities on 07/22/11 from 2:00 PM until 8:00 PM;
-Assessment of the patient's activity and restrained extremities on 07/24/11 at 6:00 AM and at 6:00 PM;
-Care performed on 07/24/11 from 12:00 AM until 8:00 AM.

8. Record review of Patient #24 closed medical record showed that on 07/17/11 from 8:00 AM until 8: PM, there was no documentation of assessment of the patient's activity and restrained extremities, or care perfomed.

9. During an interview on 09/29/11 at 2:30 PM, Staff D, Chief Clinical Officer (CCO) stated that patient care staff should document the assessment of the patient every two hours, but stated that the documentation (while reviewing patient restraint records) was inconsistant.

Based on policy review, observation, record review and interview the facility failed to provide adequate supervision of patient care by nursing as evidenced by numerous failures to respond to call lights in a timely manner for seven patients (#12, #13, #15, #26, #39, #53 and #54) of seven records (3 current, 4 discharged) reviewed for this concern and inconsistent/incorrect documentation of fall risk assessment for two patients (#3 and #39) (one current, one discharged) reviewed for this concern. These failure had the potential to affect all patients. The facility census was 53.

Findings included:

1. Review of facility policy H-PC 03-006, titled "Patient Call Devices" dated 05/2009, gave staff direction to assure that there is a functional call light easily accessible to the patient and to evaluate the patient's ability to use the standard call light. The policy does not outline the facility's expectation for response time when a call light is activated or who is responsible to respond to the call light.

2. During an interview on 09/26/11 at 2:00 PM current Patient #13 stated that he/she is very well taken care of but it can take up to 30 minutes for staff to respond to call light. Patient #13 was able to demonstrate how to initiate the call light.

3. During an interview on 09/26/11 at 2:30 PM current Patient #12 stated that sometimes it takes as long as 45 minutes for staff to respond to call light. Patient # 12 stated that he/she is happy with care at facility but the call light response time is a problem.

4. During an interview on 09/27/11 at 10:15 AM current Patient #15 stated that he/she has waited as long as 30 minutes for staff to respond to call light. Patient #15 stated that everyone is very busy.

5. Record review of facility Grievance Log showed that 12 of 69 grievances entered from 04/01/11 to 08/31/11 were based on response time to call lights.

6. Record review of facility's investigation of four actual grievances contained print outs from "Room Call Transaction Report" (system that electronically records when a call light is activated and when a staff responds to deactivate the light. The system can print out a report on all call light activity) which showed in part:

-Patient #26 response times to call light request:
08/16/11: 9 minutes 29 seconds, 11 minutes 30 seconds, 12 minutes 53 seconds, 35 minutes 33 seconds;
08/15/11: 8 minutes 11 seconds, 11 minutes 12 seconds,
-Patient #53 response times to call light requests:
05/30/11: 20 minutes and 12 seconds, 06/01/11: 17 minutes 55 seconds, 17 minutes 40 seconds, 17 minutes 55 seconds, 12 minutes 9 seconds, 9 minutes 49 seconds, 8 minutes 54 seconds;
06/04/11: 25 minutes 51 seconds, on 06/06/11: 10 minutes 14 seconds;
06/07/11: 12 minutes 36 seconds,12 minutes 21 seconds, 11 minutes 1 second, 15 minutes 21 seconds, 9 minutes 8 seconds, on 06/08/11: 11 minutes 31 seconds, 9 minutes 30 seconds, 9 minutes 10 seconds;
06/09/11: 19 minutes 32 seconds, 9 minutes 14 seconds.
-Patient #39 response times to call light requests:
05/07/11: 19 minutes 31 seconds, 10 minutes 48 seconds;
05/08/11: 12 minutes 20 seconds, 37 minutes 32 seconds;
05/10/11: 16 minutes 57 seconds.
-Patient #54 response times to call light requests:
03/01/11: 23 minutes 6 seconds, 12 minutes 15 seconds;
03/02/11: 20 minutes 43 seconds, 10 minutes 1 second;
03/03/11: 9 minutes 55 seconds;
03/05/11: 12 minutes 3 seconds, 18 minutes 51 seconds, 12 minutes 21 seconds;
03/06/11: 24 minutes 38 seconds, 18 minutes 11 seconds;
03/07/11: 10 minutes 36 seconds, 16 minutes 6 seconds;
03/08/11: 15 minutes 29 seconds, 17 minutes 12 seconds, 13 minutes 32 seconds;
03/09/11: 24 minutes 6 seconds, 10 minutes 56 seconds, 10 minutes 4 seconds;
03/10/11: 13 minutes 14 seconds, 16 minutes 42 seconds, 10 minutes 45 seconds;
03/11/11: 24 minutes 5 seconds, 12 minutes 55 seconds;
03/14/11: 21 minutes 48 seconds;
03/15/11: 37 minutes 49 seconds.

7. During an interview on 09/29/11 at 1:35 PM Staff D, Chief Clinical Officer, stated that it is the facility's expectation that all call lights are responded to within five minutes. Staff D stated that it is everyone's responsibility. Staff D stated that there is no ongoing monitoring of call light response times; the reports would be printed if there was a complaint. Staff D stated that ultimately it is the nurses responsibility to ensure the patient's are responded to and that disciplinary action would be taken if a problem is uncovered.

8. Review of facility policy H-PC 05-016, titled "Fall Prevention" revised 11/10, showed the following direction:
A fall risk assessment (This is an electronic form containing a series of questions about patient's condition which the nurse answers. Each response gets a numeric score. The scores are then totaled) score of greater than or equal to 10 puts patient in "At Risk" category and a variety of interventions should be considered. If a patient has a previous history of a fall that should result in an automatic score of at least 10 and the patient should be placed in "At Risk" category. Patients identified as "AT Risk" for falls via the "Falls Risk Assessment" will have an interdisciplinary care plan initiated by the registered nurse.

9. Record review of Patient #39's closed medical record showed:
- On 04/05/11 the nursing admission assessment placed patient at a score of 11 (indicating patient was in the "At Risk" category).
- On 04/11/11 the patient experienced a fall;
- On 04/13/11 the nursing fall risk assessment score was 5;
- On 04/20/11 the nursing fall risk assessment score was 6;
- On 04/27/11 the nursing fall risk assessment score was 5 or 2 (completed by two different nurses);
- On 04/28/11 at 5:07 AM the patient experienced another fall;
- On 04/29/11 the care plan reflects the first initiation of "Potential for injury related to history of previous falls";
- On 04/30/11 the nursing fall risk assessment score was 15;
- On 05/05/11 the nursing fall risk assessment score was 21;
- On 05/12/11 the nursing fall risk assessment score was 3;

10. Record review of current Patient #3's medical record showed the following:
- On 09/08/11 the nursing fall risk assessment score was 2;
- On 09/14/11 the nursing fall risk assessment score was 6;
- On 09/19/11 the patient experienced a fall;
- On 09/21/11 the nursing fall risk assessment score was 16; and
- On 09/28/11 the nursing fall risk assessment score was 2.

11. During an interview on 09/29/11 at 1:35 PM Staff D, Chief Clinical Officer, stated that the facility is aware of inconsistent documentation on the "Fall Risk Assessments" and that the corporate office is working on software to ensure automatic population of certain fields. Staff D stated that currently there are no ongoing audits of this documentation except upon admission. Staff D stated that the facility is considering a new form to make sure shift-to-shift reporting is consistent.