HospitalInspections.org

.
Based on interview, record review, and review of hospital policies and procedures, the hospital failed to develop and implement an effective process to ensure that patients were advised of their right to formulate an advance directive for 5 of 5 patient records reviewed (Patient #501, #502, #503, #504, and #505).

Failure to obtain direction for life-sustaining treatment could result in resuscitating a patient and/or prolonging the patient's life against the patient's wishes.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Advance Directives, 300.00," policy number 10773953, revised 12/21, showed the following:

a. CHI Franciscan Health will provide each adult inpatient with information about their rights under Washington State law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives.

b. At the time an individual is admitted as an inpatient, the registrar shall inquire if the patient has an advance directive. If the patient has an advance directive, the registrar shall insert the type in the electronic health record.

c. Although federal law only requires the advance directive status of inpatients, whenever possible, outpatients who are in the Emergency Department, who are in Observation status, or who are undergoing same day surgery or procedure will be asked their status at the time of registration as an opportunity to increase the awareness and the importance of an advance directive.

d. The registrar shall inform the patient/family that written information pertaining to the patient's right to make decisions is available. If the patient/family would like some information the registrar can provide the patient with a Decisions booklet that describes Living Will and a Healthcare Power of Attorney. The booklet includes these forms. If information is provided, this is noted in the electronic health record.

e. In addition to the registration record, information regarding the status of the advance directive is documented in the electronic health record nursing admission assessment, unless otherwise specified by unit standards.

f. The plan of care should note the status and availability of the advance directive. The presence of an advance directive is noted on the patient Storyboard under the patient's name. This should match the Registered Nurse's (RN) assessment of advance directives in the RN admission assessment.

2. On 02/06/23 at 10:58 AM, Surveyor #5 and the Infection Control Program Manager (Staff #508) reviewed the medical record for Patient #502 who was admitted to the Emergency Department on 02/05/23 at 12:20 PM for the treatment of failure to thrive, hypertension and bilateral foot pain. The patient was admitted to the hospital on 02/06/23 at 7:58 AM but was receiving inpatient care in the Emergency Department.

The medical record demographics showed that the patient was last asked about advance directives on 08/25/17. Surveyor #5 found no evidence the patients advance directive status and availability were updated/current.

3. On 02/06/23 at 1:57 PM, Surveyor #5 and an Educator (Staff #505), reviewed the medical record for Patient #501, who presented to the Emergency Department on 02/05/23 at 12:08 PM, for the treatment of Atrial Fibrillation with a Rapid Ventricular Rate. The patient was admitted to an inpatient telemetry bed on 02/05/23 at 4:59 PM, but was receiving inpatient care in the hospital's Emergency Department.

Surveyor #5 found no evidence the patients advance directive status and availability were addressed by hospital admission staff or nursing staff on admission.

4. On 02/06/23 at 3:45 PM, Surveyor #5 and an Educator (Staff #505), reviewed the medical record for Patient #503, who presented to the Emergency Department on 02/05/23 at 7:54 PM, for the treatment of alcohol intoxication, abdominal pain, and hypertension. The patient was admitted to an inpatient bed on 02/05/23 at 11:07 PM but was receiving inpatient care in the hospital's Emergency Department.

Surveyor #5 found no evidence the patients advance directive status and availability were addressed by hospital admission staff or nursing staff on admission.

5. At the time of the review, Staff #505 verified the finding, stated that advance directives are the responsibility of both nursing and registration, and that she would follow up to see if there was anywhere else in the medical record where advance directives could be documented.

6. On 02/07/23 at 9:16 AM, Surveyor #5 and an Educator (Staff #505), reviewed the discharged medical record for Patient #504, who presented to the Emergency Department on 01/31/23 at 10:10 AM, for the treatment of a slow heart rate and heart arrhythmia (bradycardia with a right bundle branch block and Atrial ventricular disassociation), with a history of lung cancer with current metastasis, liver cirrhosis, and Hepatitis C. The patient was admitted to an inpatient bed on 02/05/23 at 11:48 AM but was receiving inpatient care in the hospital's Emergency Department.

Surveyor #5 found no evidence the patients advance directive status and availability were addressed by hospital admission staff or nursing staff on admission.

7. On 02/07/23 at 10:17 AM, Surveyor #5 and an Educator (Staff #505), reviewed the discharged medical record for Patient #505, who presented to the Emergency Department on 01/28/23 at 5:19 PM, for the treatment of dizziness. The patient was admitted to an inpatient bed on 02/05/23 at 11:48 AM and then changed to observation on 01/28/23 at 7:19 PM. The patient was receiving care in the hospital's Emergency Department.

Surveyor #5 found no evidence the patients advance directive status and availability were addressed by hospital admission staff or nursing staff on admission.

8. At the time of the review, Staff #505 verified the finding and stated that advanced directives should be addressed when patients are admitted.

.

.


Based on record review, interview, and review of hospital policy and procedures, the hospital failed to modify the patient's plan of care after placing patients in restraints or seclusion for 1 of 1 records reviewed (Patient #501).

Failure to modify care plans for patients in restraints or seclusion puts patients at risk of harm by not meeting their physical and emotional needs.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion Policy," policy number 964.00, revised 02/21, showed that the Registered Nurse (RN) will modify and individualize the Plan of Care upon initial application of restraints and daily to reflect monitoring and care required for safe use of restraints.

2. On 02/06/23 at 1:57 PM, Surveyor #5 and an Educator (Staff #505) reviewed the medical record for Patient #501 who presented to the Emergency Department on 02/05/23 at 12:08 PM, for the treatment of Atrial Fibrillation with a Rapid Ventricular Rate. The patient was admitted to an inpatient telemetry bed on 02/05/23 at 4:59 PM but was receiving this inpatient care in the hospital's Emergency Department. The medical record showed the following:

a. On 02/06/23 at 7:13 AM, a provider note showed that the patient was experiencing shortness of breath and substernal chest pain. The provider note diagnosed the patient with congestive heart failure exacerbation and bilateral pleural effusions. The note stated that the patient lived at home independently and that she had baseline confusion with paranoia that was normal for the patient. The patient did not take any medications.

b. On 02/06/23 at 5:45 AM, a nursing note stated, "Patient getting agitated, trying to hit staff, and messing with medical equipment, 1 mg Ativan given as ordered."

c. On 02/06/23 at 7:00 AM, a nursing note stated, "Patient extremely combative and refusing to keep nasal cannula on. Patient placed in soft limb restraint to left upper extremity and right upper extremity. Attempted to contact MD (medical doctor) with no response. Next shift Registered Nurse (RN) made aware."

d. On 02/06/23 at 7:50 AM, a nursing note stated, "This RN received report from previous RN. Report then given to Staff #501 for patient to be taken over to boarding side. This RN had minimal involvement in patient care. Dr. (Staff #502) made aware of patient remaining in soft wrist restraint due to confusion, agitation, and interfering with required care."

Surveyor #5 found no evidence the patients care plan was updated to reflect restraint.

3. On 02/06/23 at 3:14 PM, during interview with Surveyor #5, the patient's Registered Nurse (Staff #501), stated that she had removed the patient from restraint sometime between 9:45 AM and 10:00 AM. Staff #501 verified that there was no documentation of patient restraint at all including updating the patients care plan.


.

.
Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure that staff members assessed and monitored patients while in restraints or seclusion as directed by the hospital's restraint policy, as demonstrated by 2 of 7 patient records reviewed (Patient #301 and #501).

Failure to follow approved policies and procedures for restraint or seclusion use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion Policy, 964.00," PolicyStat ID number 12719679, Last approved 12/22, showed that patients placed in restraints or seclusion for violent or self-destructive behavior requires documentation of psychological status, circulation, and signs of injury every 15 minutes. The patient will be continuously observed, and the Registered Nurse (RN) may delegate this task to trained staff.

2. On 02/06/23 at 1:57 PM, Surveyor #5 and an Educator (Staff #505) reviewed the medical record for Patient #501 who presented to the Emergency Department on 02/05/23 at 12:08 PM, for the treatment of Atrial Fibrillation with a Rapid Ventricular Rate. The patient was admitted to an inpatient telemetry bed on 02/05/23 at 4:59 PM but was receiving this inpatient care in the hospital's Emergency Department. The medical record showed the following:

a. On 02/06/23 at 7:13 AM, a provider note showed that the patient was experiencing shortness of breath and substernal chest pain. The provider note diagnosed the patient with congestive heart failure exacerbation and bilateral pleural effusions. The note stated that the patient lived at home independently and that she had baseline confusion with paranoia that was normal for the patient. The patient did not take any medications.

b. On 02/06/23 at 5:45 AM, a nursing note stated, "Patient getting agitated, trying to hit staff, and messing with medical equipment, 1 mg Ativan given as ordered.

c. On 02/06/23 at 7:00 AM, a nursing note stated, "Patient extremely combative and refusing to keep nasal cannula on. Patient placed in soft limb restraint to left upper extremity and right upper extremity. Attempted to contact MD (medical doctor) with no response. Next shift Registered Nurse (RN) made aware.

d. On 02/06/23 at 7:50 AM, a nursing note stated, "This RN received report from previous RN. Report then given to Staff #501 for patient to be taken over to boarding side. This RN had minimal involvement in patient care. Dr. (Staff #502) made aware of patient remaining in soft wrist restraint due to confusion, agitation, and interfering with required care."

Surveyor #5 found no evidence staff monitored the patient after chemical restraint for patient behaviors of agitation, trying to hit staff, and messing with medical equipment.

Surveyor #5 found no evidence staff monitored the patient after physical restraint applied for behaviors of combativeness, refusing to keep nasal cannula on, confusion, agitation, and interfering with required care.

3. On 02/06/23 at 3:14 PM, during interview with Surveyor #5, the patient's Registered Nurse (Staff #501), verified that there was no documentation of patient monitoring at all. Staff #501 stated that she had removed the patient from restraint sometime between 9:45 AM and 10:00 AM.

4. On 02/07/23 at 9:00 AM, Investigator #3 and a Program Manager for Regulatory Affairs (Staff #301) reviewed the medical records of six patients who were placed in restraints or seclusion for violent or self-destructive behavior during their stay at the hospital. The review showed the following:

a. Patient #301 was 32-year-old who presented to the Emergency Department (ED) with acute agitation. The patient displayed violent behavior towards staff and himself and was placed in 4-point restraints on 01/30/23 at 11:57 PM. The patient was released from restraints on 01/31/23 at 2:00 AM. The investigator could find no documentation that Patient #301's psychological status, extremity circulation, or signs of injury were evaluated and recorded every 15 minutes as required by policy.

5. At the time of the review, Investigator #3 interviewed the Program Manager for Regulatory Affairs (Staff #301) who confirmed the medical record lacked documentation that showed the patient's psychological status, extremity circulation status, or signs of injury was assessed and evaluated during the restraint period.


.

.
Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure that patients placed in seclusion received a face-to-face assessment within one hour by a provider as directed by hospital policy for 1 of 6 patients reviewed (Patients #302).

Failure to perform the required face-to-face evaluation to determine whether the patient actually meets the specific criteria for restraint or seclusion places patients at risk of harm, injury, or other decline in status.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion Policy, 964.00," Policy Stat ID number 127196789, last approved 12/2, showed that a provider will perform a face-to-face evaluation within one hour which will include the following information:

Patient's immediate situation
Patient's reaction to the intervention
Patient's medical and behavioral condition
The need to continue or terminate the restraint or seclusion.

The Registered Nurse (RN) will document "yes" for provider in person evaluation.

2. On 02/07/23 at 9:00 AM, Investigator #3 and a Program Manager for Regulatory Affairs (Staff #301) reviewed the medical records of six patients who were placed in restraints or seclusion for violent or self-destructive behavior during their stay at the hospital. The review showed the following:

a. Patient #302 was 27-year-old who presented to the Emergency Department (ED) with acute agitation. The patient began yelling and screaming and attempted to grab the nurse and technician while they were attempting to administer medication to the patient for anxiety. As a result, the patient was placed in seclusion on 01/24/23 at 2:19 PM. The patient was released from restraints on 01/24/23 at 5:10 PM. The investigator could find no documentation that a face-to-face evaluation was performed and documented by a provider in the medical record.

3. At the time of the review, Investigator #3 interviewed the Program Manager for Regulatory Affairs (Staff #301) who confirmed the medical record lacked documentation that showed a provider performed a face-to-face evaluation. Staff #301 also acknowledged the provider's documentation did not reflect the patient was placed in seclusion.
.

.
Based on document review and interview, the hospital failed to ensure and document staff completed restraint education for 2 of 6 staff education records reviewed for staff currently monitoring patients in the hospital's Emergency Department (Staff #506 and #507).

Failure to ensure staff are competent in restraint application, assessment, monitoring, and documentation can result in patient harm or death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion Policy," policy number 964.00, revised 02/21, showed the following:

a. Only staff who have been trained and demonstrated competence in applying restraint may apply restraints per manufacturer's instructions.

b. All members of Hospital, ancillary and medical staff, and any contract staff employees, shall receive training in the following subjects as it related to their duties performed under this policy including the safe application and use of all types of restraint used by staff members, including training in how to recognize and respond to signs of physical and psychological distress or injury.

c. Such training shall take place during new employee orientation and on a periodic basis as indicated by the results of quality monitoring and recommendations from Education Services.

2. On 02/08/23 at 9:00 AM, Surveyor #5, a Hospital Educator (Staff #505), a Human Resource Manager (Staff #503), and a Human Resources Assistant (Staff #504) reviewed the employee education files for Staff #502 and #503. The review showed the following:

a. Surveyor #5 found no evidence Staff #506 completed training in the application and removal of mechanical restraint.

b. Surveyor #5 found no evidence that Staff #507 received annual restraint education/training.

3. At the time of the review, Staff #505 stated that she miss documented the education for Staff #506 and that Staff #507 had not attended the education fair and had not completed required annual restraint training.
.